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1) When billing for a retina injection drug like Eylea or Lucentis, what is a critical consideration when selecting the appropriate NDC code?
D. Whether the drug was supplied as a single-use vial or a prefilled syringe
Rational:
Retina injection drugs often have separate NDC codes depending on whether they are packaged as a single-use vial or prefilled syringe. Using the incorrect NDC may result in claim denials, incorrect reimbursement, or compliance exposure under drug pricing audits.
2) What type of service is not billable when administering a sample drug?
D. The drug itself
Rational:
Sample drugs cannot be billed because there is no expense to the provider; only the administration can be billed. Many payers will deny an administration code billed without a corresponding drug. It is recommended to add the correct drug code and bill at 0.00 or .01 with a comment of sample drug in Box 19 of the claim form.
3) Which modifier should be used when an unrelated E/M is performed during a postoperative period?
C. Modifier 24
Rational:
Modifier 24 identifies an E/M service unrelated to the original procedure during the global period.
4. What is the significance of the Bilateral Indicator 2 on a CPT code?
D. It determines if Modifier 50 can be used
Rational:
Bilateral Indicator guides appropriate use of modifier 50 for procedures performed on both sides of the body. Some CPT, by definition, are inherently bilateral and the use of modifier 50 is not acceptable.
5. Why is linking a clinically appropriate diagnosis code to a procedure like 92136 (Ocular ultrasound with A-scan and B-scan) essential for medical necessity?
C. It supports clinical medical necessity and aligns with payer coverage policies (LCD/NCD)
Rational:
All CPT codes, including 92136 require documentation of clinical medical necessity and a supporting diagnosis. Linking an appropriate diagnosis to the procedure code ensures it meets LCD/NCD coverage criteria and avoids denial due to lack of medical necessity.
6. What is the Medicare policy regarding OCT (CPT 92134) frequency for patients undergoing active treatment?
C. No more than one per month
Rational:
CMS allows OCTs monthly for actively treated retinal diseases, as stated in the LCD documentation. Be sure to refer the CMS LCD for SCODI services to avoid frequency of service claim denials.
7. What is the function of MUE (Medically Unlikely Edits)?
B. To limit billing of clinically excessive units of service
Rational:
MUEs are set to ensure that the units billed are clinically reasonable for a patient on a given date.
8. When reporting strabismus surgery using CPT codes 67311–67318, how is the procedure appropriately billed when horizontal muscles in both eyes are treated?
C. Use 67311 with modifier 50 to indicate a bilateral procedure
Rational:
CPT codes 67311–67318 describe strabismus surgery per eye, not per muscle across both eyes. If the same procedure is performed on a muscle in each eye (e.g., one horizontal muscle in the left and one in the right), you should report 67311-50 (bilateral procedure), as confirmed in AMA CPT guidance. Using 67312 in this case would be incorrect, as that code is specific to two muscles operated in the same eye.
9. Why is documentation of test interpretation date important in ophthalmology diagnostics?
B. It determines the correct date of service for billing
Rational:
CMS recommends using the date of interpretation to ensure the service was rendered and documented correctly.
10. What is required when reporting bilateral injections with J0178?
C. Report J0178 x 4 with one charge line and a bilateral diagnosis code
Rational:
For bilateral retina injections, dosage is doubled and billed once using the correct bilateral diagnosis and units.
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