Documentation Requirements for CPT 11721

I am trying to educate my physician about the documentation requirements for CPT code 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?

There are two different sets of coverage criteria for the documentation requirements for CPT 11721: Debridement of nail(s) by any method(s); 6 or more. They are the following:

Routine Foot Care Exception aka “At Risk,” Routine Foot Care

1. Class Findings 
2. Systemic Disease
3. Mycotic/Fungal Toenails 
4. The Mycotic Toenails DO NOT Have to be Symptomatic

Otherwise Healthy Individual

1. No Class Findings
2. No Systemic Disease
3. Mycotic/Fungal Nails
4. Symptomatology (ie. a marked limiting of walking due to the thickness of the fungus nail, pain due to the thickness of the fungus nail, a secondary infection due to the thickness of  the fungus nail)

With respect to the above post, although the issues posted relate to both sets of coverage criteria, I feel that it is important to concentrate on the documentation requirements for the “Otherwise Healthy Individual.” Medicare requires adequate documentation to allow payment for mycotic nail services. Clearly indicate in your medical record the following information: This must be documented for EACH of the affected toenails.

1. PAIN and/or
2. SECONDARY INFECTION and/or
3. MARKED LIMITATION OF AMBULATION and
4. CLINICAL FINDINGS INDICATION THE FUNGUS INFECTION (ie. Thickness Coloration, Odor, Texture, Subungal debris)
5. ACTIVE TREATMENT PLAN

Furthermore:

1. All of the affected toenails need to be identified
2. A Thorough description of the fungal infection needs to be documented for ALL of the affected toenails in question
3. The secondary, qualifying diagnosis (i.e. pain, difficulty with ambulation, secondary infection) needs to be documented for ALL of the affected toenails in question
4. The instrumentation used needs to be documented
5. The word DEBRIDEMENT needs to be used

Hard copy proof? The best way to find the above documentation criteria in writing is to go on the website of your Medicare Administrative Carrier and access the Local Coverage Determination (ie. LCD) and the associated article specific for coding and billing for the Debridement of Nails or the Debridement of Mycotic Nails. Unfortunately, not all of the Medicare Administrative Carriers have this LCD. However, since all Medicare Administrative Carriers share information, I am providing you with a Medicare Administrative Carrier that does have this information. The Medicare Administrative Carrier is Novitas. The LCD is L35013– Debridement of Mycotic Nails and the associated article is A56640 – Billing and Coding: Debridement of Mycotic Nails.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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