Medical Ethics, Legal, and Regulatory Issues CH7

Question 1

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

Answer 1

b) The purpose of CPT codes is to communicate with insurance companies, or “third-party payers,” regarding health care services rendered.

Question 2

CPT has a direct impact on:
a) clinical certification
b) presenting evidence in court
c) patient feedback
d) reimbursement

Answer 2

d) Coding, be it proper or improper, directly affects the reimbursement that the practice gets from third-party payers.

Question 3

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

Answer 3

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.

Question 4

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

Answer 4

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).

Question 5

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

Answer 5

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).

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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.

Question 8

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.

Answer 8

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

Question 9

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

Answer 9

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.

Question 10

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)

Answer 10

a) HIPAA establishes the rights of a patient to protection of his or her health information

Question 11

OSHA has developed laws regarding:

a) standards for safety lenses
b) eye protection in the workplace
c) privacy laws
d) scope of practice

Answer 11

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).

Question 12

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.

Answer 12

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

Question 13

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”

Answer 13

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

Question 14

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

Answer 14

b) OSHA does not legislate prescribing or dispensing of medical devices

Question 15

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

Answer 15

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

Question 16

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.

Answer 16

c) PPACA does not deal with health care privacy. The other statements are true

Question 17

Quality assurance (QA) depends upon:

a) opinions of caregivers
b) patient compliance
c) being able to measure something
d) having favorable surgical results

Answer 17

c) QA requires that something be measured, regardless of whether the data come from a
patient survey, patient records, checklists, etc.

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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.

Question 20

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.

Answer 20

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

Question 21

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

Answer 21

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.

Question 22

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

Answer 22

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.

Question 23

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

Answer 23

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.

Question 24

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

Answer 24

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

Question 25

The physician is out of the office, and a patient comes by on his way to an optical shop. He has broken his glasses and asks you to “test me for glasses” and give him a new,
updated prescription to take to the optician. For you, as an ophthalmic assistant, this
is a question of:
a) patient rights
b) scope of practice
c) confidentiality
d) moral obligation

Answer 25

b) “Scope of practice” relates to what you are allowed to do in the performance of your job. Because ophthalmic/optometric technicians are not permitted to “refract” (ie, measure refractive error and then apply clinical judgment to write the prescription), this request would be beyond your scope of practice

Question 26

Your new patient had cataract surgery at another practice in town 6 months ago and is unhappy with her vision. She states that she was nearsighted before, but now she
cannot read anything up close without glasses. Your refractometric measurement of the eye is +3.75 sphere for distance, with a +2.25 add for near. Which of the following
is a potentially libelous thing to say?

a) “You’re the second patient in a month from that practice who has this problem!”
b) “We’ll know more after Dr. Davis looks at you.”
c) “Unfortunately, measuring for the power of an implant is an inexact science.”
d) “Has the surgeon suggested anything that might help?”

Answer 26

a) The comment in answer a suggests that there is a problem with the surgeon, who has made the same mistake twice in just a few weeks. Discussing another doctor, practice, or
even someone in your own clinic in a negative fashion is not good ethics…even if they are at fault

Question 27

Which of the following does not carry with it the “duty to report?”
a) incompetence
b) child abuse
c) data collection
d) impaired eye care professional

Answer 27

c) In QA, data are collected and compared; there is no duty to report. Accusations of a
health care worker’s incompetence or impairment needs to be evaluated with caution, but evaluated nonetheless. And even the suspicion of child abuse must be reported.

Question 28

Which of the following is true regarding certifications for eye care paraprofessionals?

a) Certification is required in order to be employed.
b) Certification acknowledges that a person has attained specific professional standards.
c) Certification legally permits the individual to evaluate and interact with patients.
d) Certification is required in order to perform certain functions, such as refractions

Answer 28

b) Certification attests to a person’s ability to meet a specific professional standard. It is not
required in order to work in the field of eye care, but it is a statement to patients, to other
professionals, and to the community at large that a person has attained those standards. It
is not licensure, a legal instrument that allows the bearer certain privileges. It is not legal
for any eye care paraprofessional (certified or not) to “refract” patients. See answer 9

ANSWER 9: 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.

Question 29

Compliance with the American National Standards Institute (ANSI) standards is:

a) required by federal law
b) required by state statutes
c) relative to the type of industry involved
d) voluntary

Answer 29

d) Were you surprised to learn that compliance with ANSI standards is voluntary? It is!

Question 30

Which of the following is true regarding the ANSI standards concerning eyeglasses?

a) The ANSI standards apply only to prescription eyewear.
b) The ANSI standards designate allowable variance between the power of the lenses ordered and the lenses dispensed.
c) The ANSI standards apply to safety lenses, but not to any type of lens coating.
d) The ANSI standards apply only to safety lenses and frames.

Answer 30

b) The ANSI standards allow for a slight amount of difference in lens power between the lenses ordered and those that are actually dispensed. The stronger the lens power, the
smaller the allowable variance.

Question 31

Which of the following is true regarding the ANSI standards concerning contact
lenses?

a) The ANSI standards apply to contact lens materials but not to care products.
b) The ANSI standards apply to rigid contact lenses, but not to soft contact lenses.
c) The ANSI standards dictate what information must appear on the contact lens label.
d) The ANSI standards do not mention disinfection of multiuse trial contact lenses

Answer 31

c) The ANSI standards detail specific information that must appear on the labels of contact lenses. In addition, the standards apply to contact lens materials, rigid and soft lenses, contact lens care products, and disinfection of multiuse trial sets.

Question 32

Regarding intraocular lens implants, which of the following is not covered by the
ANSI standards?

a) phakic IOLs
b) optical properties and biocompatibility
c) sterility and shelf-life
d) patient selection

Answer 32

d) The ANSI standards do not apply to patient selection

Question 33

At its most basic, the duty of a scribe is:
a) personal assistant to the practitioner
b) patient educator and advocate
c) coding and charting coordinator
d) patient flow coordinator

Answer 33

a) Scribing is essentially being the practitioner’s right hand. While the main duty may be documentation, the scribe also performs other duties at the physician’s discretion, including patient education, coordinating patient flow, and overseeing billing forms and chart work.

Question 34

Which of the following is not a function of scribing?

a) documenting what the practitioner tells the patient about his or her diagnosis
b) writing and signing a prescription for the patient’s glaucoma drops
c) remaining after the physician and teaching the patient how to do lid scrubs
d) recording exam findings as the doctor dictates them

Answer 34

b) A scribe may write out a prescription for medication as directed by the practitioner, but
may not sign it. A scribe generally documents the physician’s findings as dictated during
the patient exam and during the patient briefing. A scribe may also remain after the doctor has left the exam room, providing patient education as necessary

Question 35

You are scribing for the physician, and he tells the patient that while he expects her
vision to improve, it will not be 20/20 after cataract surgery because of macular degeneration. Which of the following notations best illustrates the scribe’s function as a witness in this case?

a) that cataract surgery has been recommended
b) that the patient has cataracts and macular degeneration
c) that the physician told the patient that cataract surgery would improve vision
d) that the physician explained the effects of macular degeneration on postoperative vision

Answer 35

d) Charting for this patient’s visit will not be complete unless there is a statement indicating the physician specifically explained that cataract surgery will not restore “perfect” vision because of the macular degeneration. If the case went to court, the scribe would be able to say he or she was in the room at the time and heard the surgeon explicitly tell the patient that macular degeneration will prevent 20/20 vision even after the cataract is removed.

Question 36

You are functioning as a scribe in a practice that uses paper charts. At first, the doctor
describes a cataract as 3+. You write this in the chart. Later, the physician changes
that rating to 2+. Which of the following is the right way to make the correction?

a) scratching out the first entry so it cannot be read
b) using a commercial product that covers errors
c) completely erasing the first entry
d) drawing one line through the error and writing the correction above it

Answer 36

d) Never eliminate a written chart entry or render it unreadable. The only proper way to
make corrections in a written record is to draw one line through the mistake, write the cor
rection above it, and initial.

Question 37

You may discuss a patient’s case with another technician if:

a) you do so only in front of the patient
b) it is pertinent to the patient’s care
c) the patient was difficult to handle and you need to unload
d) the patient has symptoms of communicable disease

Answer 37

b) Discussing a patient with another assistant is permissible if it is pertinent to the patient’s
care (eg, you need advice on what testing needs to be done).

Question 38

It is permissible to ask a patient questions related to his or her health:

a) in the reception area, if all the exam rooms are full and you are running behind
b) in a group if everyone has gathered for the same purpose, such as surgical counseling
c) in front of someone whom the patient has brought into the exam room
d) in a multipurpose room where other patients are having tests run

Answer 38

c) Privacy is the key in taking a history. If others can hear, it is not private enough. However, if a patient has someone accompany him or her, it is implied that the guest has the
patient’s permission to hear the history.

Question 39

Which of the following is a breach of confidentiality?

a) Leaning across the front desk and saying, “Here are your glaucoma drops, Mrs. Smith.”
b) Discussing the exam results of a minor child with a parent over the phone.
c) Telling the operating room nurse what a surgery patient’s drug allergies are.
d) Telling your boss that the patient has recently lost her spouse and is very upset today.

Answer 39

a) In answer a, you just announced to the entire waiting room (which may be filled with Mrs. Smith’s peers) that she has glaucoma (a disease). This is a breach of confidentiality.
The other situations are acceptable.

Question 40

Regarding minor surgery and informed consent:
a) informed consent is not required if the procedure has minimal risk
b) informed consent is not required if general anesthesia is not used
c) informed consent is not required if intravenous injection is not used
d) informed consent is required prior to any surgical procedure

Answer 40

d) Any procedure requires an informed consent regardless of risk, anesthesia type, or use of an IV.

Question 41

Each of the following is a key element of informed consent except:
a) potential risks and benefits
b) description of procedure
c) watching a video about the procedure
d) optional treatments

Answer 41

c) Watching a video may be part of the practice’s patient education routine, but there are numerous ways in which a patient may be “advised” regarding the risks, benefits, procedure, and optional treatments.

Question 42

Which of the following statements regarding informed consent is true?
a) The physician may have a technician do the patient education.
b) It only involves having the patient sign papers.
c) It is necessary only if the patient is a minor.
d) Only the patient can sign.

Answer 42

a) It is permissible for the physician to have someone else do the patient education. The key is that the information be presented in a way that the patient (or parent/guardian) can understand. Informed consent consists of more than signed papers (which in some cases must be signed by someone else [parent, power of attorney, etc]) and is necessary regardless of the patient’s age.

Question 43

You have just finished counseling an alert 87-year-old man who needs cataract surgery, and you ask him to sign the informed consent. “I understand what you’ve told me,” he says, “but I’m just not sure.” His 62-year-old daughter has accompanied him and says, “Oh, come on, Dad! Just sign it and let’s go!” An appropriate response from you would be:

a) “You’ll be very happy with your vision after surgery.”
b) “Why don’t you discuss this at home and give me a call later?”
c) “Dr. Snyder thinks this is the best thing for you.”
d) “This is a very common surgery, nothing bad ever happens.”

Answer 43

b) Of the answers offered, b is the best. The others sound too much like guarantees or even coercion. If the patient is mentally competent to make the decision, he must be allowed to make it. Other options are to ask the patient what his specific concerns are, if he has more questions, or if he would like to speak to the doctor again.

Question 44

Which of the following is appropriate wording on an informed consent regarding the description of the procedure?
a) “The recommended procedure is a lateral rectus recession.”
b) “The recommended procedure is laser trabeculoplasty.”
c) “The recommended procedure is removal of redundant skin from both upper lids.”
d) “The recommended procedure is CE with IOL.”

Answer 44

c) The informed consent must contain the information in lay terms that someone with a sixth to eighth grade reading level can understand. Also, abbreviations are not acceptable.

Question 45

Which of the following is not appropriate when explaining the risks of cataract surgery?
a) “A person is more likely to be in a car accident than to go blind from having a cataract removed.”
b) “The risk of developing glaucoma after surgery is so miniscule that you don’t have to worry about it.”
c) “While very unlikely, you do run a slightly higher risk of retinal detachment because you’re so nearsighted.”
d) “The chances of developing a severe infection after cataract surgery are less than one fourth of 1%.”

Answer 45

b) Telling a patient that the risk is so small he or she “does not have to worry about it” is discounting a viable risk and suggests a guarantee that it will not happen. The other answers appropriately acknowledge the risk involved.

Question 46

Which of the following would not be allowed due to informed consent?
a) A vitrectomy when vitreous suddenly comes forward during cataract surgery.
b) An unplanned arcuate keratectomy during cataract surgery to reduce the patient’s astigmatism.
c) Cryotherapy to seal a scleral hole caused inadvertently during extraocular muscle surgery.
d) Exploratory surgery to locate a “dropped” extraocular muscle during strabismus surgery.

Answer 46

b) A surgeon may not simply “decide” to do an extra procedure. Unforeseen difficulties during surgery, as in answers a, c, and d may necessitate procedures that are not specifically spelled out in the informed consent, however. In such cases, the surgeon must respond in the way that most other surgeons would reasonably respond given the same circumstances.