Long-lasting Tips for Superior Nail Coding
Pay attention to five details when filing claims.
By Sivaraj Ramesh, CPC, CEMC, CCS
To file accurate claims when coding and billing nail procedures, be familiar with the nuances of nail anatomy, common conditions, treatments, services, and procedures. Here are some tips to point you towards better nail reporting.
Tip 1: Nail Down Your Anatomy
Nails are thin, horny coverings that grow over the upper tip of a finger or toe. They are composed mainly of keratin (a hard protein) and provide protection and sensation. The basic parts of the nail include:
- Nail plate
- Nail bed
- Nail matrix
- Nail walls
- Nail grooves
- Free edge
Tip 2: Know What Ails Your Nails
Common causes of fingernail or toenail changes include trauma, aging, infection, skin diseases, and severe malnutrition. Common diseases of nails include the following:
- Erythronychia: Red streaks in the nail that may present as a single or paired band in one nail, or as multiple bands in multiple nails.
- Koilonychia: Also called spoon nail because the outer surface of the nail becomes concave, resembling a spoon. May be associated with iron deficiency anemia.
- Melanonychia: Brown or black discoloration of the nail.
- Onychia/Onychitis: Infection of soft tissue surrounding the nail, leading to inflammation and loss of nail.
- Onychocryptosis: A common nail disease also known as an ingrown toenail, or unguis incarnates, in which the growing nail cuts either one or both the sides of the nail bed, causing pain, inflammation, and possible infection. May be caused due to pressure from a tight fitting shoe or improper cutting of toenails.
- Onychodystrophy: Dystrophic changes of the finger or toe nail such as change in nail texture or composition, discoloration, or malformation. May be congenital or acquired due to illness, injury, or infection.
- Onychogryphosis: Overgrowth resulting in long, curved nails that resemble claws. The nails become thick and deformed, with discoloration. Occurs due to tight shoes, infection, trauma, decreased blood supply, and poor hygiene.
- Onycholysis: Lifting of the nail from the underlying nail bed or from the sides. May be caused by external irritants such as harsh chemicals and detergents. Can be a sign of skin disease, an infection, or injury. Most cases are seen in women with long fingernails.
- Onychomadesis: Complete shedding of nail from nail bed, causing localized infection, minor injury to the matrix bed, or severe systemic illness.
- Onychomycosis: A fungal infection of the nail, also called tinea unguium. The nail becomes rough, thick, and brittle.
- Onychophosis: Growth of horny epithelium in the lateral or proximal nail folds.
- Onychorrhexis: Brittle nails with splitting at its free edge, which may result from strong soap, nail polish remover, anemia, etc.
- Onychoptosis: Shedding of the nails resulting from fever, trauma, or adverse reaction to drugs.
- Onychoschizia: Splitting of the distal nail plate into layers at the free edge.
- Onyxis: Ingrown nail.
- Onychomatricoma: A benign nail matrix tumor clinically characterized by a thickened, curved nail plate, with multiple holes at the distal margin of the nail plate.
- Paronychia: Bacterial or fungal infection of the finger or toe where the skin and nail meet at the side or base. May progress to an abscess.
- Subungual hematoma: A collection of blood under the nail due to trauma.
Tip 3: Get Familiar with Common Services
Common nail procedures include trimming of nondystrophic and dystrophic nails, debridement of nail(s), avulsion of nail plate, evacuation, excision of nail and matrix, biopsy of nail unit, repair and reconstruction of nail bed, and wedge excision of nail fold skin.
If the provider orders trimming of nails, review the documentation to determine either dystrophic (G0127 Trimming of dystrophic nails, any number) or nondystrophic (11719 Trimming of nondystrophic nails, any number). Apply either code appropriately for one or more nails.
Debridement of nails is reported according to the number of nails treated. For five or fewer nails, report 11720 Debridement of nail(s) by any method(s); 1 to 5. For debridement of six or more nails, report 11721 Debridement of nail(s) by any method(s); 6 or more.
When reporting avulsion of nail plate, assign 11730 Avulsion of nail plate, partial or complete, simple; single for the first procedure. For each additional nail plate avulsed, turn to add-on code +11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure). For example, if the provider performed three avulsions, report 11730, 11732 x 2.
Report evacuation of subungual hematoma with 11740 Evacuation of subungual hematoma. Local anesthesia may be required.
Excision of nail and nail matrix may occur with or without amputation of tuft of distal phalanx:
11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;
11752 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal phalanx
Per CPT® Assistant (December 2002), when amputation is part of the procedure:
The tuft at the end of the distal phalanx is dissected free and removed with a cutting instrument (eg, bone cutter or rongeur). The edges of the stump are smoothed with a rasp, and the adjacent soft tissues are brought over it and sutured in place. The wound is closed in layers.
Nail biopsy is a surgical procedure in which a tissue specimen is obtained from the growth plate of a fingernail or toenail, reported with 11755 Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure). Per CPT® Assistant, “When a biopsy of the nail bed is performed after avulsion of the nail plate, it is inclusive of the avulsion procedure and is not coded separately.”
For repair of nail bed, report 11760 Repair of nail bed.
Report reconstruction of nail bed with 11762 Reconstruction of nail bed with graft. Per CPT® Assistant:
The intent of reconstruction of the nail bed is to correct a defect from trauma, excision of a lesion, or other condition and, to the extent possible, restore its structural and functional integrity. The details of reconstruction will differ in each case, depending on the nature and extent of the defect. Generally, a split thickness graft is obtained from the nail bed of the great toe; however, full thickness grafts may be utilized in some cases.
Wedge excision of the nail fold skin (11765 Wedge excision of skin of nail fold) is performed typically to remove hypertrophic lateral nail folds that result from chronic ingrown toenails. CPT® Assistant explains:
… a longitudinal incision is made on the affected side of the digit, extending from the proximal nail fold along the nail groove to the distal end of the nail. A second incision is made so that it curves slightly outward from the lateral nail fold and meets the first incision at each end. The wedge of tissue is removed and the edges of the wound are approximated with sutures.
Tip 4: Research CMS Policies
Be sure to check payer guidelines related to specific procedures. For example, Medicare Local Coverage Determination (LCD) L33833 for Surgical Treatment of Nails, relative to nail avulsion (11730, 11732) specifies:
- When a complete nail avulsion is performed, another avulsion should not be required for at least 12 weeks on the same digit. Services performed more often than every 12 weeks on the same digit are not reasonable and necessary and will be denied.
- In the unusual circumstance of a repeat partial avulsion of the same digit within a 12-week period, the medical record must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated.
- Partial nail avulsion of separate borders of the same nail is a single procedure.
- Both avulsion and routine trimming/debridement is not allowed on the same nail on the same day.
Tip 5: Watch Out for Separate E/M
In some cases, an evaluation and management (E/M) service may be prompted by a symptom or condition occurring when a procedure or service is also provided during the same visit. You may report this circumstance by adding modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the appropriate E/M service code. Different diagnoses are not required to report the E/M service and procedure on the same date.
Sivaraj Ramesh, CPC, CEMC, CCS, is assistant manager, coding at Global Healthcare Resource. He has a professional degree in physical therapy, a master’s degree in Psychology, and more than 10 years of experience in medical coding.
CPT® Assistant, December 2002
CMS, Local Coverage Determination (LCD): Surgical Treatment of Nails (L33833):