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Documentation of Nail Debridement

SUEV

Guru
Local Chapter Officer
Messages
202
Best answers
0
My provider wants to know what documentation supports 11720 or 11721. Per LCD L3176 "Simple trimming of the end of the toenails by cutting or grinding is not considered debridement". What do others see documented? Are the tops and sides of the nail supposed to be debrided also to meet the LCD requirements? Any insight would be appreciated.
Thanks,
Sue
 

espressoguy

Expert
Messages
406
Location
Tacoma, WA
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Here are notes from an encounter one of my providers submitted today:

Complaint: Patient presents for at risk nail care. Unable to render adequate care. Pain with ambulation and worse with shoes.
...

Exam: Nails are elongated, discolored, dystrophic and thickened x 10. Subungual debris present to all nails. Clinical onychomycosis present. Class findings B1 and B3

Impression:
1. Type II or unspecified type diabetes mellitus without mention of complication, not stated as uncontrolled
2. Dermatophytosis of nail

Plan: Debrided mycotic nails by 10. No insult to the skin. Discussed proper care for the at risk foot. Recommend follow up for continued at risk foot care in 9-12 weeks.
 

SUEV

Guru
Local Chapter Officer
Messages
202
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0
"Debrided"

Thanks for your replies!

I was able to find a clinical vignette from CPT Assistant that describes what 11720 entails so I passed that on to my provider.
 
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