Nail Biopsy and How is CPT Code 11755 Billed Correctly

I need to understand what exactly is a nail biopsy and how is CPT code 11755 billed correctly?

CPT Code 11755

• • It is amazing to me how often this CPT code is misused and abused.
•  • There seems to be a common denominator among a number of providers. They look at the numbers and don't read the words. What do I mean by this?
• • The CPT code is accessed and then it is determined what this particular CPT code reimburses when it is billed. The definition or description of the CPT code is either ignored, glossed over or "interpreted."
•  • CPT description or definition of 11755 is the following: Biopsy of nail unit (eg. plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure). There is nothing within this definition to indicate that obtaining "nail clippings" and submitting them to pathology demonstrates that a "biopsy of a nail unit" was performed and it is appropriate to bill CPT code 11755.

CPT Assistant, October, 2004

• • The article states that CPT code 11755 "is not intended to be reported when obtaining nail clippings or nail scrapings for purposes of performing a fungal culture, KOH preparation, stain or test, or PAS stain.
•  • These activities are part of an evaluation and management visit involving the medical management of the nail condition.
• • When medically appropriate, nail trimming and/or nail debridement services should be indicated with the specific codes."

What is the biopsy of a nail unit?

• • When you look at the CPT description, it appears to be quite inclusive.
• • Once again in order to obtain clarity, CPT Assistant needs to be accessed

CPT Assistant, December 2002

• • The article states that ''The nail plate and nail bed may be biopsied using one of several techniques.
•  • A small punch may be used to obtain a tissue sample. The punch is placed on the nail plate and pushed down through the plate and into the nail bed. The punch is removed and the specimen is gently pried out of the hole with a small needle and then cut out with scissors.
• • For larger biopsies, a longitudinal incision is made over the affected area with a scalpel and extended down to the periosteum. The specimen is removed and the wound is closed with sutures.
• • When the nail matrix is biopsied, short longitudinal incisions may be made on either side of the proximal nail fold in line with the lateral nail folds. The tissue is elevated and lifted off the proximal nail plate, a portion of which is removed for access to the nail matrix. A punch or scalpel is used to remove the biopsy specimen. The wound is closed with sutures."

By the way, if the toenail is avulsed to gain access to the targeted area, CPT code 11730 is a Column 2 code to CPT code 11755 the Column 1 code within the CCI edits and is not separately reimbursable.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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