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03/06/2006    Charles F. Ross, DPM

Nail Avulsion

Query: Nail Avulsion


A new Medicare patient presented to the office
with a partially
avulsed, painful nail secondary to trauma. There
was mild rubor and
no exudate with the nail extremely loose. I
completely avulsed the
nail plate without anesthesia, with little to no
major effort or
pain reported.


My initial gut feeling would be to bill an
initial visit code (CPT
9920x) without any treatment code. Would I be
short changing myself
by not additionally billing a procedure (e.g.,
CPT 11730 - avulsion
of nail)? I wish to do what is most appropriate.


Charles F. Ross, DPM, Pittsfield, MA


Response: Most Medicare carriers have local
carrier determinations
(LCDs) in place that would not allow for billing
a nail avulsion
(CPT 11730) without injecting local anesthesia
(or evidence of an
anesthetic foot).


That being said, I agree with your "gut
reaction" and feel you would
be best served by billing CPT 9920x - initial
office visit - and any
reasonable and necessary follow-up visits, CPT
9921x.


Paul Kinberg, DPM, Dallas, TX


Additional responses can be found at
http://www.codingline.com


Other messages in this thread:


05/11/2006    Elliot Udell, DPM, Jeffrey Kass DPM

Nail Avulsion by Urea (Ray Brown, DPM)

RE: Nail Avulsion by Urea (Ray Brown, DPM)
From: Elliot Udell, DPM, Jeffrey Kass DPM


I have tried this method in the past and it does
work; however there
are problems. The patient has to leave it on for
a number of days
and this means no washing of the foot. Most
people will not truly
comply and thus the treatment tends to fail.


I have had better success with applying topical
Keralac gel bid
without occlusion. It contains a high
concentration of urea as well
as other ingredients. They now make it in a pen-
like applicator form
which is quite user-friendly. Another product
that I have had great
success with is called Onychol. It is derived
from citrus seeds. It
softens the nail, partially debrides it and
kills a great deal of
the fungi present.


Elliot Udell, DPM, Hicksville, NY,
Elliotu@aol.com


I have patients occlude the nail with a piece of
Saran wrap, cover
with a Band-aid overnight for one or two days. I
then have them come
back. The nail is usually very friable and soft
and most of the nail
if not all can be debrided away. In most of
these the purpose of the
urea is to make the debridement much easier. I
might perform such a
procedure on an older patient with poor
vascularity and feel a
traditional avulsion or even debridement might
be too traumatic.


I do not use this type of procedure to eliminate
fungus. While urea
may have some antifungal property, I don't feel
it would have a high
success rate to eliminate onychomycosis, at
least not in a thick
mycotic nail. I don't particularly find any of
the known topical
antifungals to be highly efficacious for that
matter in a very thick
nail. For mild to moderate cases of
onychomycosis, I think urea
compounds work just as well as the topical
antifungal medications.


Jeffrey Kass, DPM, Forest Hills, NY,
Jeffckass@aol.com


05/10/2006    Ray Brown, DPM

Nail avulsion by Urea

Query: Nail avulsion by Urea


Has anyone had success in removing mycotic
toenails with either 40%
or 50% urea ointment. I understand it can be
done by using urea
under occlusion. If yes, how are the nails
occluded specifically and
how long does it take? How successful is this
process in eliminating
the fungus.


Ray Brown, DPM Charlotte, NC,
raybrown@bellsouth.net


01/23/2006    Adrienne Sabin, DPM

Nail Avulsion in a Post-op Period

Query: Nail Avulsion in a Post-op Period


If a patient in 90-day global period for a right
foot bunion surgery requires a nail avulsion on
right great toe, how can this be billed?


Adrienne Sabin, DPM, San Jose, CA


Codingline Response: The nail avulsion has no
relationship to the bunion surgery performed
even if it is on the same foot. The billing for
the nail avulsion would be: CPT 11730-T5-79


Harry Goldsmith, DPM, Cerritos, CA


01/03/2005    Tammy Cox

Bilateral Nail Avulsions

Query: Bilateral Nail Avulsions


How do you properly code bilateral hallux nail
avulsions? We have billed the procedures several
ways, and have been getting denials recently. Is
the proper way to code these procedures:


- CPT 11730 (twice) with the correct "T" codes,
or
- CPT 11730 for the first and CPT 11732 for the
second avulsion, using the correct "T" codes on
each? We have tried billing both ways, as well
as with modifier "-59", but still are getting
denials.


Tammy Cox
Bremerton, WA


Codingline Response: My recommendation would be
your second choice:


CPT 11730- TA
CPT 11732-T5


You need to review your explanation of benefits
to see why these codes are being rejected. I
have noticed some insurance companies only will
pay for a "permanent' excision/destruction of a
matrixectomy, and not for performance of nail
avulsions.


Paul Kinberg, DPM
Dallas, TX


11/23/2004    Mark Sturge, DPM

Granuloma Excision – Nail Avulsion

Query: Granuloma Excision – Nail Avulsion


I recently saw a patient who presented a
neglected ingrown toenail with proud flesh and
granuloma. After administration of local
anesthesia, I performed a partial nail avulsion,
excised the fleshy border, and followed with
application of silver nitrate to the granuloma
base. I am considering coding the procedures as:
CPT 11730 (partial nail avulsion) and CPT 17250
(chemical cauterization of granulation, tissue
[proud flesh, sinus or fistula]


I cannot find CPT 17250 in the CCI edits for CPT
11730, so should I expect payment?
Since both are performed on the same toe, should
I use a "-51" modifier or "-59" modifier anyway?
I think "-51" is more appropriate in this case.
I would be linking ICD-9 681.11 (paronychia) and
ICD-9 686.1 (granuloma) to the procedure codes.


I saved the fleshy border specimen in
formaldehyde, and will send it to pathology, if
needed, to justify my reimbursement, as well as
cover myself and the patient.


Mark Sturge, DPM
Miami, FL


Codingline Response: You cannot separately bill
for both the nail avulsion (CPT 11730) and the
chemical cauterization of granuloma (CPT 17250)
performed on the same toe, same session.


The CPT parenthetical rule following the CPT
17250 listing states,


“17250 is not to be used with removal or
excision codes for the same lesion”


Plus, the Correct Coding Initiative (CCI) DOES
link and bundle these two codes together with
CPT 17250 being a component of the comprehensive
code, CPT 11730. While they can technically
be “unbundled” with a “-59” modifier,
again, “same toe, same session” procedures such
as these would normally be considered
reimbursable as a single code, CPT 11730.


As far as the need to send in a path specimen,
your primary reason for obtaining the specimen
and submitting it for study must be for
medically necessary determination/confirmation
of tissue type when any uncertainty exists. If
your primary reason for obtaining and submitting
a specimen is concern over evidencing tissue
removal for an insurance company, you may want
to think about taking close-up [patient
identified, dated, and measured] digital photos
of the specimen in situ and post-op.


Once the initial investment is made in a good
digital camera, there are hardly any ongoing
costs. If a question arises from an insurance
company, the photo is usually sufficient to
warrant its weight in “reimbursement” – whether
it helps evidence a code to be an independently
reimbursable procedure, or whether it helps
support reimbursement of a more comprehensive
procedure, or whether it serves as a visual
validation of clinical findings in the
submission of a claim for either an unlisted
procedure code or a “-22” modified code. Of
course, as a clinician, if you need the
information, a path report can be included to
confirm your suspicions and allow you to treat
in a more effective fashion, and then submit the
specimen at conclusion of the case.


Harry Goldsmith, DPM
Cerritos, CA


09/09/2003    Kristina Williams, DPM

Bilateral Margin Nail Avulsions

Query: Bilateral Margin Nail Avulsions


I read in one of our podiatry coding tip
resources that when performing partial avulsions
of both borders of a single toenail, there is an
appropriate way to code, and be reimbursed, for
each border separately.


Can partial avulsions of both borders of a
single toenail be billed independently, and be
reimbursed? If the answer is 'yes', how would
one code this? How would one code right hallux
medial and lateral nail margin 'slant back'
avulsions?; partial matrixectomies on both the
medial and lateral nail margins of a right
hallux?


Kristina Williams, DPM
Hyattsville, MD


Codingline Responses:


In my experience, one cannot bill for more
than one avulsion (whether one or two borders;
or the whole nail) on one nail. For Medicare, be
sure to identify the toenail with the
appropriate "T" modifier. Also, check with your
carrier regarding any requirements that local
anesthesia be administered or neuropathy be
present to qualify CPT 11730 or CPT 11732
procedures.


R. Kurt Meier, III, DPM
Brick, NJ


I don't believe that two partial nail
avulsions performed on a single toe should be
coded as two separate procedures. CPT 11730 (or
11732) would include a single margin avulsion,
two partial margin avulsions per toe, or a
complete nail plate avulsion.


Also, check with your carrier regarding any
requirements that local anesthesia be
administered or neuropathy be present to qualify
CPT 11730 or CPT 11732 procedures.


Walter J Pedowitz MD
Linden, NJ


08/25/2003    Richard Nichols, DPM

Nail Avulsion & Evacuation of Hematoma

Query: Nail Avulsion & Evacuation of Hematoma


Can you bill for avulsion of bilateral
borders, if bother borders of the same nail are
partially avulsed? For CPT 11730, the CPT notes
this is for partial or complete, one nail
(avulsion), while CPT 11732 is defined for each
additional nail.


Also, CPT 11740 is defined as "evacuation of
subungual hematoma." I was directed to use this
code by other experts to use this code
for "sharp excision of the nail without
anesthesia", but was also given CPT 10060 to use
as well. Which would be the correct code for
sharp excision of the nail without anesthesia?


Richard Nichols, DPM
Grapevine, TX


Codingline Response:


While each insurance company sets its own
policies, guidelines, definitions, etc., almost
all, that I am aware of, reimburse only a single
nail avulsion (CPT 11730 or CPT 11732) allowance
per toe. If you question this, you would need
to check with the specific insurance company you
are dealing with. CPT 11740 is for evacuation of
a hematoma.


CPT 10060 is for drainage and incision of an
abscess (which is defined as a collection or
cavity filled with purulent exudate). If the
abscess is associated with the presence of a
paroncyhia, it's I&D is billed as CPT 10060. Is
that what was present? Is that what you did?


A hematoma is not an abscess. Always choose the
code that most closely reflects the service you
rendered to the condition present.


There is no code for 'wedging a nail spicule
out' without anesthesia. I would recommend, if
you are managing related pain and/or
inflammation, you work up the problem and bill
the evaluation and managment service (the
trimming out or wedging of nail would not be
covered in the E/M service).


Tony Poggio, DPM
Alameda, CA


06/21/2003    Jay Goldstein DPM, Barrett E Sachs, DPM

Atypical Use of Lamisil Following Nail Avulsion (Paul Busman, DPM)

RE: Atypical Use of Lamisil Following Nail
Avulsion (Paul Busman, DPM)
From: Jay Goldstein DPM, Barrett E Sachs, DPM


I give patients with onychomycosis several
options along with the advantages and
disadvantages of each. If they have only one or
two involved toenails, the options include
avulsion followed by topical medication. If they
choose that option, I also offer them the
additional choice of including a short course of
oral antifungal medication.


Jay Goldstein, DPM
Portland, OR.
jcgdome@hotmail.com


As you know the use of Lamisil should be 1
tablet daily for 3-4 months. If the onychomycosis
should start to return you can retry the Lamisi,
but be sure it is at least one year since past
treatment as the Lamisil can remain in your
system for 1 year. In this case though, since
therapy was so short, I wouldn't hesitate to
start immediately.


Barrett E Sachs, DPM
Plantation, FL
uncletenose@aol.com

Therapath