Routine Foot Care, which includes trimming or debridement of the asymptomatic, dystrophic, mycotic, or normal toenails are covered by Medicare only when the patient has one of the Medicare-specified systemic diseases with clinically significant peripheral complications 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 of Nails that cause Symptomatic Conditions
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 Carriers/ MACs will not allow payment for both debridement and one of the other procedures on the same nail billed on the same day 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 management of the periungual symptom. This is NOT considered to be a partial nail avulsion.
The trimming and/or resection procedure are considered routine and not payable (based on Medicare limitations). The examination, assessment and nonsurgical management of the symptomatic conditions may be covered as an E/M service.
The trimming and/or resection procedure are considered routine and not payable (based on Medicare limitations). The examination, assessment and nonsurgical management of the symptomatic conditions may be covered as an E/M service.
Individual Medicare Carriers may have varying policies as to how to bill these services. Please refer to your individual carrier’s or MAC’s policy. The potential for abuse is present and carriers are directed to take appropriate measures to assure compliance with Medicare policy.
This is my opinion.
Michael G. Warshaw
DPM, CPC
GREAT NEWS!!!
THE 2023 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flashdrive formats. It has been completely updated including the 2023 E/M coding changes. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 3275
Read Comments