Wiki 11750 Documentation

[kle0204]

Good afternoon,

I just wanted to double check if the following documentation is enough for 11750 (Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal):

"Procedure: The patients left hallux was locally anesthetized with a 50/50 mixture of 0.5% Marcaine and 1% lidocaine plain. The patients toe was prepped in the usual sterile fashion.
After adequate anesthesia of the toe(s) was obtained, an elastic toe tourniquet was applied to the patients toe(s). A sterile elevator was then used to elevate the affected nail border from the nail bed and from the overlying skin fold. The nail was split distally with a English anvil. The nail was then split completely with a Beaver blade to the level of the nail root. The nail spicule was then grasped with a hemostat and removed. The area was then debrided of any redundant skin and soft tissue debris which were removed. The affected nail groove was then treated with 3 applications of phenol acid using fine tipped cotton tip applicators. Each application was performed for 30 seconds. The area was then rinsed with isopropyl alcohol to neutralize acid. Silvadene cream was applied to the affected area. The toe was then dressed with a dry sterile dressing and secured with Coban. The patient tolerated the local anesthetic and procedure well."

Does the provider have to mention 'the nail matrix' specifically or is the indication of phenol used on the nail indicative of permanent removal?

Thank you!

 

[Kristen Bensel]

my provider specifically states that it is a matrixectomy in her procedure note

 

[amyjph]

It would probably be best to document the actual word so it is clear and no question can be brought should it be requested for documentation audit. I mean, we all know what that procedure is described above, but may as well save any trouble later by adding the word.

 

[kle0204]

Thank you!

 

[m_albrecht]

I have another question about 11750. Hoping either of you can help.
The provider excised the nail and the nail matrix from the right great toe and the left great toe.
They billed:
11750 T5
11750 TA

The insurance added the 51 modifier and processed the claim. The provider is insisting that the 51 modifier should not have be used and stating the insurance company should have added a 50 modifier.

Am I correct in thinking that the 50 modifier would not be appropriate because the T5 and the TA already identifies the left and right?
Also, when I look the CPT code up in the Optum Encoder it does not show that 50 is a valid modifier.
Can you confirm if I am on the right track?
Thank you!

 

[amyjph]

I have another question about 11750. Hoping either of you can help.
The provider excised the nail and the nail matrix from the right great toe and the left great toe.
They billed:
11750 T5
11750 TA

The insurance added the 51 modifier and processed the claim. The provider is insisting that the 51 modifier should not have be used and stating the insurance company should have added a 50 modifier.

Am I correct in thinking that the 50 modifier would not be appropriate because the T5 and the TA already identifies the left and right?
Also, when I look the CPT code up in the Optum Encoder it does not show that 50 is a valid modifier.
Can you confirm if I am on the right track?
Thank you!

The 51 shouldn't really matter either way because the CPT are the same and would have the same RVU/reimbursement so it wouldn't matter which one the multiple procedure reduction was put on. Some plans want the 51 on additional CPT no matter what. A 50 wouldn't be correct on this one because it is once per digit and this is not a "paired" body part like knees, eyes, hips. If you look up the CPT on the CMS fee schedule it has a bilateral indicator of 0 meaning: “0" indicates a unilateral code; modifier 50 is not billable. Modifier 50 cannot be appended when bilateral indicators are 0, 2, 3 or 9.

Modifier 50 Fact Sheet

www.novitas-solutions.com

 

[podcoder70]

Most payers including Medicare add the 51 modifier as a system edit. It generally does not affect the claim. (There are some Medicaid exceptions) While 11750 can be billed bilaterally, the 50 modifier does not apply as the T modifier is required for payment and so should be coded on separate lines. As to your previous question, the code is defined as "excision of nail and nail matrix, partial or complete for permanent removal" and the word "matrix" would be advised in the document as well as "permanent".