CDC Compliance, Ethics, & Legal Considerations 2 — Questions and Answers
Question 1: Under HIPAA, which action constitutes a 'minimum necessary' violation when dental staff access patient records?
- Viewing only the treatment plan needed to schedule an appointment
- A receptionist accessing full clinical notes to confirm tomorrow's appointments (Correct answer)
- A hygienist reviewing periodontal charting before a cleaning visit
- A biller accessing procedure codes to submit a claim
Correct answer: A receptionist accessing full clinical notes to confirm tomorrow's appointments
HIPAA's minimum necessary standard requires staff to access only the PHI needed for their specific job function; a receptionist needs scheduling info, not full clinical notes.
Question 2: A dental office receives a subpoena for a patient's records. What is the FIRST step the office should take?
- Immediately release all records to comply with the court order
- Notify the patient and consult the office attorney before releasing records (Correct answer)
- Redact all clinical notes and then release the remaining records
- Deny the request because HIPAA prohibits all disclosures without patient authorization
Correct answer: Notify the patient and consult the office attorney before releasing records
A subpoena alone (without a court order) generally requires patient notice and an opportunity to object, so legal counsel should be consulted before releasing records.
Question 3: Which federal law specifically prohibits physicians and dentists who have a financial relationship with an entity from referring Medicare/Medicaid patients to that entity for designated health services?
- Anti-Kickback Statute
- Stark Law (Physician Self-Referral Law) (Correct answer)
- False Claims Act
- HIPAA Privacy Rule
Correct answer: Stark Law (Physician Self-Referral Law)
The Stark Law prohibits self-referrals to entities in which the referring provider has a financial interest for certain designated health services billed to federal programs.
Question 4: A dental office administrator discovers a colleague has been billing for services not rendered to increase the practice's revenue. Under the False Claims Act, what should the administrator do?
- Report the fraud internally to the office manager and document the concern
- Ignore it if the amounts are small to avoid workplace conflict
- Submit a qui tam lawsuit on behalf of the government to recover damages (Correct answer)
- Notify the insurance company but take no further action
Correct answer: Submit a qui tam lawsuit on behalf of the government to recover damages
The False Claims Act's qui tam provisions allow a private individual (whistleblower) to file a lawsuit on behalf of the government and potentially receive a portion of the recovery.
Question 5: When a dental patient requests an amendment to their health record under HIPAA, the covered entity may deny the request if:
- The amendment would increase the length of the record
- The record was not created by the covered entity receiving the request (Correct answer)
- The patient has outstanding balances with the practice
- The dentist believes the original record is accurate
Correct answer: The record was not created by the covered entity receiving the request
HIPAA permits denial of an amendment request when the covered entity did not create the information and the originating entity is available to respond.
Question 6: Which of the following best describes 'unbundling' in dental coding compliance?
- Combining multiple procedure codes into a single comprehensive code
- Billing separately for procedures that should be reported with one comprehensive code (Correct answer)
- Using a higher-level code than the service actually performed
- Submitting claims to two insurers simultaneously for the same service
Correct answer: Billing separately for procedures that should be reported with one comprehensive code
Unbundling means reporting individual component procedures with separate codes when a single comprehensive CDT code exists that covers all components, inflating reimbursement.
Question 7: A dental coder notices the dentist documented 'simple extraction' but the claim was submitted with the code for a surgical extraction. This is an example of:
- Upcoding (Correct answer)
- Downcoding
- Unbundling
- Balance billing
Correct answer: Upcoding
Upcoding occurs when a higher-complexity or higher-paying procedure code is billed than the service documented in the patient's record.
CDC Compliance, Ethics, & Legal Considerations 2
Under HIPAA, which action constitutes a 'minimum necessary' violation when dental staff access patient records?