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AAPC Ethics Committee Policies and Procedures

Section 1 Definitions
Section 2 Statement of Rights and Obligations
Section 3 Procedures for Filing a Complaint
Section 4 Investigation Procedures
Section 5 Executive Committee Review and Initial Determination
Section 6 Request Procedure for Appeals to AAPC Ethics Committee
Section 7 Ethics Committee Hearing Process

Definitions
1. Appeal — Process by which the Initial Determination of the AAPC Executive Committee is elevated for review by the AAPC Ethics Committee.
2. Circumstantial Evidence — Evidence based on inference and not on personal knowledge or observation.
3. Complainant — The party making an Complaint against a named member of the AAPC for Violation of the AAPC Code of Ethics.
4. Complaint – Allegation of a Violation of one or more provisions of the AAPC Code of Ethics.
5. Complaint Form – The form designated by the AAPC Executive Committee as the appropriate form for submission of the information justifying the allegation that the Defendant has violated the AAPC Code of Ethics.
6. Credential — Any certification, or designation conferred by the AAPC.
7. Date of Discovery — The date upon which the alleged Violation became known to the Complainant.
8. Date of Occurrence — The date the alleged Violation took place.
9. Defendant Member – The party who is alleged to have violated one or more provisions of the AAPC Code of Ethics.
10. Dismissal — A determination by the AAPC Executive Committee or AAPC Ethics Committee that disposes of a Complaint based upon a determination that there was no Violation of any provision of the AAPC Code of Ethics.
11. Due Notice – Sufficient and proper notice that is intended to and likely to reach a particular person under the circumstances.
12. Ethics Committee (of the AAPC) – The body appointed by the AAPC Board of Directors consisting of three members of the AAPC National Advisory Board and all members of the AAPC Legal Advisory Board.
13. Executive Committee (of the AAPC) – The body appointed by the AAPC Board of Directors responsible for making an Initial Determination of Violation of the AAPC Code of Ethics.
14. Evidence — Something (including testimony, documents, and tangible objects) that tends to prove or disprove the existence of an alleged fact.
15. Final Determination – The determination of the AAPC Ethics Committee of an Appeal of an Initial Determination by the AAPC Executive Committee.
16. Initial Determination – The determination made by the AAPC Executive Committee with respect to the validity of a Complaint, after investigation, to include the determination of appropriate action; i.e, dismissal, reprimand, suspension, or revocation.
17. Investigator — An AAPC Executive Committee or Staff member appointed to gather data for the purpose of review when making an Initial Determination. The Investigator will gather data for the AAPC Executive Committee, and maintain a case file containing the Complaint and all relevant Evidence. The Investigator cannot be involved in any of the decision-making processes related to an Initial Determination.
18. Letter of Dismissal — A formal letter sent to the Defendant, a copy of which is placed in the permanent file of the AAPC member, indicating that the Complaint filed against the member has been dismissed.
19. Letter of Revocation — A formal letter sent to the Defendant, a copy of which is placed in the permanent file of the AAPC credentialed member, indicating that there is Evidence of Violation of the AAPC Code of Ethics and that AAPC credentials, membership or both have been revoked.
20. Letter of Reprimand (Published) — A formal letter sent to the Defendant, a copy of which is placed in the permanent file of the AAPC member, indicating that there is Evidence of Violation of the AAPC Code of Ethics, but not to the degree that action needs to be taken in regard to suspension or revocation of either membership or credential. Notice of the Violation and determination will be published in the AAPC Coding Edge Magazine.
21. Letter of Reprimand (Non-Published) — A formal letter sent to the Defendant, a copy of which is placed in the permanent file of the AAPC member, indicating that there is Evidence of Violation of the AAPC Code of Ethics, but not to the degree that action needs to be taken in regard to suspension or revocation of either membership or credential, and not to the degree that justifies publication of the Complaint and reprimand in the AAPC Coding Edge Magazine.
22. Letter of Suspension – A formal letter sent to the Defendant, a copy of which is placed in the permanent file of the AAPC credentialed member, indicating that there is Evidence of Violation of the AAPC Code of Ethics and that AAPC credentials, membership or both have been suspended. The period of time of the suspension and the process of reapplication for membership or credential shall be specified.
23. Probation – A disciplinary action that does not involve loss of credential but may include additional continuing education in topics assigned by either the AAPC Executive Committee for an Initial Determination or the AAPC Ethics Committee making a Final Determination, to correct the apparent deficiency in knowledge that led to a Violation of the standards.
24. Relevant Evidence – Evidence that tends to prove or disprove the existence of a fact.
25. Revocation of Credential — Permanent loss of credential.
26. Standard of Review: For an Initial Determination, the criterion used by the AAPC Executive Committee when making a determination of the validity of the Complaint. For a Final Determination, the criterion used by the AAPC Ethics committee in affirming or making a recommendation for modification, either upward or downward, of the determination of the AAPC Executive Committee.
27. Suspension of Credential — Action to suspend a credential for a specific time period with or without specific conditions to be met for restoration.
28. Violation — Any breach or infringement of the AAPC Code of Ethics.
Statement of Rights and Obligations
1. The Complainant has the right:
  1. To present any credible Evidence that would assist the AAPC Executive Committee in making an Initial Determination or the AAPC Ethics Committee in making a Final Determination. The Evidence must be relevant. While strict Rules of Evidence are not applicable, the AAPC Executive Committee and the AAPC Ethics Committee have the discretion to determine the weight given to any piece of Evidence based on its character.
  2. To present the sworn or notarized affidavit of third persons in support of the allegations in the Complaint.
  3. To receive notice of the Initial Determination of the AAPC Executive Committee where the determination is not Appealed, or the Final Determination of the AAPC Ethics Committee in the event of an Appeal of an Initial Determination.
2. The Complainant has the obligation:
3. The Defendant Member has the right:
  1. To receive due notice of a Complaint to include the identity of the Complainant and all information supplied by the Complainant or developed by the AAPC Investigator appointed by the AAPC Executive Committee to investigate the allegations. Notice shall be sufficient where such notice is sent via US Mail to the address of record in the AAPC member file of the Defendant Member.
  2. To be represented by legal counsel.
  3. To present any credible Evidence that would assist the AAPC Executive Committee in making an Initial Determination. While strict rules of Evidence are not applicable, the AAPC Executive Committee and the AAPC Ethics committee have the discretion to determine the weight given to any piece of Evidence based on its character.
  4. To present the sworn or notarized affidavit of third persons to the AAPC Executive Committee in response to a Complaint, or to the AAPC Ethics Committee when Appealing an Initial Determination.
  5. To request an informal interview with the members of the AAPC Executive Committee prior to the AAPC Executive Committee rendering an Initial Determination.
  6. To provide a written statement of rebuttal regarding the findings and sanction contained in an Initial Determination of the AAPC Executive Committee as part of an Appeal to the AAPC Ethics Committee.
  7. To Appeal the Initial Determination of the AAPC Executive Committee to the AAPC Ethics Committee for Review and Final Determination.
Procedure for Filing a Complaint Alleging a Violation of the AAPC Code of Ethics
Any member, health information management professional, employer, consumer, or regulatory agency representative can file a written formal Complaint with the AAPC alleging that an AAPC credentialed or non-credentialed member has violated the AAPC Code of Ethics provided that the Complaint is forwarded to the AAPC Executive Committee within four (4) years of the date of occurrence.
1. Complaints Initiated By Any Person
  All complaints must be written and submitted on the Complaint Form created by the AAPC for the purpose of making an allegation of a Violation of the AAPC Code of Ethics. The Complaint must indicate the name of the entity or person making the Complaint and the identity of the Defendant Member and other identifying information as may be necessary such as the member number or address of the Defendant Member. Anonymous complaints will be automatically dismissed without investigation. The Complainant shall include all relevant supporting information as an attachment to the Complaint Form. The Complaint Form must be submitted to the AAPC Executive Committee and be received within four (4) years of the date of the alleged Violation, or one year from the date that an alleged Violation is discovered, whichever is sooner.
  1. Except where the complaint is properly and timely filed by the AAPC Executive Committee as a result of its own investigation, once the AAPC Executive Committee has received the Complaint Form and supporting information as supplied by the Complainant alleging that a credentialed or non-credentialed member of the AAPC has violated the AAPC Code of Ethics, the AAPC Executive Committee may, at its discretion, take either of the following actions as appropriate under the circumstances:
    1. Dismiss the Complaint as not properly or timely filed;
    2. Where the Complaint Form and attached information provided is properly and timely filed, and alleges that a Violation of the AAPC Code of Ethics has occurred, the AAPC Executive Committee shall appoint an Investigator who shall gather all additional Evidence regarding the matter that is reasonably ascertainable so that the AAPC Executive Committee can render an Initial Determination; or
  2. Once a Complaint has been initiated and accepted by the AAPC Executive Committee as being properly and timely filed, the Defendant shall be given due notice of the Complaint by US Mail at the address in the AAPC member’s file. Where such notice is sent by certified mail or by any means where delivery confirmation is required and the Defendant Member refuses delivery, the Defendant Member shall be presumed to have received notice of the Complaint. The Defendant Member shall be provided with a copy of the Complaint form and supporting documentation, the provision(s) of the AAPC Code of Ethics that are alleged to have been violated, and the possible sanctions if the allegations are proved.
  3. Upon receipt or presumed receipt of the Complaint, the Defendant Member shall:
    1. have a minimum of thirty (30) days to respond to the Complaint and to submit any written or documentary Evidence, or submit the sworn or notarized affidavits of third parties that he or she feels are relevant;
    2. request additional time for submission of Evidence to the AAPC Executive Committee. The AAPC Executive Committee should grant reasonable requests for additional time.
  4. Following receipt of the Evidence submitted by the Defendant Member or the passage of the deadline for submission of Evidence, the AAPC Executive Committee shall render an Initial Determination within thirty (30) days. The standard of review is a preponderance of the Evidence. Appropriate actions are:
    1. dismissal in the event that AAPC Executive Committee concludes that no Violation of the AAPC Code of Ethics has occurred. Where the Complaint is dismissed a letter of dismissal shall be sent to the member and a copy placed in the member’s permanent file;
    2. public or private reprimand; suspension of credential, membership or both; or revocation of credential, membership or both as warranted by the facts supporting the conclusion that a Violation of the AAPC Code of Ethics occurred. Based on the sanction imposed, a letter of reprimand (public or private), letter of suspension, or letter of revocation shall be sent to the member within ten (10) business days of the decision and a copy shall be placed in the Defendant Member’s permanent file.
  5. Following appropriate notice of the Initial Determination, the Defendant may either:
    1. Accept the Initial Determination of the AAPC Executive Committee regarding both the factual conclusions related to the alleged Violation of the AAPC Code of Ethics and to the sanction imposed; or
    2. Accept the charge that the Defendant committed a Violation of the AAPC Code of Ethics, but within thirty (30) calendar days from the date of receipt of notice of the decision, submit an Appeal to the AAPC Ethics Committee containing a statement setting forth the reasons why the sanction should not be imposed, or reasons why the sanction should be mitigated or reduced; or,
    3. Within thirty (30) calendar days from the date of receipt of notice of the decision, initiate an Appeal of the factual conclusions related to the alleged Violation of the AAPC Code of Ethics and to the sanction imposed. Included in the Appeal, the Defendant Member shall present information showing that the findings of fact of the official body relied upon by the AAPC Executive Committee to initiate the Complaint were erroneous and request reconsideration by the AAPC Ethics Committee. The AAPC Ethics Committee, after review of the case record and the additional statement(s) of the Defendant or third parties, shall render a Final Determination. The AAPC Ethics Committee, on proper vote of its members, may affirm the Initial Determination, or may modify the factual conclusion or sanction in the event that the AAPC Ethics Committee finds by a preponderance of the Evidence that the factual findings and sanction in the Initial Determination were erroneous.
2. Continuation of Complaint Process
  If a member relinquishes membership, fails to renew membership, or fails to cooperate with the ethics investigation, the Committee shall nevertheless continue to process the Complaint, noting in its report the circumstances of the Defendant’s action. Such actions shall not deprive the AAPC Executive Committee of the ability to render an Initial Determination.
Investigation Procedures
1. Appointment: Where the AAPC Executive Committee determines that an investigation is necessary, it shall appoint an Investigator to collect information regarding the alleged Violation of the AAPC Code of Ethics. The Investigator shall be a member of the AAPC Executive Committee or AAPC National Advisory Board (who is not a member of the AAPC Ethics Committee) and where a AAPC Executive Committee member, this member shall abstain from voting on the Initial Determination in the case.
2. Responsibilities: The Investigator has the following obligations:
  1. Initiate a case file that will contain the Complaint, information submitted by the Complainant in support of his or her Complaint, any other such information determined to be relevant by the Investigator, and the recommendation of the Investigator.
  2. The Investigator may conduct an interview of the Complainant, Defendant Member, or any third party having relevant information. Where any interview is conducted, the Investigator shall include the notes of any interview in the case file.
  3. The Investigator shall perform an unbiased and objective investigation and shall include all information reasonably ascertainable that is reasonably likely to be relevant to the issues contained in the Complaint.
  4. The Investigator shall conduct a prompt investigation. Where the Investigator cannot complete his or her investigation within sixty (60) days of the date of appointment, the Investigator shall notify the AAPC Executive Committee of the need for additional time and provide supporting rationale. Where approved by the AAPC Executive Committee, the Investigator shall be given up to an additional thirty (30) days to complete his or her investigation. The failure of the member or Complainant to provide additional requested information shall not constitute a reasonable basis for additional time. In these cases, a notation in the case file shall be made indicating the information requested, who the information was requested from, the method of notice, and the lack of response. At the completion of the investigation, the Investigator shall forward the case file and all information gathered to the AAPC Executive Committee along with the recommended action to be taken by the AAPC Executive Committee.
AAPC Executive Committee Review and Initial Determination Procedure
After reviewing the case file, the AAPC Executive Committee shall conduct an informal interview with the Defendant Member where requested. The AAPC Executive Committee may also conduct an informal interview of the Complainant for issue clarification purposes only. The AAPC Executive Committee may, at its discretion, solicit the testimony of experts to assist it in understanding the issues raised in the Complaint as well as the information in the case file.
1. Making a Determination: AAPC Executive Committee shall deliberate and vote on the action to be taken. These actions can include:
  1. Dismissal of the case;
  2. Rendering a determination that the information supports a finding that a Violation of the AAPC Code of Ethics Occurred
  A majority vote of the members of the AAPC Executive Committee who are not required to abstain from voting will determine the decision. In the event that a majority cannot be obtained for either action, the case is deemed dismissed.
2. Complaint Dismissed
  1. Where the decision of the AAPC Executive Committee is to dismiss the Complaint, the chair of the committee shall provide due notice to both the Complainant and the Member of the decision within ten (10) working days from decision date.
  2. A copy of the decision shall be placed in the Member’s permanent file.
3. Determination of Violation
  1. Where the decision of the AAPC Executive Committee is that a Violation of the AAPC Code of Ethics has occurred, the AAPC Executive Committee shall deliberate further on the issue of an appropriate sanction. Possible sanctions include: public or private reprimand; suspension of credential, membership or both; or revocation of credential, membership or both as warranted by the facts supporting the conclusion that a Violation of the AAPC Code of Ethics occurred. A majority vote of the members of the AAPC Executive Committee who are not required to abstain from voting will determine the decision. In the event that a majority cannot be obtained for a particular sanction, the appropriate sanction shall be deemed to be a private reprimand.
  2. Based on the sanction imposed, a letter of reprimand (public or private), letter of suspension, or letter of revocation shall be sent to the member within ten (10) business days of the decision and a copy shall be placed in the Member’s permanent file.
  3. In addition to notice of the Initial Determination and sanction, the Member shall be provided with instructions and timely filing deadlines as well as appropriate form for Appealing the Initial Determination of the AAPC Executive Committee to the AAPC Ethics Board.
  4. Following appropriate notice of the Initial Determination, the Defendant may either:
    1. Accept the Initial Determination of the AAPC Executive Committee regarding both the factual conclusions related to the alleged Violation of the AAPC Code of Ethics and to the sanction imposed; or
    2. Accept the charge that the Member committed a Violation of the AAPC Code of Ethics, but within thirty (30) calendar days from the date of receipt of notice of the decision, submit an Appeal to the AAPC Ethics Committee containing a statement setting forth the reasons why the sanction should not be imposed, or reasons why the sanction should be mitigated or reduced; or,
    3. Within thirty (30) calendar days from the date of receipt of notice of the decision, initiate an Appeal of the factual conclusions related to the alleged Violation of the AAPC Code of Ethics and/or to the sanction imposed. Included in the Appeal, the Defendant Member/Petitioner shall present information to rebut the determination that a violation of the AAPC Code of Ethics occurred, that a modification of the sanction imposed by the AAPC Executive Committee is appropriate, or both consistent with the basis for the Appeal. The AAPC Ethics Committee, after review of the case record and the additional statement(s) of the Defendant Member/Petitioner or third parties, shall render a Final Determination consistent with the provisions of Section VI.D of this Policy.
4. Continuation of Complaint Process
  If a Member relinquishes membership, fails to renew membership, or fails to cooperate with the ethics investigation, the AAPC Executive Committee shall nevertheless continue to process the Complaint, noting in its report the circumstances of the Defendant Member’s action. Such actions shall not deprive the AAPC Executive Committee of the ability to render an Initial Determination.
Request Procedure for Appeals to the AAPC Ethics Committee
1. Purpose
  The purpose of the Appeal process is to:
  1. Provide a fair and timely process of review for the purpose of evaluating an adverse decision and sanction imposed by the AAPC Executive Committee regarding a filed Complaint against the Defendant Member/Petitioner. A determination shall be rendered within forty five (45) calendar days from receipt of the Defendant Member’s Appeal request unless an extension of time is necessary and is granted by the Defendant Member/Petitioner.
  2. Review all information submitted by all parties, the recommendation of the Investigator and the Initial Determination of the AAPC Executive Committee.
  3. Apply the appropriate standard of review; specifically, to determine if there is clear and convincing Evidence to warrant a reversal of the Initial Determination or if credible Evidence supports that a Violation of the AAPC Code of Ethics occurred, whether independent review of all the Evidence presented warrants either an upward or downward modification to the sanction recommended by the AAPC Executive Committee.
  4. Render a decision supported by a majority vote of the members of the AAPC Ethics Committee that is based on the information and Evidence provided, the testimony of the Defendant Member where the opportunity to testify is requested by the Defendant Member, and any other such Evidence deemed relevant by the AAPC Ethics Committee.
2. Appeal Rights
  Only the Defendant Member/Petitioner has the right to Appeal if an adverse Initial Determination has been rendered against him or her by the AAPC Executive Committee.
  1. The Complainant does not have the right to Appeal a dismissal of the case.
  2. The Defendant has an automatic right of Appeal to an adverse Initial Determination by the AAPC Executive Committee with respect to a finding that a Violation of the Code of Ethics occurred; and may additionally Appeal the imposition of a sanction except where the minimum sanction (private reprimand) was imposed.
  3. The Defendant Member/Petitioner has the right to provide a written testimonial statement to the AAPC Ethics Committee.
  4. The Defendant Member/Petitioner has the right to submit a rebuttal to the Initial Determination of the AAPC Executive Committee and/or justification for a modification of the sanction imposed by the AAPC Executive Committee.
  5. The Defendant Member/Petitioner has the right to timely notice of the Final Determination of the AAPC Ethics Committee. The AAPC Ethics Committee shall render a Final Determination within forty five (45) calendar days of receipt of the Defendant Member/Petitioner’s application for Appeal and shall provide due notice of the Final Determination within ten (10) business days of the determination.
  6. The Defendant Member/Petitioner has the right to legal counsel at his or her own expense.
3. Filing an Appeal to the AAPC Ethics Committee
  1. The Defendant Member/Petitioner must complete the appropriate AAPC Ethics Committee Appeal form, provided for this purpose, which shall include the justifications for a reversal of a finding of Violation of the AAPC Code of Ethics and/or a modification of the sanction imposed by the AAPC Executive Committee in its Initial Determination.
  2. The Defendant Member/Petitioner shall submit the completed Appeal form and any attached justifications such that they are received by the AAPC within sixty (60) calendar days following receipt of the Initial Determination of the AAPC Executive Committee.
  3. The AAPC shall forward the Appeal form to the AAPC Ethics Committee along with the case file from the record consistent with the provisions at subsection B of this section.
4. Actions
  Upon timely receipt of the Appeal form, the AAPC Executive Committee shall forward the Appeal form and a copy of the case file to the AAPC Ethics Committee.
  The AAPC Ethics Committee Secretary or other designated person shall
  1. Acknowledge receipt of the Defendant Member/Petitioner’s request for Appeal by first class letter to the Defendant Member.
  2. Following receipt of the case file, Appeal form and any additional information submitted by the Defendant Member/Petitioner as permitted by subsection B of this section, notify the members of the AAPC Ethics Committee of the request for a hearing.
  3. Verify that each member of the Ethics Committee will be able to evaluate the issue objectively and without any conflict of interest or bias.
  4. Schedule a hearing to review the findings expressed by the AAPC Executive Committee in the Initial Determination and all other information provided and where necessary, to request any additional information that, in the sole discretion of the AAPC Ethics Committee, is necessary to render a Final Determination. Once all information is received and considered, render a Final Determination based on a majority vote of the members of the AAPC Ethics Committee.
    1. Where the decision of the AAPC Ethics Committee is to affirm the Initial Determination of the AAPC Executive Committee, due notice of the Final Determination shall be provided to the Complainant, the Defendant Member/Petitioner, and the AAPC Executive Committee within ten (10) business days of date of Final Determination.
    2. Where the Final Determination of the AAPC Ethics Committee supports a finding that a Violation of the AAPC Code of Ethics has occurred, the AAPC Ethics Committee shall deliberate further on the issue of an appropriate sanction unless the finding of the AAPC Executive Committee was a private reprimand. Possible sanctions include: public or private reprimand; suspension of credential, membership or both; or revocation of credential, membership or both as warranted by the facts supporting the conclusion that a Violation of the AAPC Code of Ethics occurred. The Ethics Committee will make a new determination regarding the sanction to be imposed after careful consideration of all Evidence presented and the sanction imposed may be more or less severe than the sanction recommended by the AAPC Executive Committee. A majority vote of the members of the AAPC Ethics Committee who are not required to abstain from voting will determine the decision. In the event that a majority cannot be obtained for a particular sanction, the appropriate sanction shall be deemed to be the sanction recommended by the AAPC Executive Committee.
    3. Based on the sanction imposed, a letter of reprimand (public or private), letter of suspension, or letter of revocation shall be sent to the member within ten (10) business days of the decision and a copy shall be placed in the Defendant Member permanent file.
  5. Notify the Complainant, the Defendant Member/Petitioner, and the AAPC Executive Committee of the Final Determination of the AAPC Ethics Committee within ten (10) business days following the date that the Final Determination was rendered.
  6. eturn case file and all other materials used by the AAPC Ethics Committee to the AAPC for storage.
AAPC Ethics Committee Appeal Hearing Procedure
1. The Chair of the AAPC Ethics Committee provides the Opening statement, detailing the procedure to be followed and presents the Initial Determination of the AAPC Executive Committee. The Chair will then read any additional information submitted by the Defendant Member/Petitioner submitted in accordance with Section VI.B of this policy provided that such information was submitted and received at least ten (10) calendar days prior to the scheduled hearing.
2. The AAPC Ethics Committee will review the entire record of the case, including any new information or arguments submitted as permitted by Section VI. B of this policy. The AAPC Ethics Committee may also request any additional information that it believes, in its sole discretion, is necessary to make a Final Determination.
3. The AAPC Ethics Committee will deliberate and must make a decision consistent with the provisions of Section VI.D(4) of this policy by majority vote of the members present who do not have a conflict.
4. The Chair of the AAPC Ethics Committee announces the majority decision of the AAPC Ethics Committee and is responsible to publish its recommendation to the AAPC.
5. Due notice of results shall be transmitted to the Defendant Member/Petitioner either by receipted personal delivery or by registered letter (return receipt requested), mailed the Defendant Member’s address on file with the AAPC or Defendant Member/Petitioner’s last known address within ten (10) business days from the date of the AAPC Ethics Committee’s decision. Simultaneously, the AAPC Ethics Committee shall mail the results to the respondent via first-class mail. Where a sanction is imposed, the effective date of the sanction shall be the date that the notice of the Final Determination is received by the Defendant Member. Receipt of the notice of the Final Determination by the Defendant Member/Petitioner will be presumed five (5) calendar days after the date of mailing.

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