“Can a dystrophic nail trim be coded without using Routine Foot Care rules?
For example, there is a patient with dementia whose dystrophic nails had grown so long that they were causing pain. The patient would only allow a professional to trim them. The nails were documented as dystrophic rather than fungal, so we couldn't bill 11721. The patient also had no systemic conditions. The podiatrist billed G0127 and 99203. What are your thoughts on using G0127 or a similar code in this situation? An Advanced Beneficiary Notice of Non-Coverage (ie. ABN) was not obtained.”
HCPCS Level II code G0127 is defined as the following: Trimming of dystrophic nails, any number. When you access the LCD and the associated article for billing and coding for Debridement of Mycotic Nails, HCPCS Level II code G0127 is not mentioned. When you access the LCD and the associated article for Billing and Coding for Routine Foot Care, HCPCS Level II code G0127 is present. Therefore, it is only reimbursable if the patient has a covered systemic disease and Class findings. The most appropriate ICD-10-CM codes for G0127 are L60.2 (Onychogryphosis, hypertrophic nails) and L60.3 (nail dystrophy).
In your example, the patient has dementia and painful, dystrophic toenails. The patient requires a professional to trim the toenails. Clearly, since the toenails are dystrophic as opposed to mycotic, CPT code 11721 is not appropriate. Since the patient does not have a qualifying systemic disease, G0127 is not appropriate and cannot be billed. Class findings at this point are moot. The patient should have signed an Advanced Beneficiary Notice of Non-Coverage, and the service should have been paid out of pocket.
Even though the service being provided is statutorily non-covered, the signed Advanced Beneficiary Notice of Non-Coverage is the only hard copy proof that you have in your possession that the patient was informed in advance of service that the service being provided is not covered, why it is not covered and how much needs to be paid out of pocket for the service. This is crucial in the event that the patient appeals the fact that they paid for the service and should have been covered.
E/M code 99203 was also billed which is defined as the following: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30 minutes of total time is spent on the date of the encounter. This must be met or exceeded. Based upon the fact that the patient does not have mycotic toenails, does not have a covered systemic disease and does not have Class Findings, without seeing the medical record, it would be difficult to justify a low level of medical decision making. I believe that 99202 would be more justifiable as the medical decision making is straightforward especially since the nail trimming is reimbursable out of pocket.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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