11/24/2014    Robert Vranes, DPM

Abuse of CPT 11755 (Nail Unit Biopsies)

In my 38 year professional career, which has
included a number of years as Chairman of the
Insurance Committee of the Texas Podiatric Medical
Association and eleven years in a large, group
practice, I have seen my share of abusive billing
practices. 5 The use of CPT 11755 (nail unit
biopsy) rises to the top of the list. I just
reviewed a Medicare report by the esteemed Dr.
Paul Kinberg who cited that 3,991 such procedures
were billed to Texas Medicare in 2013 by Texas
DPMs.

A biopsy is classified as a (diagnostic) procedure
because it carries and element of risk, such as
bleeding or infection. It typically requires the
use of a local anesthetic, with rare exception.
Procedures are assigned Relative Value Units.
Allow me to quote some relevant RVU comparisons:
G0126 Trimming of nails (0.65 RVU); 11720 Debride
mycotic nails, 5 or more (0.91); 11730 Debride
mycotic nails, 6 or more (1.26); and then comes
11755 nail unit biopsy @ 3.76 RVUs.

I challenge anyone who contends that the
submission to pathology of nail clippings and/or
nail bed scrapings, for the purpose of diagnosis
nail fungus, by whatever testing means ordered,
constitutes a nail unit biopsy.

In 2004, the American Medical Association
published the following: "A nail unity biopsy may
be performed to evaluate for neoplasia involving
the structures of the nail unit. A nail avulsion
(11730) may not be submitted with a nail unit
biopsy. Submission of nail clippings and/or nail
bed scrapings do NOT constitute a nail unit
biopsy. These activities are part of E&M services
involving the medical management of the nail
condition. When medically appropriate, nail
trimming and/or nail debridement should be
indicated with the specific codes." (American
Medical Association, CPT Assistant, October 04:1-
4)

The CPT manual defines the nail unit as the plate,
bed, matrix, hyponychium, proximal AND (my
emphasis) lateral nail folds. It is not an a la
carte submission of tissue. And you better have a
detailed pathology report to back you up. If the
pathology report simply references submission of
nail clippings and/or nail bed scraping, you did
not perform a nail unit biopsy. What you submitted
was akin to swabbing an open wound to submit for
culture and sensitivity studies. Furthermore, if
you read the dermatology blogs, you will see that
dermatologists are upset at the low RVUs assigned
to 11755 compared to 11750 nail ablation @ 6.30
RVUs.

My dear brothers and sisters, if you have been
abusing 11755 in the manner described above, I
urge you to identify those cases and make refunds
to insurance as soon as possible. Most will accept
your refund check with no questions asked
including Medicare. However, if you are identified
as an abusive biller, Medicare can fine you $5,000
- $11,000 per incident in addition to whatever
other penalties it deems appropriate. The small
print in the Obamacare law now gives Medicare the
right to approach private insurance carriers so
that they may engage in recovery of abusive
billing practices.

Robert Vranes, DPM, San Antonio, TX

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11/28/2014    Bryan C Markinson, DPM

Abuse of CPT 11755 (Nail Unit Biopsies)

Dr. Vranes assessment of the use of code 11755 for
the evaluation of dystrophic nails as abusive
deserves a closer look. The reason for this is
that poor definition of the code by AMA does not
necessarily equate to abuse if the code is used.
In fact, this code has been subject to controversy
for years simply because as written, it is subject
to wide differences in interpretation.

For the record, I have advised colleagues to stay
away from the code in evaluation of dystrophic
nails, especially if it is not used with the
intention to treat onychomycosis and just merely
to support the diagnosis for mechanical
debridement only. I also agree with Dr. Vranes
that the code is abused, but for different
reasons. Although I do not share Dr. Vrane's
clarity on the subject, I do object to the use of
the code when there is no intent to treat the
infection with FDA-approved agents.

Dr. Vranes states that "A biopsy is classified as
a (diagnostic) procedure because it carries and
element of risk, such as bleeding or infection."
This is only an opinion. Dermatologists scrape
things off of foreheads all day long with no risk
of bleeding or infection and bill for biopsy.
Having said that, when I take a sample or
evaluation of a dystrophic nail, I take an
aggressive piece of nail plate AND nail bed tissue
specimen which often results in bleeding. Dr.
Vranes goes on to say "It typically requires the
use of a local anesthetic, with rare exception."
This too is an opinion.

There is nothing in the code descriptor requiring
anesthesia. For codes 11100 (no anesthesia
required) and CPT11300 shave biopsy series of
codes (anesthesia required), the AMA is very
specific about when anesthesia is required. Since
the descriptor for CPT 11755 makes no mention of
anesthesia, it is not unreasonable for any
practitioner to assume it is not required. Dr.
Vranes is correct about the statement that "The
CPT manual defines the nail unit as the plate,
bed, matrix, hyponychium, proximal AND (my
emphasis) lateral nail folds, " but his
interpretation that "It is not an a la carte
submission of tissue" is not supported on clinical
grounds.

I can biopsy a pigmented lesion of the proximal
nail matrix requiring anesthesia and reflection of
the proximal nail fold to rule out melanoma
without touching the medial or lateral nail folds.
The assumption that the code requires all parts of
the nail unit to be included (as asserted by Dr.
Vranes) is NOT at all clear simply because the
descriptor defines all the elements that make up
the nail unit.

Likewise, I can ellipse out a lesion from the nail
bed which may be malignant without touching the
matrix or folds. The assumption that a nail unit
biopsy must include all this tissue is patently
ridiculous. Repeating, these differences in
interpretation reflect a severe weakness in the
description of the code, but before I would march
my colleagues down the plank with the label
"abusive." I would petition the coding committee
to seek definitive clarification, from the AMA.

Bryan C Markinson, DPM