Mycotic Nail Debridement in the Otherwise Healthy Individual
1. This patient does not qualify for “At Risk,” Routine Foot Care.
2. There are no Class Findings.
3. There is not a covered Systemic Disease.
4. There are mycotic/Fungal toenails.
5. The fungal toenails in question are symptomatic.
IMPORTANT:
UNLESS THE FUNGUS INFECTION IN A NAIL REQUIRES DEBRIDEMENT BECAUSE IT CAUSED THE NAIL TO BE ABNORMALLY THICK WHICH RESULTED IN EITHER PAIN OR A SECONDARY INFECTION OR A MARKED LIMITATION OF WALKING, THE TREATMENT SERVICE IS CONSIDERED SIMPLY A NAIL TRIMMING AND IS NOT PAYABLE BY MEDICARE.
MYCOTIC NAIL SERVICES ARE PAYABLE IF…..
FOR AN AMBULATORY PATIENT:
The Patient must have a marked limiting of walking due to the thickness of the fungus nail
OR
The Patient must suffer from pain due to the thickness of the fungus nail. This is based upon the physical examination of the treating physician.
OR The Patient must suffer from a secondary infection due to the thickness of the fungus nail
AND
There must be documented clinical findings to substantiate the fungus diagnosis. This needs to be clearly documented per each affected toenail in question.
FOR A NON-AMBULATORY PATIENT:
The Patient must suffer from pain due to the thickness of the fungus nail. This is based upon the physical examination of the treating physician.
OR The Patient must suffer from a secondary infection due to the thickness of the fungus nail
AND
There must be documented clinical findings to substantiate the fungus diagnosis. This needs to be clearly documented per each affected toenail in question.
INCLUDE THE FOLLOWING IN YOUR MEDICAL RECORD:
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
Are the nails thick?
Are the nails discolored? What is the discoloration?
What is the texture of the nails? Are the nails crumbling, cracking, splitting, scaling?
Is there subungual debris present?
ACTIVE TRETMENT PLAN:
1. Rx oral medication
2.Rx or OTC topical medication
3.General treatment plan for onychomycosis: The patient was instructed to keep his/her feet clean, dry between the toes, change the socks/hose and footwear daily and apply a topical antifungal medication to the affected toenails on a regular basis.
How to Bill Medicare for Mycotic Nail Services in the Otherwise Healthy Individual:
If the patient’s condition meets the published, very specific, limitations for payment for Fungus Nail services, Medicare can be billed by using either 11720 or 11721. The 11720 code is used for debridement of 1, 2, 3, 4, or 5 nails by any method. The 11721 code is used for debridement of 6 or more nails by any method. These codes are considered appropriate only for the surgical debridement of markedly thickened nails that require debridement to a more normal thickness.
NOTE: CPT code 11721 is being looked at very, carefully by the Medicare Administrative Carriers for mycotic toenail debridement in the otherwise healthy individual for inappropriate use of this CPT code.
INCLUDE THE FOLLOWING ON THE BILLING CLAIM FORM:
The Primary Mycotic Diagnosis (ICD-10-CM Code) in Block 21 line 1
The Secondary Condition Diagnosis (ICD-10-CM code) in Block 21 line2
Use either 11720 or 11721 in Block 24d as appropriate
PRIMARY DIAGNOSIS: B35.1 Tinea pedis
SECONDARY DIAGNOSIS:
R26.2 Difficulty walking, not elsewhere classified
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
L03.031 Cellulitis of right toe(s)
L03.032 Cellulitis of left toe (s)
*L03.031 and L03.032 are the crosswalks for paronychia
IMPORTANT DOCUMENTATION FOR MYCOTIC TOENAILS
1. All of the affected toenails need to be identified
2. A through 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
This is my opinion.
Michael G. Warshaw
DPM, CPC
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