Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 15, 2008 PDF

Question: I saw in your last issue that a podiatrist was sent to prison for billing routine foot care when he only performed nail trims. In our case, we do perform nail trims sometimes, and I want to make sure I-m billing them properly. For instance, yesterday I saw an established patient complaining of pain in toes on both feet. He presented with a swollen, red left pinky toe and a swollen right big toe. I performed a level-two E/M and diagnosed two ingrown toenails. I then performed partial nail excision on both toes. Can I report a code for each nail trimming?

Answer: Because the nail excisions occurred on different feet, you should be able to report a removal code for each, assuming you documented medical necessity for the excisions (which are different from trimming a patient's nails).

T modifiers are vital: On your toe care claims, you should include the appropriate T modifiers to show payers which toes the physician treated. CPT has a list of all the T modifiers. On the claim, report the following:

- 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown or deformed nail] for permanent removal) for the left toe nail trimming with modifier T4 (Left foot, fifth digit) to indicate the location of the procedure.

- 11750 for the right toe nail trimming with modifier T5 (Right foot, great toe) to indicate the location of the procedure.

- modifier 59 (Distinct procedural service) appended to the second 11750 entry to show that the procedures were separate.

- 703.0 (Ingrowing nail) linked to 11750 and 11750-59 to represent the patient's toenail problems.

- 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service.

- 729.5 (Pain in limb) linked to 99212 to represent the patient's foot pain.

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99212 to show that the nail excision and E/M were separate services.

Payer exceptions: Some Medi-care carriers will not want to see modifier 59 appended to the second 11750. Medicare in Florida, for example, wants to see modifier 51 (Multiple procedures) on this claim because the physician performed pre- and postoperative services once. Other Medicare carriers consider the T modifiers evidence that the excisions happened on different toes. So you might not need modifier 59 for these payers.