New Rules for CPT Codes 11730 and 11750

Utilization Parameters

1. 1. CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
2. 2. CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision.
3. 3. A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

Documentation Requirements

1. 1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. 4. The following information must be clearly documented in the patient’s medical record:
   •      • Complete detailed description of the pre-operative findings. Include the patient’s symptoms, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale why surgical treatment is being selected over other treatment options.
   •      • Method of obtaining anesthesia (if not used, the reason for not using it).
   •      • A complete detailed description of the procedure performed.
   •      • Identify the specific digit(s) and make note to the nail margin(s) involved on which the procedure was performed.
   •      • Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).
   •      • Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).

Sources of information: MCD (Medicare Coverage Database):

LCDs                                                  
L33833 - Surgical Treatment of Nails 

Articles
A57666 - Billing and Coding: Surgical Treatment of Nails 

Michael G. Warshaw

DPM, CPC