This LCD describes conditions under which the coverage of nail avulsion/excision may be considered.
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.
The surgical treatment of ingrown nails is considered to be medically appropriate and reasonable for an ingrown toenail in the advanced stage in which the lateral nail fold bulges over the nail plate causing erythema, edema, and tenderness, and granulation of the epithelium inhibits serous drainage and precludes any chance of elevating the nail edge from the dermis of the lateral skin fold.
Treatment of simple uncomplicated or asymptomatic ingrown nail such as removal of a nail spicule may be 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. (Refer to LCD: Routine Foot Care).
The following surgical procedures represent the options used to treat a complicated/symptomatic ingrown 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 (unless the digit is devoid of sensation, which should be documented) 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 code 11765).
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.
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.
• Complicated wounds of the toes involving nail components.
• Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.
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.
Removal of nail plate
Removal of nail plate, add-on
Removal of nail bed - Average fee payment $190
Excision of nail fold, toe
Cellulitis and abscess of finger, unspecified
Onychia and paronychia of the finger
Cellulitis and abscess of toe
Cellulitis and abscess of unspecified digit
Leukonychia, onychauxis, onychogryposis, onycholysis
Other specified anomalies of nails
Open wound of finger(s)
Open wound of the toe
Contusion of fingernail
Contusion of toe nail
Crushing injury of finger(s)
Crushing injury of toe(s)
Burn of lower limb (including toe and nail unit), third degree
Burn of lower limb (including toe and nail unit), deep third degree without mention of loss of body part