Routine Foot Care, which includes trimming or debridement of the asymptomatic dystrophic, mycotic, or normal toenails is covered by Medicare only when the patient has one of the Medicare-specified systemic diseases with a clinically significant peripheral complication placing the patient “at risk” for infection and/or injury if a non-professional attempts to trim or debride the nail. However, when the nail becomes ingrown, and the surrounding soft tissue is complicated by pain or inflammation, then its care is no longer “routine” but involves a pathological state. This state is characterized by one or more of the following: pain, inflammation of the nail bed, inflammation of the surrounding soft tissue, infection and/or abscess.
TREATMENT:
The provider may, according to the presenting pathology, elect to treat the patient with medication and corrective measures to remove the cause or may elect to treat the nail and surrounding soft tissue surgically. This treatment may include debridement, resection, avulsion, excision, incision and drainage of a paronychia or matrixectomy.
The provider may elect to use incision and drainage of a paronychia or abscess, avulsion or resection of a nail, or destruction of the nail matrix if trimming or debridement is not, in the medical judgment of the provider, sufficient to treat the nail problem. Medicare Administrative Contractors/ MACs will not allow payment for both debridement and one of the other procedures on the same nail billed on the same date of service.
CPT codes 11720 or 11721 for surgical debridement are only for severely deformed or diseased nails that are documented in the medical record as the cause of the symptoms present.
If the nail is found to be clinically normal or merely dystrophic, but the surrounding soft tissue is inflamed, infected and/or painful as direct results of irritation from the essentially normal nail structure, the trimming or partial resection of the offending portion of the nail is a reasonable and necessary adjunct in the management of the periungual symptom. This is NOT considered to be a partial nail avulsion.
The trimming and/or resection of the offending portion of the nail are considered routine and not payable (based on Medicare guidelines). The examination, assessment and nonsurgical management of the symptomatic conditions may be covered as an E/M service.
The level of EM coding is dependent upon the documented conditions found and the circumstances surrounding the symptoms. The Medical Record should specify the location of the symptoms, evidence of any drainage, description of the symptoms, and document the medical management. The treatment’s medical reasonableness and necessity should be clearly evident within the Medical Record.
The potential for abuse is present, and Medicare Administrative Contractors are directed to take appropriate measures to ensure compliance with Medicare policy.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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