“I need some clarification on the proper coding for a paronychia on an established patient office visit. I’ve received mixed advice over the last year or so. Anything from CPT 10060 alone, to adding CPT 64450 and CPT 99212. I just want to be correct.”
There are essentially two ways to treat a paronychia, surgically and medically. I am assuming that the patient is being treated procedurally or surgically on this encounter. The primary surgical procedure that is performed to resolve a paronychia is a nail avulsion, usually a partial nail avulsion. The CPT code that is used to bill for a nail avulsion is CPT code 11730 which is defined as: Avulsion of nail plate, partial or complete, simple. Unless the patient has peripheral neuropathy or a neurological disorder where they feel no pain, the affected toe needs to be injected or blocked with a local anesthetic.
Despite the fact that a local anesthetic is administered, it is not appropriate to bill CPT code 64450 for the injection of the affected toe. It is included in the procedure. CPT code 64450 is defined as: Injection anesthetic agent(s) and/or steroid; other peripheral nerve or branch. CPT code 64450 is quite unique. When the CCI edits are accessed, CPT code 64450 is a Column 2 code to every other CPT code. Therefore, it is NEVER appropriate to bill CPT code 64450 in conjunction with ANY other CPT code.
What about CPT code 10060? It is defined as: Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. It is conceivable that a paronychia is so serious that an abscess has developed at the site of the paronychia. If the abscess is treated by performing a nail avulsion, CPT code 10060 CANNOT be billed. Why? Think about it for a second. An incision and drainage of the abscess was not performed. Yes, the abscess was treated, but what was actually performed was in all likelihood a partial nail avulsion and that is what needs to be billed. CPT code 11730.
However, if a partial nail avulsion was not performed and the paronychia that has developed into an abscess is INCISED AND DRAINED, then it would be appropriate to bill CPT code 10060. It would probably be a good idea to submit a sample of the “drainage” to your pathology lab of choice so that a Culture and Sensitivity can be performed to not only disclosed the appropriate antibiotic to place the patient on, but more importantly, to prove that the incision and drainage was in fact performed.
Lastly, what about whether or not to bill for an E/M code in addition to the appropriate CPT/procedure code? This patient is clearly an established patient. If an established patient is seen for a NEW problem that has never been evaluated for previously (ie. never mentioned, never examined, never treated) and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service and the diagnosis code for the minor surgical procedure can be the SAME. In the posted scenario, assuming that within the medical record documentation, the History is Expanded Problem Focused and/or the Examination is Expanded Problem Focused and clearly the Medical Decision Making is of Low Complexity, it would be appropriate to bill CPT 99213. Of course, this would be appended by the 25 modifier to indicate a significant, separately identifiable E/M service. Either CPT code 11730 or 10060 would follow on the second line appended by the correct toe modifier.
This is my opinion.
Dr. Michael G. Warshaw
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