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 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 of Nails that cause Symptomatic Conditions
The provider may, according to the presenting pathology may 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 level of EM coding is dependent upon the documented condition(s) found and 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 reasonableness and necessity should be clearly evident within the Medical Record.
This is my opinion.
Michael G. Warshaw
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