Medical Ethics, Legal, and Regulatory Issues CH7 Flashcards
Current procedural terminology (CPT) codes are used to:
a) communicate between providers
b) communicate with insurance companies
c) provide legal documentation
d) inform patients regarding their health care
b) The purpose of CPT codes is to communicate with insurance companies, or “third-party payers,” regarding health care services rendered.
CPT has a direct impact on:
a) clinical certification
b) presenting evidence in court
c) patient feedback
d) reimbursement
d) Coding, be it proper or improper, directly affects the reimbursement that the practice gets from third-party payers.
A procedure might carry a different charge, depending on who performs it. This maymean that the procedure code needs an additional code called a(n):
a) service number
b) qualifier
c) modifier
d) HIPAA code
c) Modifiers provide more explicit information about a procedure. Thus, a modifier might be called for when a procedure carries an additional element, such as being performed by a technician or by a mid-level practitioner.
The International Classification of Diseases (ICD) codes of nuclear cataract 366.16
and astigmatism 367.21 are examples of:
a) AMA codes
b) procedure codes
c) diagnosis codes
d) encounter codes
c) ICD codes are numeric codes that identify disorders, diseases, conditions, etc. The current edition is 9 (ie, ICD-9), but version 10 is already in use and will eventually be mandatory (ie, ICD-10).
A reviewer is looking over an encounter form for a patient visit to your practice to make sure that diagnosis codes and procedure codes match up. Which of the following would
be marked as unacceptable?
a) CPT: incise and drain ICD: chalazion
b) CPT: epilation ICD: trichiasis
c) CPT: probe and irrigation ICD: cataract
d) CPT: biopsy ICD: lesion of the eyelid
c) It is vital that procedure codes have an appropriate diagnosis code to justify them. One would expect a CPT code indicating that a probe and irrigation had been done would be coupled with a diagnosis code of nasolacrimal duct obstruction (or some other associated lacrimal problem).
A patient who had a blepharoplasty is upset because now she has dry eyes. The court determined that the patient was not told about this risk prior to surgery. This is an example of:
a) failure to disclose
b) breach of promise
c) failure to perform
d) intentional harm
a) “Failure to disclose” occurs when a patient has not been informed about the risks of a particular procedure. This “duty of disclosure” is part of the informed consent process. See
the section titled Informed Consent
A patient who is moving to another state has stopped by the office requesting his records. He would like you to hand over the chart so he can take it with him. Your response to this is to:
a) make copies for the office and give him the original
b) tell the patient you will mail the original to his new provider
c) give the patient lab work reports from his chart
d) make copies for the patient and keep the original for the office
d) The physical chart belongs to the practice; the information belongs to the patient. That means that choices a, b, and c are incorrect. Of course, prior to providing the copies, you
must get a signed release of information form. Some clinics have further rules that govern how medical records are to be handled.
Which of the following is a legal regulation?
a) An eye care practitioner must fit any patient who desires it with contact lenses.
b) The patient who has a refractive eye exam must be provided with a copy of the glasses prescription.
c) A prescription for glasses is only good for 6 months.
d) K readings must be included on every glasses prescription in case the patient decides to get contact lenses.
b) A patient has a right to a copy of the glasses prescription. The expiration of glasses prescriptions varies from state to state, but the minimum will be 1 year
An ophthalmic assistant who measures a patient’s refractive error and then writes the patient a glasses prescription, where the physician does not see the patient or review
the record, is:
a) breaking the law
b) violating patient privacy
c) doing the patient a favor
d) in accordance with current practice
a) The procedure described is a refraction, which involves clinical judgment allowed only to a licensed professional. A technician who performs refractions is practicing medicine
without a license, which is illegal. Ophthalmic technicians may, however, perform refractometry, where the refractive error is measured but the prescribing/clinical judgment is left to the licensed practitioner.
The right of a patient to protection of his or her personal health information is a federal law known as:
a) Health Insurance Portability and Accountability Act (HIPAA)
b) Occupational Safety and Health Administration (OSHA)
c) Joint Commission on Accreditation of Health Care Organizations (JCAHO)
d) American Academy of Ophthalmology (AAO)
a) HIPAA establishes the rights of a patient to protection of his or her health information
OSHA has developed laws regarding:
a) standards for safety lenses
b) eye protection in the workplace
c) privacy laws
d) scope of practice
b) OSHA deals with employee safety and has rules regarding eye protection in the workplace (such as safety goggles worn when assisting with laser surgery).
Which of the following is true?
a) An eye care practitioner may charge a fee to release a patient’s glasses prescription.
b) An eye care practitioner may restrict eye exams only to those who agree to purchase eyewear from the practice’s optical shop.
c) An eye care practitioner may refuse to release a patient’s glasses prescription until the patient has paid for the eye exam, if it is customary to require payment at the time of
service.
d) An eye care practitioner who has fit a patient for contacts may require that the patient buy the first year’s supply of lenses from the practitioner’s practice.
c) The FTC has determined that if it is customary to ask any patient to pay when services are rendered, then the prescription may be withheld until payment is made.
The scenarios in the other answers are strictly forbidden
The Federal Trade Commission (FTC) has regulations affecting all of the following
except:
a) the “intraocular lens implant rule”
b) advertising for refractive surgery
c) the “eyeglass rule”
d) the “contact lens rule”
a) For more information on marketing refractive surgery, see the FTC’s Marketing of Refractive Eye Care Surgery: Guidance for Eye Care Providers.6 For more information on the Eyeglass Rule and the Contact Lens Rule, see the FTC’s Q&A: The Contact Lens Rule and the Eyeglass Rule.7
OSHA regulations regarding medical practices require all of the following except:
a) every new hire is to be trained in infection control practices
b) all contact lenses must be fit by a licensed eye care practitioner
c) the employer must provide personal protective equipment to employees
d) OSHA regulations must be posted in the workplace
b) OSHA does not legislate prescribing or dispensing of medical devices
The “Red Flags Rule” was developed by the FTC in order to prevent:
a) employee injuries
b) identity theft
c) insurance fraud
d) sexual harassment in the workplace
b) The Red Flags Rule was developed by the FTC in order to detect identity theft. The rule requires businesses (including medical practices) to develop a plan of identifying “relevant patterns, practices, and specific forms of activity—the ‘red flags’—that signal possible identity theft
All the following are true regarding the Patient Protection and Affordable Care Act
(PPACA) except:
a) It affects insurance coverage for pre-existing conditions.
b) It is concerned with health insurance reform.
c) It enforces health care privacy laws.
d) It was signed into law by President Barack Obama.
c) PPACA does not deal with health care privacy. The other statements are true
Quality assurance (QA) depends upon:
a) opinions of caregivers
b) patient compliance
c) being able to measure something
d) having favorable surgical results
c) QA requires that something be measured, regardless of whether the data come from a
patient survey, patient records, checklists, etc.
Which of the following does not apply to QA?
a) One characteristic of QA is to minimize problems and poor outcomes.
b) One characteristic of QA is to identify procedures that need to be changed.
c) One characteristic of QA is to be a once-and-done procedure.
d) One characteristic of QA is that it can lead to better patient care
c) The intent of QA is to monitor routine procedures so that problems can be identified and corrected, resulting in better patient care. To be effective, QA is an ongoing process, not
something done once to qualify for a certification or to pass an inspection
An example of data collected for QA purposes regarding outcomes would be:
a) employee turnover
b) visual acuity after cataract surgery
c) number of patients seen daily
d) number of referral patients
b) A formal QA program collects data that give an indication of the quality of the service
rendered in part by evaluating outcomes. Simply counting the number of patients does not really yield data that reflect quality. But, evaluating the postoperative vision of the practice’s cataract surgery patients helps monitor treatment outcome.
Which of the following is true?
a) QA is the responsibility only of the practitioner.
b) QA helps hold health care workers accountable.
c) QA is only an issue if the practice is to be inspected.
d) QA is not concerned with access to health care.
b) A practice’s QA system helps to set minimum standards to which all in the clinic (not just the practitioner) are held. QA is generally focused on outcome (eg, vision after cataract surgery), the relationship of cost to benefit (eg, time, money, and effort put into patient care versus benefit to the patient), and access to care (eg, availability of the services needed by the patient). While a viable QA system may be required for certain clinical certifications, every practice needs to have such a system
Your practice is developing a QA program. One area to be addressed is strabismus surgery. Which of the following would not fit into the list of the logical assessments?
a) preoperative and postoperative prism measurements of the deviation
b) patient or parental survey of satisfaction with the process as a whole
c) data concerning postoperative complications
d) putting strategies into place that will prevent alterations to the process
d) One of the main goals of QA is to identify problems (which could be revealed by items in answers a, b, and c) and implement the change that is needed to improve outcome.
The standards that govern moral conduct, especially of a person/group with some
type of power in issues regarding conduct, rights, and actions is:
a) informed consent
b) patient rights
c) ethics
d) medicolegal code
c) Ethics are the standards that govern our personal and professional behavior. In medicine, these are the standards that help us make moral judgments regarding such things as how we treat our patients (both personally and medically), how we treat our peers, what kind of employee we are, and much more. It includes providing the best and most intelligent care of which we are capable and maintaining honest relationships with others.
The basis for medical ethics is:
a) The Oath of Hammurabi
b) The Hippocratic Oath
c) The Mayflower Compact
d) The Constitution of the United States
b) Hippocrates lived in the fifth century BC. He was a Greek physician who held himself
to a strict code of behavior and quality of care, which included conduct, confidentiality, and
scope of practice. From this grew the concept of medical ethics, and the Hippocratic Oath
(which speaks to those same virtues) is named after him.
You have just seated your patient and ask if she’s having any problems with her eyes.
She states that she would like to discuss that only with the physician. You explain your
role in gathering information and assure her of confidentiality, but she insists that she
will speak only to the doctor. You should:
a) explain that it is office policy that she speak to you first
b) offer to appoint her for another day when she may feel more cooperative
c) affirm her right to speak only to the physician and acquiesce
d) recommend that the physician dismiss her from the practice
c) It is the patient’s right to discuss her case with the physician only; be sure to document
in the chart that the patient has made this choice. You might ask if you can go ahead and do a “few tests” so that the doctor will have some information when she speaks to the patient, such as visual acuity, lensometry, pupil evaluation, slit-lamp evaluation, and
perhaps noncontact tonometry. Without a history, it is inadvisable to instill drops or perform any type of contact test (tonometry, Schirmer’s, etc). In addition, while the patient may not wish to discuss his or her eye problems, he or she may be willing to give other information about his or her history
