Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27532

Surgical Treatment of Nails

L27532

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

An ingrown nail is a condition which results in the growth of the nail edge into the surrounding soft tissue that may result in pain, inflammation, or infection. This condition most commonly occurs in the great toes and may require surgical management. Other conditions may also require avulsion of part or all of the nail. This policy addresses those conditions under which Medicare payment for nail avulsion may be made.

Treatment of simple uncomplicated or asymptomatic ingrowing nail by removal of the offending nail spicule, not requiring local anesthesia, is considered to be routine foot care. Trimming, cutting, clipping, and debriding of a nail distal to the eponychium are also considered routine foot care. Routine foot care is only covered when certain systemic conditions are present. Routine foot care should NOT be coded with 11730/11732 but rather with G0127 and 11719-11721 Please review LCDs Coverage Requirements for Routine Foot Care and Debridement of Mycotic Nails for additional information.

Avulsion of a nail plate (CPT codes 11730 and 11732) is, generally, performed under local anesthesia. This procedure involves the separation and removal of a border of the nail or removal of the entire nail from the nail bed to the eponychium.

Excision of nail and nail matrix (CPT code 11750) is performed under local anesthesia and requires removal of part or all of the nail along its length, with destruction or permanent removal of the matrix (e.g., chemical/surgical matrixectomy).

Wedge excision of skin of nail fold (CPT code 11765) is designed to relieve pressure on the nail/soft tissue and requires an excision of a wedge of the soft tissue and ingrown nail from the involved side of the toe.

Indications

Surgical treatment of nails is covered for the following indications:

• Ingrown toenails

• Paronychia

• Subungal abscess

• Onychogryposis or onychauxis

• Contusion injury of the fingers or toes

• Crushing injury of the fingers or toes

Nail avulsions usually offer only temporary relief for ingrown toenails. The nail often grows back to its original thickness and the offending margin again may become problematic, resulting in another nail avulsion. Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails. When a nail avulsion is done, another avulsion should not be required for at least 12 weeks.

Limitations

The following indications are non-covered because they are considered routine foot care:

• Cutting small chips

• Excising less than the full length of the affected nail
  
  
• Simple treatment of ingrown toenails (e.g., trimming, cutting, clipping of the distal unattached nail margins)

Foot Care, Surgical Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Surgical treatment of toenails, in general, requires the use of local anesthesia. The medical record must indicate the anesthesia used (digital, local or topical). If digital or local anesthesia is not used, it must be clear, in the medical record, why (e.g., "patient requested topical anesthesia", "patient allergic to lidocaine", etc.).
   
   
5. It is inappropriate to state "no anesthesia used due to a possible anesthetic reaction" without indicating the patient's allergies in the medical record.
   
   
6. For procedure codes 11730, 11732, 11750, 11765 an operative report or complete detailed description of the procedure being performed is required. Documentation must support the medical necessity and the frequency of the service. Failure to include the following information in the patient's medical record could result in denial of the claim.

• The patient's chief complaint (e.g., painful toe)
• Procedure being performed (making note to the nail margin involved)
• Method of obtaining anesthesia (if not used, the reason for not using it)
• A complete detailed description of the procedure
• Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied)
• Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments)

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Services performed more often than every 12 weeks are considered to be not medically reasonable and necessary.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27532

05/22/2008

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