This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34887 Surgical Treatment of Nails. Please refer to the LCD for reasonable and necessary requirements.
Coding Guidelines
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
The description of CPT codes 11730, 11732 and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT code 11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border.
Procedure code 11750 (Excision of nail and nail matrix, partial or complete, [e.g., ingrown or deformed nail] for permanent removal) requires the removal of the full length or the entire nail plate, with destruction or permanent removal of the matrix by any means.
Reporting CPT codes 11730 or 11732 (avulsion) with CPT code 11750 (excision) and or 11765 (wedge resection) for the same digit on the same DOS is not correct coding.
Reporting CPT code 11750 (excision) with CPT code 11765 (wedge resection) for the same digit on the same DOS is not correct coding.
CPT code 11765 requires an excision of a wedge of the skin of the nail fold from the involved side of the toe. Reporting CPT code 11765 for the removal of a small piece of the skin and/or the nail without local anesthesia is not correct coding.
Procedure code 11730 (Avulsion of nail plate, partial or complete, simple; single) is reported when removing part of the nail plate or the entire nail plate.
Claims must include the nail on which the procedure is performed using one of the modifiers listed in the Coding Information section below to identify the digit in order for payment to be considered.
For services performed on different nails:
- If CPT procedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with one unit of service (UOS) and append with the appropriate identifying digit modifiers.
- For every subsequent avulsion, CPT 11732 is reported as the add-on code with one UOS and the appropriate identifying digit modifier appended.
Utilization Parameters
CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision.
A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- The following information must be clearly documented in the patient’s medical record:
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- Complete detailed description of the pre-operative findings. Include the patient’s symptoms, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale why surgical treatment is being selected over other treatment options.
- Method of obtaining anesthesia (if not used, the reason for not using it).
- A complete detailed description of the procedure performed.
- Identify the specific digit(s) and make note to the nail margin(s) involved on which the procedure was performed.
- Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).
- Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).