“I have a question concerning Medicare’s rules when billing for repeat CPT 11750. What is the recommendation for billing these for a regrowth following a previous CPT 11750? In another scenario, on the same subject, what if the procedure needs to be performed on a nail border that is adjacent to one that was already billed? Can and should we use an ABN and upon denial, bill the patient?”
CPT code 11730: Avulsion of nail plate, partial or complete, simple; single
CPT code 11732: Avulsion of nail plate, partial or complete, simple; each additional nail plate (list separately in addition to code for primary procedure)
CPT code 11750: Excision of nail and nail matrix, partial or complete (eg, , for permanent removal)
First, let’s take a look at the rules that were put into place on June 6, 2022, by CMS/Medicare with respect to CPT 11730 and CPT 11750:
The rule changes are the following: Sources of information – L33833 – Surgical Treatment of Nails, A57666 – Billing and Coding: Surgical Treatment of Nails
Utilization Parameters:
CPT 11730 and CPT 11732 for nail avulsion will be denied if billed for the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT 11750 for nail excision permanent removal will be denied if billed for the same toe following a previous excision.
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:
All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
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.
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.
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).
This has the potential to be a major pain in the butt. However, CMS has modified its new policy regarding specifically CPT 11730 and CPT 11750.
For a reasonable and necessary repeat nail avulsion on the same toe less than 8 months (32 weeks) following a previous avulsion, the KX modifier must be appended to the claim (Requirements specified in the medical record have been met). The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated.
For a reasonable and necessary, repeat nail excision on the same toe, report modifier KX (Requirements specified in the medical record have been met). The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border previously treated.
KX Modifier: Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service.
The bottom line is that an Advanced Beneficiary Notice of Non-coverage for CPT codes 11730 and 11750 is NOT needed.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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