CDC Clinical Documentation & Records 3 — Questions and Answers
Question 1: A dental consultant identifies a claim where the narrative description does not match the procedure code billed. This is most consistent with:
- Accurate upcoding for complexity
- A documentation-to-billing discrepancy requiring review (Correct answer)
- Standard coding variation between offices
- An acceptable alternative billing practice
Correct answer: A documentation-to-billing discrepancy requiring review
When a narrative and procedure code conflict, it signals a potential billing error or misrepresentation that warrants further investigation.
Question 2: State dental practice acts typically specify record retention periods. If a patient is a minor, retention typically extends:
- Until the patient turns 18
- Until the age of majority plus an additional statutory period (Correct answer)
- Only 3 years from the last visit regardless of age
- Indefinitely for all pediatric patients
Correct answer: Until the age of majority plus an additional statutory period
For minors, most states require records to be retained until the patient reaches the age of majority plus an additional period, often 3–7 years.
Question 3: Which component of a dental record documents the patient's self-reported symptoms and chief complaint?
- Objective findings
- Subjective information (Correct answer)
- Assessment data
- Plan section
Correct answer: Subjective information
The subjective component of the SOAP note format captures the patient's own description of symptoms, pain levels, and reason for the visit.
Question 4: A dental practice receives a subpoena for a patient's records. The appropriate first action is to:
- Immediately send all records to the requesting party
- Consult with legal counsel before releasing any records (Correct answer)
- Notify the patient that records will be released without review
- Destroy any records that may be unfavorable
Correct answer: Consult with legal counsel before releasing any records
Consulting legal counsel ensures that the subpoena is valid and that the release complies with applicable laws, including HIPAA.
Question 5: Perio charting recorded at each recall visit is important for dental consultants evaluating claims because it:
- Determines the patient's insurance copayment
- Provides baseline data to justify periodontal treatment necessity (Correct answer)
- Replaces the need for radiographic evidence
- Is required only for patients with systemic disease
Correct answer: Provides baseline data to justify periodontal treatment necessity
Documented perio charting establishes a trend of disease progression or stability, which is essential to justify the medical necessity of periodontal procedures.
Question 6: When a dental consultant reviews records for an internal audit, which documentation deficiency poses the highest liability risk?
- Missing tooth diagram color coding
- Absence of informed consent documentation for a surgical procedure (Correct answer)
- Unstandardized abbreviation use in chart notes
- Handwriting that is difficult to read
Correct answer: Absence of informed consent documentation for a surgical procedure
Missing informed consent documentation for surgery is the most serious liability risk because it suggests the patient was not properly informed before an invasive procedure.
Question 7: Which of the following would be considered a breach of patient confidentiality in a dental practice?
- Sharing records with a treating specialist with patient authorization
- Discussing a patient's treatment in a public waiting room (Correct answer)
- Providing records in response to a valid court order
- Disclosing PHI to a public health authority as required by law
Correct answer: Discussing a patient's treatment in a public waiting room
Discussing identifiable patient information in a public area where others can overhear is a HIPAA violation regardless of intent.
CDC Clinical Documentation & Records 3
A dental consultant identifies a claim where the narrative description does not match the procedure code billed.
This is most consistent with: