Orthopedic Coding Alert

Question: A Medicare patient presented with a painful ingrown toenail, and our foot surgeon trimmed the nail. Which code should I use? Also, since the patient doesn't have a systemic condition, will Medicare cover the procedure?

Utah Subscriber

Answer: Medicare carriers usually consider nail trimming routine foot care and a noncovered service absent a systemic condition and qualifying findings. But Utah's Part B carrier, Regence Blue Cross Blue Shield, will pay you to remove an infected ingrown nail (703.0, Ingrowing nail; 681.11, Onychia and paronychia of toe; or 686.9, Unspecified local infection of skin and subcutaneous tissue). You should report 11765 (Wedge excision of skin of nail fold [e.g., for ingrown toenail]) for this service.
 
But if the ingrowth is not infected, you should report 11719 (Trimming of nondystrophic nails, any number) or G0127 (Trimming of dystrophic nails, any number). Choose the code based on whether the nail is nondystrophic or dystrophic. Regence (and most other payers) will deny the service as routine foot care, so you should inform the patient that Medicare will deny the service before you trim his nail. If the patient still wants the physician to perform the trimming, he should sign an advance beneficiary notice.

 - You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J.