Dermatology Coding Alert

Published on Tue Apr 19, 2016 PDF

Key: Distinguish 11730, 11750, and 11765 from routine care.

In your practice, you might commonly see your dermatologist perform treatment of nails. So knowing the CPT^® codes for the procedures performed and the clinical circumstances allowing you to report them for full reimbursement is critical.

Understand the Codes You Will Report for Nail Treatment Procedures

When your dermatologist treats ingrown nails, you will typically report the procedure from one of these few CPT^® codes:

• 11730 (Avulsion of nail plate, partial or complete, simple; single) and 11732 (…each additional nail plate [List separately in addition to code for primary procedure])
• 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown or deformed nail], for permanent removal)
• 11765 (Wedge excision of skin of nail fold [e.g., for ingrown toenail]).

“It’s worth noting that these codes are not limited to toenails,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “They can be reported for either a toenail or fingernail, as appropriate.”

Routine or not? Certain ingrown toenail treatments are considered part of routine foot care, and thus billable only with G0127 (Trimming of dystrophic nails, any number), 11719 (Trimming of nondystrophic nails, any number), and 11720-11721 (Debridement of nail[s] by any method[s]…) for some payers.

“Treatment of simple uncomplicated or asymptomatic ingrowing nail by removal of the offending nail spicule, not requiring local anesthesia, is considered to be routine foot care,” according to a local coverage determination (LCD) from Medicare carrier Novitas. “Trimming, cutting, clipping, and debriding of a nail distal to the eponychium are also considered routine foot care. Routine foot care is only covered when certain systemic conditions are present.”

Know the Nail Procedure Basics

Avulsion: CPT^® codes 11730 and 11732 describe a single, simple, avulsion (removal) of the nail plate. It can be either partial or complete, involving the removal of all of the nail or just part of the nail. Your physician administers a standard digital block, and uses a nail elevator, iris scissors, or nail cutters to separate the nail plate from the nail bed. Any small wounds are restored with a simple repair.

Example: A patient presents with five ingrown toenails. Your clinician completed simple avulsion on both sides of the great toe on each foot and the second digit on the left foot. You would report 11730 for the first avulsion and +11732 for each of the additional two avulsions. If you want to indicate to the payer which toes are involved, you can append Healthcare Common Procedure Coding System (HCPCS) modifiers TA (Left foot, great toe), T5 (Right foot, great toe), and T1. “Because +11732 is an add-on code and there are no Correct Coding Initiative edits between 11730 and +11732, no modifiers are required,” Moore says.

Excision: CPT^® code 11750 describes a procedure in which your dermatologist removes all or part of the toenail, including the nail plate, matrix, and lunula. To prevent a new nail from forming, your clinician uses phenol, electrocautery, sodium hydroxide, or laser to destroy or permanently remove the nail matrix. 

Example: A patient presents for a follow-up of an ingrown toenail. Your dermatologist finds that the patient now has two ingrown toenails — one on each foot. The physician removes both the nail and nail matrix from each of the two toes and also does a silver nitrate cauterization. Report 11750 twice (or with two units of service) to capture both excisions. “To avoid the appearance of duplicate billing or otherwise distinguish the two excisions, you may want to append the appropriate HCPCS modifier to each unit of 11750 or use a CPT^® modifier such as 51 (Multiple procedures) or 59 (Distinct procedural service) to the second unit,” suggests Moore.

Wedge excision: CPT^® code 11765 describes removal of the inflamed tissue adjacent to the nail and a section of the nail itself, along the whole length of the nail. It is used as a treatment of a nail bed that has been injured due to laceration, crush, or avulsion, or for pain caused by an ingrown toenail. After administering local anesthesia, your physician makes an elliptical incision through the granulating or subcutaneous hypertrophied tissue of the affected nail groove. A wedge-shaped incision removes soft tissue from the nail margins. Your dermatologist then closes the wound with sutures to promote healing.

Example: A patient is suffering from an ingrown left second-digit toenail. Your clinician wedges the nail to treat the ingrowth, removes adjacent tissue, and then packs it with Iodoform gauze. In this instance, report 11765.

Keep Your Documentation Straight

According to Medicare, for procedure codes 11730, 11732, 11750, and 11765, an operative report or complete detailed description of the procedure being performed is required. Failure to include the following information in the patient’s medical record could result in denial of the claim.

• The patient’s chief complaint (e.g., painful toe) 
• Procedure being performed (making note to the nail margin involved) 
• Method of obtaining anesthesia (if not used, the reason for not using it) 
• A complete detailed description of the procedure 
• Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied) 
• Postoperative instructions given to the patients and any follow-up care (e.g., soaks, antibiotics, follow-up appointments)

The medical record must be available upon request.