LABORATORY STANDARDS OF CONDUCT

JOHNS HOPKINS MEDICAL INSTITUTIONS

Department of Pathology
Carnegie 417
600 North Wolfe Street
Baltimore, MD 21287
MISSION

Our Mission is to provide the highest level of laboratory diagnostic services to our patients,
under the direction of their physician.

VISION AND IDEOLOGY

Our Vision and Core Ideology is to share with our clients a zeal for perfection, and the diligent
pursuit of that perfection – delivered with uncompromising compassion – is paramount.
Laboratory medicine will be practiced with accuracy, integrity, and high ethical standards,
establishing a professional environment for the practice of clinical laboratory science for our
staff and associates. Our most important responsibility will always be to our patients.

OUR CORE VALUES

We are employees of the Department of Pathology at Johns Hopkins Medical Institutions, and
we will promote the highest quality of care and adhere to our organization’s policies and
procedures at all times. We adhere to performance standards which ensure the delivery of
superior health care services.

ETHICAL DECISION MAKING

The laboratory staff is committed to attaining the highest level of integrity, compliance and
ethics. This is evidenced in our daily work and our decisions. Specific expectations relating to
integrity, compliance and ethics include, but are not limited to:

 Respect for the patient

 Generating and using confidential patient reports
 High quality performance of laboratory testing
 Adherence to all hospital and laboratory policies and procedures
 Accurate billing of laboratory procedures
 Determining when it is appropriate to raise an ethical issue

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Standards of Conduct – Johns Hopkins Department of Pathology

STANDARDS OF CONDUCT

The following are general guidelines delineating the Standards of Professional Conduct, to
which Johns Hopkins Pathology Department expects all laboratory staff to adhere. These
standards apply whether or not the laboratory location routinely performs procedures
compensated under any federal or state program.

These Standards are intended to summarize management’s expectations. For a detailed

explanation of any particular issue, consult the applicable laboratory or hospital policy, or
contact a member of management.

I. General Standards

A. Laboratory staff shall, at all times, perform their functions with adherence to the
highest ethical and professional standards of the laboratory profession.

B. Johns Hopkins Laboratory staff shall adhere to all statutes, regulations and other
program requirements governing federal, state and private health benefit plans,
specifically including but not limited to Medicare and Medicaid. Johns Hopkins
Laboratory management will provide all laboratory employees with the
information and training necessary to comply with applicable laws, statutes and
regulations.

C. These Standards of Conduct are an integral part of the Laboratory Compliance

Plan. It is imperative that all Laboratory employees are familiar with these
Standards. Support of and adherence to these Standards is an essential element
of each employee’s job performance.

D. These Standards of Conduct are not intended to be a moral guideline; it being

the exclusive right of each individual to determine the moral guidelines under
which they live. However, these Standards are intended to delineate the
minimum conditions under which a laboratory employee must agree to perform
professionally in order to continue employment with Johns Hopkins Department
of Pathology.

II. Orders:

A. Laboratory staff shall perform procedures only on the order of health care
providers licensed by the state of Maryland and who hold privileges on the
medical and surgical staff of Johns Hopkins Medical Institutions or one of its
affiliates.

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Standards of Conduct – Johns Hopkins Department of Pathology

B. Laboratory staff specifically shall not perform procedures for friends, family, co-
workers or others when such work is not accompanied by a bona fide physician’s
order.

C. Laboratory staff shall not use personal discretion as a basis for performing
additional work on any patient without a physician’s order.

III. Coding:

A. Every effort must be made to associate each test order received in the
laboratory with diagnostic information provided by the physician. If the
laboratory is required to convert narrative diagnostic information to an ICD-9-
CM code, the code must be valid and accurately reflect the information in the
medical record documentation.

B. CPT or HCPCS codes used to bill laboratory tests must accurately describe the
service that was ordered and performed.

IV. Billing:

A. Billing shall be performed in accordance with organizational policy.

B. Procedures will be billed only when they have been performed under the order
of a physician or other individual authorized to order laboratory tests.

C. The laboratories will only submit claims for tests that have been performed. If
the laboratory cannot perform a test due to a laboratory accident, insufficient
quantities or inappropriate specimen, the laboratory must not submit the claim.
Credits for laboratory tests will be credited upon cancellation of test(s). Johns
Hopkins Laboratory offers only HCFA-approved panels.

D. Johns Hopkins Laboratory will not bill for both calculations and the tests
performed to derive such calculations.

E. Standing orders are honored by Johns Hopkins Laboratory as long as they are
valid, medically necessary and monitored for appropriateness as required in the
Laboratory Policies and Procedures.

F. No service may be billed in a manner inconsistent with Medicare regulations,

unless the patient is not a Medicare beneficiary and full disclosure of the billing
exception is made to both the patient and the patient’s attending physician.

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Standards of Conduct – Johns Hopkins Department of Pathology

V. Reporting of Results:

A. Reporting of results shall be performed in accordance with established

organizational policy.

B. Results may be reported only to a member of the Johns Hopkins employee staff,
who demonstrates a documented need to know, or to a physician or designee.
Under no circumstances may results be reported directly to a patient, member
of a patient’s family, or a significant other to the patient. With consent from the
patient, results may be reported to non-Hopkins personnel. Consult the Legal
Department for assistance.

VI. Use of Johns Hopkins Medical Institutions’ Resources

A. Every Johns Hopkins employee is obligated to protect company assets. Company

resources such as supplies, equipment, information and time should not be used
for personal purposes.

VII. Reporting of Violations/Suspected Violations

A. If any laboratory staff member believes activities or events are occurring, have
occurred, or might occur, which would be contrary to the expectations reflected
in this policy, it is the staff member’s obligation to report such belief to a
member of management or a member of the Compliance Committee.

B. Violations of any aspect of Medicare regulations, or failure to report a known or

suspected violation of such regulations, shall be grounds for disciplinary action.

C. Whenever possible and appropriate, an attempt should be made to resolve

issues at the local level first by addressing concerns to one’s immediate
supervisor. Under no circumstances is any employee discouraged from
contacting another member of management, a Compliance Committee member,
or the Hotline if they are uncomfortable discussing the issue with a supervisor.

D. If any laboratory staff member believes he/she would be placed in personal or

professional jeopardy by reporting an actual or suspected violation to
management, that employee is obligated to report such known or suspected
violation to the Johns Hopkins Compliance Hotline at 1-877-WE-COMPLY (1-877-
932-6675).

E. Johns Hopkins will make every effort to protect the identity of an individual who
reports misconduct. Retribution or discipline for anyone who reports a violation

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Standards of Conduct – Johns Hopkins Department of Pathology

or suspected violation in good faith is strictly prohibited. Any employee who

deliberately makes a false accusation will be subject to discipline.

VIII. Miscellaneous

A. All marketing related to laboratory services shall be honest, clear, fully

informative and non-deceptive in nature.

B. The conduct of business as a laboratory should reflect the ethical conduct of

business in any venue. The intent is to treat others, whether government or
non-government, as we would expect to be treated.

C. When questions as to the appropriateness of any action arise, consult the

Laboratory Compliance Plan, laboratory policies, Johns Hopkins policies, or any
member of management.

D. Any questions pertaining to these Standards of Conduct may be directed to your

immediate supervisor, department head, or a member of the Laboratory
Compliance Committee.

Reviewed, B. Filburn, January 2009

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Standards of Conduct – Johns Hopkins Department of Pathology

Johns Hopkins Medical Institutions

Department of Pathology
LABORATORY STANDARDS OF CONDUCT
CERTIFICATION

I certify that I have received a copy of the Johns Hopkins Laboratory Standards of Conduct
(Standards), adopted June 1999. I further certify that I have read and understand the entire
contents of the Standards. I understand that adherence to all elements detailed in these
Standards is an essential element of my job performance and that failure to comply with the
Standards could be cause for disciplinary action.

Laboratory employee name__________________________________________________

Laboratory employee signature_______________________________________________

Date_________________________