Updates Regarding CPT codes 11730 and 11750

First, let’s take a look at the rules that were put into place on June 6, 2022, by CMS/Medicare with respect to CPT 11730 and CPT 11750:
The rule changes are the following: Sources of information – L33833 – Surgical Treatment of Nails, A57666 – Billing and Coding: Surgical Treatment of Nails
Utilization Parameters

1. 1. CPT 11730 and CPT 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
2. 2. CPT 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision.
3. 3. A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

Documentation Requirements

1. 1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
2. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. 4. The following information must be clearly documented in the patient’s medical record:
5.      o Complete detailed description of the pre-operative findings. Include the patient’s symptoms, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale why surgical treatment is being selected over other treatment options.
6.      o Method of obtaining anesthesia (if not used, the reason for not using it).
7.      o A complete detailed description of the procedure performed.
8.      o Identify the specific digit(s) and make note to the nail margin(s) involved on which the procedure was performed.
9.      o Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).
10.      o Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).

This has the potential to be a major pain in the butt. However, CMS has modified its new policy regarding specifically CPT 11750, Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal. Two of the Medicare Administrative Carriers, First Coast Service Options and Novitas have modified and updated their respective LCDs and the associated articles for Coding and Billing for the Surgical Treatment of Nails. A rejected claim for CPT 11750 no longer needs to be resubmitted to the Medicare Administrative Carrier for Redetermination. Providers have been instructed to append modifier KX for a medically reasonable and necessary repeat nail excision (CPT 11750) on the same toe. The KX modifier is defined as the following: DOCUMENTATION ON FILE – Use this Medicare modifier to indicate that specific documentation is contained in the medical record in order to justify the billed service. In this situation, the medical record must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. The documentation requirements are posted above. The use of the KX modifier only applies to CPT 11750.

With respect to CPT 11730 and CPT 11732, A medically reasonable and necessary repeat CPT 11730 / CPT 11732 of the same nail within 32 weeks of a previous avulsion will be considered upon Redetermination. The use of the KX modifier does not apply to repeat procedures/billing of CPT 11730 and CPT 11732. If the avulsion is performed on the opposite nail border or is there is new significant pathology on the same nail border that is specifically documented within the medical record, this would justify going through the Redetermination process.

An Advanced Beneficiary Notice of Non-coverage (ABN) is really not needed as long as the justification for performing the repeat procedure meets the guidelines as stated above. In reality, why else would a repeat matrixectomy or avulsion need to be performed on the same toe? Think about this question for a moment before answering.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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