Nail Avulsion CPT code 11730 ,11732, 11750, 11765

An ingrown nail is 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 a nail. This policy describes 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 as are other trimming, cutting, clipping and debriding of a nail distal to the eponychium. Routine foot care is covered only when certain systemic conditions are present. Payment conditions for routine foot care are described in the TrailBlazer LCD “Routine Foot Care – 4P-11AB.”

The following surgical procedures represent the options used to treat complicated/symptomatic ingrowing nail(s):

• Avulsion of a nail (CPT codes 11730 and 11732) involving separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium). A nail avulsion usually requires injected local anesthesia except in instances wherein the digit is devoid of sensation or there are other extenuating circumstances for which injectable anesthesia is not required or is medically contraindicated.
• Excision of the nail and the nail matrix (CPT code 11750) performed under local anesthesia requiring separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium) followed by destruction or permanent removal of the associated nail matrix.
• Wedge excision of the nail fold hypertrophic granulation tissue with removal of the offending portion of the nail (CPT procedure code 11765).

Regrowth of the nail usually requires at least four months. With appropriate surgical management and instruction for proper shoes and nail care, the problem of ingrowing nails should not recur.

The surgical treatment of nails is also covered for the following indications:

• Subungal abscess.
• Contusion injuries of nails.
• Crushing injuries of the toes.
• Crushing injuries of the fingers.
• Paronychia.
• Complicated wounds of the toes involving nail components.
• Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

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.

12X, 13X, 21X, 22X, 23X, 71X, 75X, 85X

Revenue Codes

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.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance.

0450, 050X, 051X, 052X, 0761

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
11730©	Removal of nail plate
11732©	Removal of nail plate, add-on
11750©	Removal of nail bed
11765©	Excision of nail fold, toe

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 11730, 11732, 11750 and 11765:

Covered for:

681.00	Cellulitis and abscess of finger, unspecified
681.02	Onychia and paronychia of the finger
681.10–681.11	Cellulitis and abscess of toe
681.9	Cellulitis and abscess of unspecified digit
696.1	Psoriasis, nail
703.0	Ingrowing nail
703.8	Leukonychia, onychauxis, onychogryposis, onycholysis
757.5	Other specified anomalies of nails
883.0–883.2	Open wound of finger(s)
893.0–893.2	Open wound of the toe
923.3	Contusion of fingernail
924.3	Contusion of toe nail
927.3	Crushing injury of finger(s)
928.3	Crushing injury of toe(s)
945.31	Burn of lower limb (including toe and nail unit), third degree
945.41	Burn of lower limb (including toe and nail unit), deep third degree without mention of loss of body part

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity

N/A

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

• If another service is provided along with the avulsion, full documentation of the medical need for the service and description of the procedure must be recorded in the patient’s file.
• The following information should be included in the patient’s medical record (in the operative note or in progress notes related to a recent/contemporaneous/subsequent E/M encounter):

• The patient’s primary symptoms and previous treatment (if any) and description of the nail(s) at the time of avulsion services.
• A complete detailed description of the procedure performed including exact portion of nail removed.
• Type and quantity of local anesthetic agent used. If injectable anesthesia was not used, the reason must be clearly documented in the patient’s medical record.
• Post-operative instructions and any follow-up care (such as use of soaks, proper shoes and nail care, to prevent recurrences, antibiotics and follow-up appointments).

Appendices

N/A

Utilization Guidelines

• Both avulsion and routine trimming/debridement will not be allowed on the same nail on the same day.
• Medicare will allow ten services per beneficiary per 24 months for CPT codes 11730 and/or 11732. Payment for services beyond this number will require medical review of patient records to determine medical necessity.
• Medicare payment for CPT codes 11730 and 11732 in places of service other than hospitals or ambulatory surgical centers is limited to 5 services (one of 11730 and 4 of 11732) per day.

Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.