Wiki Toenail excision

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G282019

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What is the proper documentation that needs to be done by the provider to be able to charge 11750 excision of nail and nail matrix partial or complete, for permanent removal?
As my provider has a template that he follows for example:

consent was signed: yes
complications discussed: yes
timed out procedure was observed: yes
Anesthesia: Lidocaine 1% lidocaine digital nerve block
Ingrown nail elevated and excised back to the nail matix: yes (using hemostat)
Excess granulation tissue debride:yes
Treated with phenol: no
Hemostasis assured: no
Blood loss: none
Complications: none

Let me know what you think or what else I should ask the provider to include in his notes as these to me seem very minimal.
Thanks
 
We look for the following type of documentation for a partial:

A nail elevator is inserted under the edge of the nail and the nail plate is freed

The new edge is identified and nail splitter is used to cut the nail straight back to the most proximal edge under the nail fold.

The severed piece of nail is grasped with a hemostat and removed by rotating the fragment outward

The nail matrix is destroyed using a electrode which is placed below the nail fold just above the nail bed.

Cautery is applied to the matrix and entire exposed nail bed. Any granulation tissue is also destroyed by electrocautery.

Antibiotic ointment and a dressing are applied.

Anesthesia method is noted: usually lidocaine

Any complications, blood loss, and discussion with the patient is also noted.


Note: A complete excision is performed in the same manner except that the entire nail is excised and the entire matrix is ablated with electrocautery.
 
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