04/04/2024 Ralph Zicherman, DPM, Herman Zicherman, DPM,
Nail Avulsion Procedure and Guidelines CPT 11730 Local Coverage Reconsideration / Challenge
National Government Services,
NGS.lcd.reconsideration@anthem.com
Nail infections and treatments have been recorded
and written about for the past 4,000 years. Nail
infections affect about 25 to 35 million patients
per year in the United States, and are responsible
for considerable complications, ranging from pain,
swelling and inflammation, to limitations in
ambulation, gangrene, amputation, and death.
The treatment for nail infections, has been termed
a partial nail avulsion, which up until the early
‘80s simply required the excision and removal of
the infected nail segment, for Medicare
reimbursement. This was a simple effective
treatment, with little complication or difficulty,
for the temporary correction and treatment of a
nail infection. Depending on the extent of
infection, the health of the patient, and the
condition of the nail, a physician could elect to
remove as much or as little nail as his clinical
judgment felt was necessary, for the infection to
resolve.
At some point in the early ‘80s, Medicare
contractors began requiring the removal of 1/2 the
nail boarder for reimbursement, and later incisions
to the eponychium, and then an incision to the nail
matrix (root of the nail situated on the bone of
the proximal phalanx) for reimbursement.
Unfortunately, under these circumstances the
Medicare guidelines have been changed three times,
requiring the removal of more nail segments at each
change of the guidelines, without disclosing the
rationale, reasoning, science, or motivation for
the guideline changes.
The failure of the Medicare contractors in
disclosing the basis of the guideline changes, has
left serious questions about the procedure
requirements (incision to the matrix/eponychium),
and has resulted in considerable confusion and
questions, concerning inaccuracies, and
ambiguities of the guidelines. The confusion
surrounding the guidelines, has resulted in an
unnecessarily aggressive procedure, causing
unnecessary patient damage and trauma (nail matrix,
bone, vasculature damage), lacking science and
research, leaving serious issues and questions
involving the validity and accuracy of the
Medicare nail avulsion guidelines.
While the Medicare guidelines require an incision
the nail matrix (root), there is no science or
research that such an incision is necessary for the
temporary treatment of a nail infection. There is
no science or research that an incision to the
matrix is superior to an incision to the
eponychium, or that an incision to the eponychium
is superior to the removal of 1//2 the nail border,
or that the removal of 1/2 the nail border is more
successful than simply removing the section of
infected nail. With this being the case, why have
Medicare contractors continued to require the
removal of increasing segments of nail tissue, when
lesser incisions have been proven to offer a
satisfactory treatment approach, and have been used
for 100’s of years, avoiding unnecessary trauma and
damage to the patient (nail, vascular , bone).
It is important to note, that prior to the Medicare
guideline changes in the early 80’s, which required
an incision to the matrix for a temporary nail
avulsion procedure, the only mention of a matrix
incision was for the treatment of a permanent nail
correction, not a temporary nail correction.
Medicare contractors have never explained or
provide research or science for over 40 years, for
why a temporary nail avulsion treatment
necessitated an incision to the nail matrix ( root
of nail situated in close proximity to the bone).
In essence, the Medicare guidelines requirements
for a temporary treatment of a nail infection, now
requires an incision near bone, which makes little
sense and should be concerning to anyone who would
ever have such a procedure performed, especially
since less aggressive treatments are available and
have been used successfully prior to the guideline
changes for many years.
In this instance, we have a less aggressive, safer,
less damaging procedure, which only required the
removal of the infected section nail, being
replaced by a more aggressive, damaging procedure,
requiring an incision to the nail matrix, without
any disclosure of medical necessity or science
based evidence. This set of circumstances calls
into question the validity, accuracy, and necessity
of the Medicare nail avulsion guidelines for this
procedure. Logically, we should see research and
science supporting any medical or procedure changes
to guidelines, at the time guideline changes are
made. In this instance, the Medicare guidelines for
the nail avulsion procedure have been changed three
times, without offering any science or research,
to support the changes being made. A close review
of the literature at the time of the guideline
changes, finds no research or science to support
the need for a matrix incision for a temporary nail
infection, leaving questions about the necessity
and rationale for the changes.
With regards to the guideline changes in the early
80’s, Medicare has not clearly revealed the basis,
rationale, reasoning, or motivation for the
guideline changes for the nail avulsion procedure,
what was discussed during the changes, or who was
ultimately responsible for the guideline changes.
This information is vital in determining the basis
and objectives of treatments and guideline
requirements, but has been not been disclosed for
40 years. How have 15 independent Medicare
contractors (MAC’s) throughout the United States,
each require a similar change in the nail avulsion
guidelines (incision to the matrix), without the
support of any science or research. It would appear
that contractors simply parroted a single
contractors guidelines, without any serious
questions or checks and balances, regarding medical
necessity, patient safety, patient damage, lack of
research, or independent investigations.
Aside from a lack of science and research to
support the guideline required incision to the nail
matrix, the Medicare guideline required incision to
the matrix / eponychium, possess considerable
obstacles in being able to accurately perform or
verify the the procedure guideline requirements.
The matrix anatomy is variable, undefined, and
ambiguous, within the context of the Medicare
guidelines, without a means of consistent and
accurate identification, making the verification of
having followed the guidelines almost impossible
for physicians.
While the guidelines require an incision to the
matrix / eponychium, the guidelines never specify
or define if they are referring to the nail plate
matrix, nail bed matrix, nail fold matrix, germinal
matrix, sterile matrix, matrix horns, apical
matrix, or the lunula. Each of these structures
occupy different anatomical positions, making the
Medicare guideline requirements for an incision to
the matrix ambiguous and confusing, resulting in
different incisions, dependent on the matrix
anatomy being used. Equally confusing is the
eponychium anatomy, which is also undefined by the
guidelines, and often confused with the nail fold,
cuticle, and cornified section of the nail fold. In
some instances, the eponychium is confusingly
referred to as the true cuticle, which adds
additional confusion to this anatomical structure.
The questions about the exact position of the
matrix / eponychium anatomy has resulted in a lack
of consensus among medical professionals regarding
these anatomical structures, and a great deal of
variations and interpretations when the nail
avulsion procedure is being performed.
Also confusing, with respect to the matrix /
eponychium anatomy, is the fact that these
structure are invisible, obstructed by the proximal
nail fold, and microscopic, making an incision into
this anatomy a blind procedure. Complicating
matters even more, the avulsion technique, which
Medicare guidelines use as a means of extracting
the nail and identifying the matrix / eponychium
anatomy, is an inexact, imprecise process, of
tearing and pulling tissue, which is unable to make
any accurate or consistent identification of the
matrix /eponychium anatomy. Under these
contradictory circumstances, medical guidelines
require a matrix incision, however, the method
Medicare provides for verification and
identification of the required anatomy (Avulsion),
is not capable of providing this function. This
puts the physician in a position of never being
able to conclusively verify and prove what was done
during a procedure, creating enormous audit and
prosecution disadvantage for any physician
performing the nail avulsion procedure.
Under these complicated circumstances, the
physician is left to using his clinical judgement
and guesswork in determining what has been done, or
if the Medicare guidelines have been met, with the
knowledge that no science based evidence exists for
the Medicare requirements of a matrix incision, and
less aggressive treatments are available, which
avoids unnecessary patient trauma and damage. In
this uncertain scenario, it is not uncommon to see
many different interpretations of the guidelines by
physicians performing this procedure, with some
variations due to anatomical confusion, and others
due to concern of unnecessary patient damage and a
lack of science and research, failing to support
the Medicare guideline requirements. In any case,
guidelines composed of performing a blind
procedure, on invisible, ambiguous, obstructed
anatomy, which lacks appropriate research or a
consistent accurate means of identifying anatomy,
serves as a poor basis of guidelines of any medical
procedure.
Additional issues surrounding the Medicare required
incision to the matrix / eponychium, involves
complications resulting in both improper coding of
the procedure, and matrix stem cell damage, not
properly evaluated, integrated, or acknowledged by
the Medicare guidelines. The nail avulsion
procedure 11730 is described by medicare as the
surgical removal of nail tissue. However, during
the nail avulsion process, sections of matrix /
eponychium are removed as well, making the
procedure an actual partial matrixectomy 11750.
This is due to the fact that the nail is attached
to the matrix, and sections of matrix are removed,
during the inexact, and imprecise, tearing and
pulling of the nail anatomy, with use of the
avulsion technique. With the removal of the matrix
stem cells during the avulsion process, there is
improper insurance coding of the nail avulsion
procedure, in addition to complications involving
nail plate damage, damage to the vasculature, and
insult to the underlying bone tissue. These
complications result in nail plate dystrophy
(loose, discolored, thickened nails), vascular
damage, and bone infection and lysis
(demineralization).
The issues of improper coding and post operative
complications have not been presented,
acknowledged, or integrated into the guidelines for
the past 40 years, in spite of science and research
confirming their presence. Concern for avoiding
unnecessary patient trauma and damage, and the
issues surrounding improper insurance coding has
significant implications for audits,
reimbursements, and prosecutions involving this
procedure, which have avoided and ignored such
issues.
In evaluating the Medicare guidelines, there are
serious issues regarding the anatomy, coding,
science based evidence, and unnecessary patient
damage. A close look at the etiology used by the
guidelines, shows a deficiency and confusion as
well. Etiology is defined as the cause of a
medical problem. In the guidelines, Medicare
describes the etiology of nail infections as a nail
growing into the skin. Unfortunately, nails do not
suddenly change direction and grow into the skin.
For more than 50 years, the primary reason
(etiology) for nail infections has been direct
trauma, improper trimming, improper shoe gear, and
comorbidities (diabetes and vascular disease), not
the nail suddenly changing direction and growing
into the skin, as implied by the guidelines.
In these instances, appropriate treatment can
consist of the removal of sufficient nail width to
allow for soft tissue healing, not an unnecessary
incision to the nail matrix, as described in the
guidelines. In more than 95 % of nail infections
there is no evidence of any nail growing into the
skin. In 5 % of cases there is evidence of a nail
spicule breaking the skin, and causing a bacterial
infection in the distal aspect of the digit, which
can also be appropriately treated by removing
sufficient nail width, also avoiding the matrix
incision required by the Medicare guidelines.
While the mistaken notion and etiology promoted by
the Medicare guidelines, which suggests that nails
can suddenly change direction and curve to grow
into the skin, may support a longitudinal incision
to the matrix, the majority of localized infections
caused by trauma to the nail fold do not require an
incision to the matrix for treatment. What must be
remembered, when formulating treatment for nail
infections, is that nail growing into the skin is
not the etiology for any significant amounts of
nail infections. If this is the case, the etiology
of nail infections used by the Medicare guidelines
is not only incorrect, it is not representative or
relevant for the vast majority of nail infections,
leaving questions about the validity and accuracy
of the guidelines.
The importance of the errors involved in the
etiology used by the Medicare guidelines, is that
this results in unnecessary longitudinal incisions
to the matrix, when more emphasis and appropriate
treatment should be placed on the removal of nail
width avoiding the matrix, to allow for the healing
of a localized infection, being caused by trauma
and irritation between the nail and nail fold, not
growth of nail into the skin. If guidelines fail in
accurately describing an etiology (cause) of a
medical problem, how accurate can the treatment be,
that is being described by the guidelines. If the
etiology is incorrect, can the guidelines and
treatment based on the mistaken etiology have any
accuracy or validity?
With ongoing questions about the Medicare nail
avulsion anatomy, procedure coding, unnecessary
patient damage, unnecessary aggressive approach,
science based evidence, etiology, and the need for
a matrix incision, the entire medical necessity and
validity of the Medicare nail avulsion procedure
guidelines becomes questionable. The federal
guidelines for the criteria of medical necessity of
a guideline or procedure is established by the
Social Security act, The 21st Century Cures Act,
and the Medicare Integrity Manuel. The main
criteria for medical necessity involves safety,
avoiding any over treatment, use of the best
alternative treatments, following medical protocol,
using established science based evidence with
supportive rational, reasoning, and motivation in
establishing guidelines and treatments.
The Medicare nail avulsion guidelines fail in
meeting essential criteria established by federal
regulations for medical necessity. The unnecessary
aggressive matrix incisions required by the
guidelines is responsible for unnecessary patient
damage and trauma, leaving questions regarding
safety. The matrix incision is at best an over
treatment, since lesser incisions, removing smaller
segments of nail result in appropriate treatment.
In addition, since a lesser incision offers
successful treatment, a better less aggressive
alternative is available, other than the Medicare
required incision to the matrix.
The lack of science based evidence for the matrix
incision, coupled with a failure to disclose the
reasoning, motivation, or rational for the matrix
incision requirement, with evidence of an over
treatment and a better alternative treatment,
result in a failure of the Medicare nail avulsion
guidelines and treatment to meet the federal
guideline criteria of a medically necessary
procedure, established by the 21st Century Cures
Act, Medicare Integrity Manuel, and the Social
Security act, calls into question the validity of
the guidelines and their audits.
Another concerning aspects of the Medicare nail
avulsion guidelines, which require an incision to
the matrix, is the fact that no research or science
supports the need for such an incision, for the
treatment of a nail infection with a temporary nail
avulsion procedure. While a matrix incision is
necessary for a permanent nail correction, there is
no need for an incision to the matrix in the
treatment of a temporary correction. Regardless of
these facts and issues, Medicare guidelines have
required the removal of increasing amounts of nail
tissue since the early 80’s.
Guidelines have been changed three times by
Medicare contractors, without disclosing the
science, rational, reasoning, or motivation for the
changes. Guidelines have been changed three times
by Medicare contractors, without explaining how
removing more nail at each guideline change is
beneficial for the patient, or results in more
appropriate treatment. While there is no evidence
that removing increasing amounts of nail tissue is
necessary (incision to the matrix) for treatment,
provides a safer procedure, offers better results,
results in less complications, allows better
healing, or less recurrence, the guidelines have
continued to require the removal of increasing
amounts of nail tissue over the years, with added
risks to patients.
Nail infections have been treated successfully for
hundreds of years, with the simple removal of the
irritated nail segment, without the need of a
matrix incision, which questions the need or
rational for such an incision, or the continued
removal of more nail tissue. Since science and
research forms the basis for patient treatment, we
must ask where the science and research evidence
exists for the Medicare guideline requirements of
increased aggressiveness over the years (incision
to the matrix), and why there has been no
disclosure for 40 years of supportive studies or
science.
A careful review of studies cited by Medicare
contractors, used to support their nail avulsion
guideline requirements, shows these cited studies
fail to support the guideline requirements in place
for the past 40 years. Studies by Exley and Eekoff
provide Cochran and met analysis of hundreds of
nail avulsion studies involving thousands of
patients, concluding nail avulsion studies over the
years represent poor research and study design,
with limited abilities to make any supportive
conclusions. Such research forms a poor basis for
guidelines or medical procedure decisions. With
this being the case, we must ask if the basis of
the Medicare guideline decision for an incision to
the matrix is the result of no science, or poor
science. In either case, this suggests a poor
decision making process.
While the Medicare guidelines require an incision
to the matrix, Medicare cited studies recommend
avoiding the matrix, and avoiding matrix damage,
since this causes and exposes the patient to damage
and dystrophy in nail structure (thickened, loose,
discolored nail dystrophy). While the Medicare
guidelines require an incision to the matrix, the
cited studies recommend an individualized
treatment, dependent on patient comorbidities,
extent of infection, and the condition of the nail.
In contrast the guidelines offer a single approach
requiring an incision to the matrix. In many
instances the studies clearly state that there
remains no one best treatment for nail infections.
Importantly, none of the cited studies offer any
consistent or accurate means of identifying the
required anatomy, or establishing the need for a
matrix incision, in the treatment of a temporary
nail avulsion, contrary to the Medicare guideline
requirements.
Not one of the cited studies evaluated
complications of matrix stem cell damage, in spite
of requiring incisions into this anatomy or the
results and comparisons of lesser incisions, which
avoided the matrix. Confusingly, in one cited study
the anatomy was incorrect, with the eponychium
being referred to as the cuticle, and in another
instance, while the Medicare guidelines seem to
require injectable anesthesia for this procedure,
the cited studies feel topical anesthesia is
appropriate. Critically, the cited study for the
revenue trail involving the treatment of a
recurrent infection, which established an 8 month
time table for additional allowable treatments
after a nail infection recurrence, is in error.
While this study established a nail growth rate of
1 mm / day, there was no evaluation by the study
for when treatment of a recurring infection is
necessary. Regardless of the failure of this
particular study to support the revenue trail for
recurrent nail infections, Medicare contractors
cited this study for such support. This faulty
evaluation of research, seems to be representative
of the same faulty process involved in establishing
the unnecessary requirements for a matrix
incision, having occurred without any supportive
science or research.
In essence, the cited studies for the nail avulsion
procedure fails to support the guideline
requirements for a matrix incision, and posses more
questions than answers as to why this requirement
has remained in place for more than 40 years.
Without a proper evaluation and interpretation of
research, there can be no basis for guideline
requirements (matrix incision). With regards to the
nail avulsion guidelines, no proper evaluation of
science or research has taken place. In these
instances there is a possibility of an abuse of
discretion, a legal process in which there is a
failure to properly and accurately evaluate science
and research, with the end result of the guidelines
incentivizing “useless or sham surgery,” having no
value or medical necessity. This has occurred in
the past with useless knee surgery, performed for
years, in spite of research and science showing
such surgery useless, and may be same case with
useless nail surgery incisions to the matrix.
A clear understanding of the deficiencies and
problems involved with the current Medicare nail
avulsion guidelines, can be seen on reviewing the
nail avulsion fraud trial of Podiatrist Samir Zaky
(2013). Dr Zaky was prosecuted for nail avulsion
fraud. During the trial a Dr Feldman and Trepal
were called as prosecution expert witnesses. Dr
Feldman was a consultant with Medicare and was
active when the nail avulsion guidelines were
changed from the removal of 1/2 the nail border to
an incision up to the eponychium. Dr Feldman
testified that the reason for changing the
guidelines (making them more aggressive) was to
insure the guidelines were crystal clear, without
any confusion. There was no mention of any
supporting science or research or newly discovered
medical necessity. However, the need expressed for
clarity, cited as a reason for the guideline
changes by the expert is not accurate, with
guideline changes requiring incision to an
unclearly defined ambiguous eponychium anatomy. In
looking at the research at the time, there has
never been any mention of confusion regarding the
nail avulsion procedure, with an incision removing
1/2 the nail border being descriptive and accurate,
without any confusion or problems of
interpretation.
In opposition, the new requirement for an incision
to the eponychium, whose anatomy is invisible,
obstructed, and microscopic, and often confused
with the nail fold and the cuticle, is clearly
confusing with a lack of consensus among
physicians. This being an odd choice of anatomy, if
one wishes to offer crystal clarity and reliability
to a procedure guideline. In this instance it is
additionally concerning, when the expert was asked
to define the eponychium, whose anatomy he
supported in making a change in the guidelines, he
remarked that the eponychium was the cuticle, which
was incorrect. In this case, the expert consultant
for Medicare at the time, supported a change of
anatomy in the guidelines, and yet was unable to
define the anatomy he was using, and could offer no
science or research for the guideline changes.
The testimony by the other witness, Dr. Trepal was
equally disappointing, when he also incorrectly
identified the cuticle as the eponychium. The Zaky
trial gives evidence that the guidelines were
changed, without any science based evidence, or a
clear understanding of the anatomy involved. With
this being the case, there fails to be any medical
necessity for the guideline requirement of a matrix
incision, and such treatment is without any
appropriate science or research to support such
actions. In spite of these shortcomings, Medicare
guidelines having established a standard of care
for this procedure, which has lacked the best
interest of patients for the past 40 years, in
combination with confusing, inaccurate, ambiguous
procedure guidelines, which continue to be the
basis of the most audited and prosecuted procedure
in Podiatry.
Finally, while audits hopefully result in accurate
statistics, the statistics for nail avulsion
procedures lack consistency, and fails to show any
significant increase in nail avulsions over the
years, in spite of conditions favoring such
increases being present. It is estimated that up to
30 million patients a year experience nail
infections, and that the rate of nail infections is
continually rising, however, Medicare statistics
have not shown significant increases over the years
for this procedure. This contradiction is
problematic, in light of facts being present,
which should be responsible for yearly increases in
these procedures. Factors such as increasing
population levels, increasing aged populations, and
increased awareness of the problem, should all have
contributed to a yearly increase in this pathology.
Additionally, medical doctors report that 20 % of
all patient visits for extremity problems involve
nail issues. Even the American Diabetic
Association, has stated that 99 % of individuals
will have a nail Issue in their lifetime. One study
in Korea, cites a 25 % increase in nail infections
over a ten year time period. These factors all give
evidence for the position that we should be seeing
significant yearly increases nail infection
treatments, however, Medicare statistics have not
show a significant increase over the years, for the
nail avulsion procedure. With this being the case,
only two explanations are possible, in one,
doctors are doing the procedure and billing for it,
or they are doing nail avulsions and billing for
another procedure. Billing for other procedures, in
order to avoid the scrutiny of Medicare nail
avulsion audits and prosecutions, have been ongoing
for the past several years, coinciding with the
increased Medicare scrutiny of this procedure. In
these instances, a patient presenting for a nail
avulsion procedure, may be being billed for an
abscess, hematoma, ulceration, biopsy, or office
visit, in order to avoid audit scrutiny or the fear
from prosecutions. With this being the case, the
entire statistical presentation for the nail
avulsion procedure becomes difficult to discern,
making for inaccurate interpretations, conclusions,
and comparisons. These actions (avoiding billing
for nail avulsions in order to avoid scrutiny of
audits), can seen immediately after high profile
audits and prosecutions are publicized, which are
then followed by reductions in billings for this
procedure, resulting in erroneous underreported and
failed statistics.
In what appears to be overwhelming
evidence, we must ask if the Medicare nail avulsion
guidelines are valid or accurate, if they contain
serious inaccuracies and questions involved with
anatomy, safety, patient damage, procedure coding,
etiology, science based evidence, medical
necessity, necessity of a matrix incision, and an
inherent inability to accurately and consistently
identify the microscopic, invisible, obstructed
involved anatomy or being able to verify what has
been done during the procedure.
It is hoped that the information contained in this
report begins a close evaluation and examination of
the process involved with the nail avulsion
Medicare guideline requirements, and begins a
process of addressing serious issues neglected by
Medicare contractors, the Podiatry profession, and
the medical community, in hopes of providing a
safer more effective treatment, for the very common
medical issue of nail infections, which affect
millions of patients each year.
Ralph Zicherman, DPM, Herman Zicherman, DPM,
West Bloomfield MI
08/11/2023 Robert D Teitelbaum, DPM
Nail Avulsion Guidelines (Ivar Roth, DPM, MPH)
I was around in the mid-eighties when the nail
avulsion guidelines were established. Right then, I
knew there was a problem. The issue was one of
enforced overtreatment. To get paid to relieve a
potentially dangerous condition, especially in
geriatric and diabetic patients, was to make one or
more injections to a toe with local anesthesia,
when freeze spray anesthesia was often adequate.
Using freeze spray also cut the time to a fraction
of the other procedure. And when you are dealing
with an anxious patient, time is trauma.
Also, strange requirements were made to incise
eponychial tissue that seemed to be 'make work'
type of actions that were not clearly correlated to
the issue that was causing the pain and incipient
infection. In other words, I was on the razor's
edge of 'assault and battery'. All that was
required was removal of 'the offending spicule" and
carefully curetting that side of the nail to avoid
leaving my own spicule.
But 'removing the offending spicule' became dirty
words not worthy of reimbursement because some
podiatrists fraudulently invoked that phrase every
time they came upon a toenail. So overzealous
podiatric consultants helped to create unreasonable
requirements for the 97% of ethical podiatrists who
were not committing fraud. Nice going, as they say
where I grew up. What was needed at that time, and
now, was a step-down procedure that removed the
'offending spicule' and at a lesser reimbursement
than a 11730. Instead, practitioners are billing
for paronychias, maybe when there are not any, and
doing P & A procedures on almost all patients,
because this way one can avoid a nasty audit for an
ill-defined procedure.
Robert D Teitelbaum, DPM, Naples, FL
07/19/2023 Gregory T. Amarantos, DPM
Nail Avulsion Guidelines
I have been in practice for 40 years and am amused
by the commentary regarding nail partial/simple
avulsions. First and foremost we must treat the
patient to the best of our abilities and to provide
comprehensive care, regardless of the LCD/billing
guidelines. That being stated, I appreciate the
passion of my colleagues regarding the guidelines
and scientific methodology discussing what may or
may not be considered an avulsion.
As a frame of reference and some historical
perspective, way back when the dinosaurs roamed the
earth and I started practicing, it was a free for
all and essentially whatever fee you billed
Medicare, you received 80%. Slowly, DRGs were put
into place and HMOs proliferated in an attempt to
control costs because of the abuse of the system,
both by the patients and physicians.
For the past forty years it seems a large
percentage of our colleagues are afraid to tell
their patients "this is not covered by Medicare
because you do not meet the criteria" and to tell
the patient the cost of the service is their
responsibility. This leads to practicing in the
"gray" area, thus the trimmed nails become mycotic,
painful etc... when in reality the patient may have
asymptomatic thickened toenails, thus not covered
by Medicare. I call this billing FRAUD.
In an attempt to rein in the over usage of CPT
codes 11720-11721, Medicare came up with guidelines
as to what criteria must be met to qualify for
coverage. You see, it is easier and less costly to
add a few sentences into the LCD than it is to go
after the bad apples. The OIG does their homework
and sends their findings to the powers that be. It
does not matter what our perception is of who
steered the conversation, ultimately the rules were
changed.
Fast forward to the present discussion. Tomato-
Tomahto, it does not matter. No one will convince
me and a I hope a majority of my colleagues would
agree that a "slant-back" procedure for ingrown
toenail symptoms is an avulsion. I do not care if
you use Ethyl Chloride or topical Lidocaine, it is
a slant back procedure and not an avulsion.
To me, it is black and white with no gray area. If
a patient has an ingrown toenail and they do not
want a definitive procedure such as a P & A and
only want the nail trimmed to relieve the
pressure/pain and they do not meet the covered
guidelines for Routine Foot Care, it is a non-
covered visit, which leads me back to my original
premise. We are afraid to tell the patient is it
not covered. Hearing aids are not covered, nor is a
refractory exam from the ophthalmologist covered by
Medicare and it is patient responsible. I thank my
residency directors Drs. Charles Jones and John
Venson for instilling ethics into my training.
There is nothing wrong with billing an E & M code
for the visit and "slant-back" procedure if there
is a true paronychia, but it is not and never will
be an avulsion. Thus when our colleagues try to
"game" the system and push the limits, Medicare
reviews the usage of the codes, the OIG
investigates and viola, the LCD guidelines are
changed to limit the fraud and abuse of our
colleagues.
It is time our colleagues stop playing the
guideline game and call the treatment what it is.
"Mrs. Jones unfortunately Medicare does not cover
Routine Foot Care and this will not be covered by
Medicare. Today’s visit will be $XXX. How would you
like to proceed?" The inevitable retort is "my
other podiatrist got paid by Medicare every 2
months and I never got a bill". I again explain I
cannot justify Medicare coverage for the service.
I do not defend the other podiatrist but state I
will not commit fraud and tell the patient I do not
look good in stripes. More often than not, the
patient agrees and they pay for the service.
A tangential finding is that for the last forty
years Medicare and insurance companies have reduced
our fee schedule. The "avulsion" that paid $120
years ago is now being reimbursed at $60. The non-
covered slant-back procedure is governed by my
office fee schedule, which has increased every year
for the past forty years.
I will remain truthful with the patient and follow
the guidelines. Ultimately the non-covered service
is more favorably reimbursed than the "gray" area
avulsion procedure. Only you can decide how you
want to practice. Do you value the service you
provide to your patients? I believe if you do the
right thing, your patients will also place a value
on the services you provide and ultimately be
willing to pay for the value of said services.
It is incumbent on our profession to police itself
and to stop covering for those who commit fraud. If
the service is a covered service, we must properly
document and code accordingly, Thank you for your
time.
Gregory T. Amarantos, DPM, Chicago, IL
07/19/2023 Lawrence Rubin, DPM
Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Ralph Zicherman, DPM)
Dr. Zicherman's response to my post regarding
Medicare's past revision of utilization guidelines
for CPT coded nail avulsion procedures questioned
the authority of the Office of the Inspector
General (OIG) to require Medicare to curb "abusive"
billing by podiatrists. The following link to the
OIG website explains this ability:
https://www.ftc.gov/office-inspector-general/what-
you-need-know-about-office-inspector-general
It is also important to know that since 2002,
podiatrists have been at high risk of audits and
punitive actions for what the OIG considers abusive
billing for debridement of onychomycosis. Read more
about this here:
https://oig.hhs.gov/oei/reports/oei-04-99-00460.pdf
The reality of all this is that Medicare claims
from podiatrists that involve toenail avulsion
and/or debridement are under close monitoring by
Medicare. They are among the most common services
that subject a podiatrist to an audit.
I strongly advise all podiatrists who submit
Medicare claims for nail avulsion and debridement
services to follow the advice of the OIG itself:
Implement the Office of the Inspector General (OIG)
Individual and Small Group Practice Compliance
Program that evidences your adherence to published
CMS-Medicare utilization guidelines.
The OIG states that, even if there is a suspicion
of abusive billing following a Medicare audit,
having a practice compliance program, "will be a
mitigating factor" against punitive action. In my
past and present work involving Medicare compliance
issues, I have found this OIG statement to be true.
Here are the details about the OIG Individual and
Small Group Compliance Program Act:
https://oig.hhs.gov/documents/compliance-
guidance/801/physician.pdf
Lawrence Rubin, DPM, Las Vegas, NV
07/18/2023 Ralph Zicherman, DPM
Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Lawrence Rubin, DPM)
Thank you Dr. Rubin (who served on the Medicare
HFCA CAC). You say that the reason for changes to
the Medicare nail avulsion guidelines were mandated
by The Medicare office Of the Inspector General. I
find this quite surprising and shocking, since the
“Inspectors General are empowered by congress to
identify and inform the legislative branch of
incidence of waste, fraud, abuse, and
mismanagement,” not formulate medical decisions or
guidelines.
In reviewing the 21st Century Cures Act, The Social
Security Act, and the Medicare Integrity Manuel,
there is no mention of The OIG having any role in
developing LCD or treatment guidelines. MACs
(Medicare Advisory Committee) have science
committees, professional consultants, medical
writers, scientist, researchers, advisory
committees, statisticians, physicians, actuaries,
the office Of Inspector General is not part of the
equation in making medical decisions. The OIG does
not have the resources, expertise, manpower. or
congressional authority to formulate or change
guidelines.
If it is accurate, that the nail avulsion
guidelines were changed and based on a mandate by
the OIG, we should all be concerned that an
investigative body of the federal government has
formulated medical policy, without having the power
or structure to do so. The rules and guidelines for
formulating LCD”s are lengthy and complex, to
insure patient safety, patients best interest, and
good medical protocol and decision making for
treatment that is medically necessary. There is no
process, mechanism, governmental authority, or
administrative checks, balances to allow for the
OIG to be involved in LCD guideline or medical
decision making.
Having the OIG make medical decisions, would be
like the FBI, telling us how to do a bunionectomy,
If it is accurate, that the OIG mandated the
changes to the nail avulsion guidelines, what is
the purpose of MAC’s or LCD’s. We should all be
alarmed and concerned. This would imply that for
the past 40 years our treatment of nail avulsions
had no basis in science, or research, rather the
explanation that guidelines were changed in order
to limit reimbursements and procedure numbers. How
many practitioners have understood, that for the
past 40 years, we were following guidelines
formulated by the OIG, not the HCFA (Medicare), and
that our actions were primarily to reduce
reimbursements and procedure numbers, not
necessarily the best interest of patients
The medical-ethical legal implications, of changing
a medical treatment or guidelines, making them more
aggressive and traumatic, in order to reduce
reimbursements and procedure numbers, should alarm
physicians and patients alike. We should have been
informing patients that the need for incising nail
infections to the matrix and eponychium, were to
reduce reimbursements and procedure numbers, not
for reasons of medical necessity. That patients had
unnecessarily aggressive procedures performed,
which resulted in nail plate dystrophy, vascular
damage, matrix damage, amputation, and in some
instances bone damage, as a result of the OIG
trying to reduce reimbursements and procedure
numbers, not medical necessity.
How many practitioners or patients were made aware
of the fact that medical decisions were being made
by an investigative branch of the government,
having no congressional power or administrative
process for making such decisions. MAKING A
PROCEDURE MORE AGGRESSIVE, IN ORDER TO REDUCE
REIMBURSEMENTS, IS INDEFENSIBLE, AND
UNCONSCIONABLE.
If true, this represents a failure of the entire
medical guideline decision making process. There
needs to be an immediate investigation by the APMA,
HFCA, MAC, Congress, and OIG. Patients have been
damaged unnecessarily, physicians have been
following guidelines based on OIG mandates, not LCD
requirements established by congress, and
physicians have been audited and prosecuted,
without properly being informed of the basis of
the nail avulsion guidelines.
Currently, there are already two national law firms
investigating class actions involving patient
damaged as a result of nail avulsion procedures. As
a profession, we need to get in front of this
issue before it turns into a national headline. I
have spent the past 10 years trying to warn the
profession about serious problems with the nail
avulsion guidelines, and hope that the profession
views these concerns as serious as well.
Ralph Zicherman, DPM, Detroit, MI
07/13/2023 Lawrence Rubin, DPM
Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Jack Ressler, DPM) From:
I want to thank Dr. Ressler for his, “Killing the
Chicken Who Lays the Golden Eggs” story. He
witnessed the flagrant abuse and outright fraud in
the early 1980's that occurred when all too many
podiatrists abused the billing of CPT code 11730 -
nail avulsion.
It is so sad that even now, because of this long
ago situation, it is no longer a question of
whether or not a podiatrist will be subjected to a
random or targeted audit of 11730 coding and
billing. It is more a question of when this audit
will occur. But this is not the end of the Golden
Egg story. Things got worse.
In the early 1980s, the abuse Dr. Ressler describes
tarnished the reputation of podiatry in the minds
of HCFA administrators. Congress was aware of that
reputation, probably from information obtained from
HCFA. So, reportedly to prevent the same podiatry
abuse that was occurring via 11730 false billing,
in the late 1980s, Congress reacted by putting into
law restrictive medical necessity and utilization
control requirements. These requirements had to be
met before a diabetic patient could receive a pair
of soon to be available therapeutic shoes
prescribed and supplied by a podiatrist. The law
went into effect in 1993, and remains in effect
today.
Then as now, in order for a diabetic patient to
receive therapeutic shoes supplied directly from
their prescribing podiatrist, a primary care
physician must confirm the medical necessity
documentation the prescribing podiatrist submits –
even when that licensed and qualified prescribing
and supplying podiatrist adheres to required
documentation that adequately supports the medical
necessity of the shoes.
And if you research this on the Internet, you will
find references to the fact that HCFA wanted this
“second opinion,” because administrators believed
many podiatrists would, “just offer patients a pair
of free shoes every year, and they would bill
Medicare for those shoes without following medical
necessity guidelines.”
There is no question about it. Compliance matters
matter more than we may think.
Lawrence Rubin, DPM, Las Vegas, NV
07/12/2023 Jack Ressler, DPM
Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Ralph Zicherman, DPM)
I totally agree with everything Dr. Zicherman has
concisely written. To understand Medicare's
reasoning is as simple as Goggling "The goose and
the golden eggs". Sadly it tells a story of a
countryman who possessed a wonderful goose that
laid golden eggs. Every day he would visit the nest
to find one golden egg which he would take into
town to sell. He began to get rich but as greed
took over, he wasn't getting rich fast enough. He
decided to cut open the goose to remove all of the
golden eggs, obviously killing the goose.
While in podiatry school in the early ‘80s, I
shadowed a podiatrist during his visit to a nursing
home. He must have seen around 30 patients that
day. As he would see a patient, he would utter the
phrase "bilateral bilateral" to his assistant as he
debrided the patients nails. A brief clean-up was
then done, sometimes followed by applying topical
antibiotic ointment. This was done on around 70% of
the patients he treated. Curiously, I asked him,
what does bilateral bilateral mean. His reply was
that he did a simple nail excision procedure on
both borders of both great toes. Enough said. The
11730 procedure code has been the golden egg in
many podiatry practices. Unfortunately, it became a
code that has been highly abused and closely
scrutinized by Medicare.
As stated in other posts, I actually went through
what I would call a silent Medicare audit based on
the high frequency I used this code. Medicare
actually showed up at two of my patients homes that
I did a 11730 procedure on. They asked my patients
two questions, did your toe hurt before the
procedure and did the doctor inject local
anesthesia. I would have had a mess on my hands had
I not gone by Medicare's guidelines with this
procedure. I do think Medicare's requirements on
this procedure could be overkill but that is what
we as a profession have created. We haven't yet
removed all the golden eggs, but the goose is
definitely on life support.
Jack Ressler, DPM, Boca Raton, FL
07/10/2023 Ralph Zicherman, DPM
Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe
For Medicare insurance guidelines to be accurate,
and offer successful treatments for clinical
problems, they must carefully adhere to the format
of evidence based medicine. This accepted process
involves reviewing the best research and evidence,
critically appraising and evaluating such evidence,
with the physicians then using their professional
and clinical experience to extrapolate the
scientific evidence as it applies to the specific
patient. In the end, the physician must apply all
the research, information, and skills in the
context of individual patients’ values and or
preferences, which at times, may and can conflict
with limited single treatment options offered by
narrow insurance guidelines. After treatment, the
outcomes are evaluated and constantly reevaluated
to insure the impact of treatment remains positive
and timely. This process has not been followed in
developing the Medicare nail avulsion guidelines,
raising serious questions regarding the best and
most appropriate care for patients presenting with
nail infections.
In the early '80s, Medicare contractors changed
nail avulsion guidelines, for the treatment of nail
infections, to require incisions to the eponychium.
This was put into effect without Medicare
contractors providing any accepted rationale,
reasoning, science, or research for the guideline
changes. Medicare contractors once again changed
guidelines in the late '80s, to require an even
more aggressive incision to the matrix, once again
without offering any accepted science, research,
rationale, reasoning, or motivation for their
guideline decisions. In these instances, the
guidelines were changed twice, without offering any
explanations for their actions. A careful review of
nail avulsion research and literature in the ‘80s,
shows no studies to support the guidelines changes.
Prior to the guideline changes in the ‘80s, nail
avulsions often consisted of the removal of small
sections of the local infected nail, without any
involvement of matrix or eponychium. This less
aggressive treatment, resulted in the resolution of
most infections, with little complication, pain, or
matrix damage. The failure of Medicare contractors
to provide the basis for the changes to their
guidelines in the early ’80s, and ‘90s has created
serious questions and confusion regarding proper
care for nail infections.
For a procedure, which has been performed millions
of times, we have no clear information about who
determined the Medicare guideline changes, the
basis for these decisions, and what was discussed
during meetings involving the guideline changes. We
still do not have this information, in spite of the
guidelines being in place for the past 40 years.
How can we make important clinical decisions about
patient care, without a clear understanding of the
rationale behind the Medicare guidelines changes.
Were guidelines changed to reflect research showing
improved results and patient satisfaction from more
aggressive incisions to the matrix - eponychium, or
were guidelines simply based on failed research and
unproven opinion of consultants? The silence from
Medicare contractors on these issues, suggests a
failure in the guideline formulation process of the
nail avulsion procedure.
Cochran and met-analysis reviews by Bloomfield in
2003, Eekhof in 20012, and Exley in 2023 evaluated
thousands of nail avulsion studies and patients,
finding the vast majority containing poor levels of
science, poor control of patient variables, and
deficient random controlled sampling and
experimental design. The latest met- analysis by
Exley, stated that, “Despite the high number of
publications, the quality of research was poor and
conclusions that can be inferred from existing
trials is limited……To put this another way, 3,756
people have taken part in research studies that do
little to guide clinical practice……..More, high
quality clinical trials to inform clinical decision
making are urgently needed in nail surgery.” From
these large Cochran and met analysis studies of
nail nail avulsions, we must assume that much past
and current nail avulsion studies and research are
of limited use in formulating clinical
applications. If this is the case, what was the
research and experimental basis for the guideline
changes to require incisions to the matrix and
eponychium in the early ‘80s and ‘90s? Were
inappropriate, poor quality research, with improper
conclusions, the basis for guideline changes, as
suggested by the Cochran and met-analysis reviews,
resulting in Medicare guidelines lacking a
foundation of science based medicine, or were
non=medical issues and poor decision making the
basis of guideline changes? Medicare contractors
must be made to explain their past actions in order
to resolve these issues, and accept the fact that
they may be responsible for patients receiving
improper, overly aggressive treatments, lacking
science based medical care.
In terms of the nail avulsion procedure, there is
no proof that removing 10 mm of nail to be more
effective than removing 9 mm or 8 mm of nail. In
addition, there is no proof that more aggressive
treatments are more successful than lesser
incisions in terms of recurrence or relief of
symptoms. If this is the case, what is the basis
for Medicare guidelines decisions requiring a more
aggressive treatment (matrix - eponychium), which
offers no clear advantage over conservative less
aggressive intervention (proximal to the nail fold
and cuticle). In the absence of good experimental
proof, conservative less aggressive treatments
should always be a more appropriate treatment
option, over unproven aggressive treatments
involving incisions to the matrix or eponychium. In
this instance, we must consider the fact that
effective treatments prior to the guideline changes
in the ‘80s, represent a conservative safer less
aggressive treatment option, opposed to more
aggressive treatments with no science based
evidence. These less aggressive treatments were
used for hundreds of years prior to the guidelines
changes, with satisfactory resolution of nail
infections.
While the Medicare guidelines require incisions to
the matrix - eponychium, there are no studies to
support more aggressive treatment, as offering any
advantage over lesser incisions to the cuticle or
distal nail plate, which avoids damaging matrix
structures. In contrast to requiring incisions to
the matrix, there has been an abundance of research
and studies illustrating the importance of nail
matrix stem cells (nail plate matrix, nail fold
matrix, nail bed matrix) as important biological
barriers to disease. There are also numerous
studies documenting permanent damage to the nail
plate structures, as a result of matrix stem cell
stem cell trauma, which should suggest avoiding
unnecessary incisions to the matrix anatomy during
nail avulsion procedures. Confusingly, even with
studies and research showing nail plate damage
resulting from matrix stem cell trauma, the
guidelines have failed to incorporate these finding
in their nail avulsion guidelines since the ‘80s.
The failure of the guidelines to incorporate
relevant matrix stem cell damage research, suggests
a failure of the current guidelines to represent
accurate factual medical science, neglecting the
best interests of patients.
Additional guideline confusion has resulted due to
a failure of incorporating anatomical clarity, as a
result of poorly defining nail organ descriptions.
This can be seen as a result of a failure of the
Medicare guidelines to make a distinction between
sterile matrix, germinal matrix, nail bed matrix,
nail plate matrix, or nail fold matrix, and simply
referring to the matrix as a single, easily
identifiable anatomical structure. In reality,
these are all separate anatomical structures
occupying different anatomical positions, and
simply referring to a matrix without clear
definitions is not medically appropriate. In
addition, in spite of the presence of a nail bed
matrix, which was first discussed in 1980, and nail
fold matrix discussed in the late 80’s, there has
been no mention of these structures in the Medicare
nail avulsion guidelines over the past 40 years.
While nail anatomy has progressed over the years,
the guidelines have failed to incorporate these
important findings.
In addition to the proposition of the incision
requirements being unnecessarily aggressive in
length (matrix - eponychium), and lacking science
based evidence, the incision requirements (to the
matrix-eponychium) are critically deficient with
regards to an unproven, incapable, avulsion
technique as well. The avulsion technique is an
imprecise, inexact, traumatic, pulling, twisting,
and tearing of tissue. The avulsion technique is
not a consistent or accurate means of verifying
invisible, microscopic, obstructed matrix anatomy
(matrix - eponychium), as suggested in the Medicare
guidelines. With this being the case, the entire
procedure lacks an essential element necessary in
meeting guideline requirements for the
identification of the matrix anatomy structure.
While the guidelines require incision and therefore
identification of the microscopic, obstructed,
invisible matrix, the avulsion process is unable to
provide such visualization. As a result, without
accurate methods for the verification of anatomy,
the entire procedure remains a blind procedure,
using clinical judgement and guesswork, not exact
identification of structures.
Of additional importance, during the process of
avulsing the nail, sections of matrix are also
removed, due to the nail having direct attachments
to the matrix. With this being the case, the nail
avulsion procedure as described by Medicare, should
be seen as as a partial matrixectomy (removal of
sections of matrix), calling into question the
entire accuracy of the insurance coding for this
procedure (11730 or 11750).
The guideline incision length requirement (matrix-
eponychium) remains unproven, lacks accurate
science based evidence, and fails to show any
improvement over less aggressive incisions. In
addition, there is no accurate or consistent
process of identifying the required guideline
anatomy (matrix - eponychium) during nail avulsion
process, since the avulsion technique is inexact
and imprecise. Medicare also fails to properly
define and specify the exact location of the
matrix - eponychium anatomy used in the guidelines
(sterile matrix, germinal matrix, nail bed matrix,
nail fold matrix, matrix horns, apical matrix,
proximal matrix, distal matrix) by simply requiring
incision to the matrix, without any specificity.
Finally, in spite of requiring incisions to the
matrix, the guidelines fail to incorporate accurate
matrix stem cell function, damage, and biology
research and studies, showing this anatomy as being
a sensitive, delicate, structure, susceptible to
damage, which often leads to nail plate dystrophy.
With regards to the nail avulsion guidelines, they
seem to have been based on poorly designed studies,
of low quality research, while at the same time,
appropriate research and studies regarding nail
anatomy and matrix stem cell function and damage
have been ignored. In contrast to guideline
requirements of incisions to the matrix -
eponychium, treatment of nail infections prior to
the 80’s offered the resolution of nail infections,
using less aggressive incisions, which were
proximal to the matrix and eponychium, with anatomy
that was easily identifiable, and lacking matrix
involvement or damage. This would suggest the
current Medicare guidelines being unproven, unsafe
and unnecessary.
As part of good medical evidenced based decision
making, treatments must take into account
individual patient needs and variables, and the
possibility of individualizing treatments. With
regards to the nail avulsion procedure, we must ask
if the individual interest of patients are met,
when every nail infection is being treated using
the same Medicare required incision to the matrix -
eponychium. The answer to this question is an
obvious no. This can best be seen by answers to the
following questions. Should a severe nail
infection, receive the same aggressive treatment as
a minor infection? Should an infection limited to
the distal aspect of the nail plate be treated the
same as one located more proximally? Should an
infection caused by tight footgear, be treated the
same as one caused by poor nail trimming? Should a
patient with vascular disease or diabetes have the
same aggressive treatment as a patient in good
health? These are questions that physicians must
face every day, which are left unanswered by
Medicare nail avulsion guidelines, requiring the
same treatment option for almost every nail
infection. If this is the case, why have the
guidelines taken such an unnecessary treatment
approach.
Logically, good medical protocol for the treatment
of nail infections, involves individualized
treatments, to meet variables involving
comorbidities, the severity of infection, the
condition of the nail, and patient wishes. The
Medicare guidelines leave no room for these
important treatment variables, leaving questions of
safety, necessity, and what is in the best interest
of patients largely unaddressed. While it appears
less aggressive incisions and treatment, used for
100’s of years, which avoided the matrix and
eponychium, and offered greater safety and equally
effective treatment, continues to be ignored by the
Medicare guidelines. This is clearly evident, when
the same nail avulsion guidelines have been used
without any significant changes for the past 40
years, in spite of an abundance of cautionary
research and studies involving matrix stem cell
anatomy, function, damage, and biology. In this
instance, Medicare has failed to evaluate and
reevaluate treatment outcomes, to ensure that the
effect of their treatment guidelines remain
positive and timely.
Ralph Zicherman, DPM, Detroit, MI
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
