LCD/NCD Portal

L29232 NAIL DEBRIDEMENT

 

 

02/02/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider the treatment of fungal (mycotic) infection of the nails a covered service when the medical record substantiates:

• Clinical evidence of mycosis of the nail, by generally accepted clinical findings such as

o discoloration,

o onycholysis,

o subungual debris,

o thickening, or

o Secondary skin infection.

• In addition one of the following must be documented for mycotic toenails:

o the ambulatory patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s)

o The non-ambulatory patient suffers from pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s).

• Appropriate anti-fungal treatment is necessary to qualify nail debridement as a medically necessary and reimbursable service unless contraindicated.

o If an anti-fungal treatment is not used, the contraindication must be documented in the medical record.

• Patients need not have an underlying systemic condition to be covered for mycotic nail care.

• For nail debridement not related to symptomatic mycotic nails but associated with a systemic condition, refer to the Routine Foot Care policy.

 

 

CPT/HCPCS Codes

 

11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5

11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE

 

 

ICD-9 Codes that Support Medical Necessity

 

110.1 DERMATOPHYTOSIS OF NAIL

112.3 CANDIDIASIS OF SKIN AND NAILS

117.0 RHINOSPORIDIOSIS

117.1 SPOROTRICHOSIS

117.2 CHROMOBLASTOMYCOSIS

117.3 ASPERGILLOSIS

117.4 MYCOTIC MYCETOMAS

117.5 CRYPTOCOCCOSIS

117.6 ALLESCHERIOSIS (PETRIELLIDOSIS)

117.7 ZYGOMYCOSIS (PHYCOMYCOSIS OR MUCORMYCOSIS)

117.8 INFECTION BY DEMATIACIOUS FUNGI (PHAEHYPHOMYCOSIS)

117.9 OTHER AND UNSPECIFIED MYCOSES

 

 

Documentation Requirements

• The provider of the service(s) must document the affected nail(s), including the clinical evidence of mycosis, and the manner in which and to what extent the nail(s) were debrided. Use of appropriate anti-fungal treatment or the contraindication of such treatment must also be documented. In addition, a description of the qualifying symptoms for debridement of toenail(s) must be documented:

o the ambulatory patient has a marked limitation in ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected nail plate(s), or

o the non-ambulatory patient suffers from pain, or secondary infection resulting from the thickening and dystrophy of the infected nail plate(s).

 

 

Sources of Information and Basis for Decision

 

Gallagher, K., (2002). Fungal nail infections. Retrieved from internet 04/08/2004. From http://yalenewhavenhealth.org/library/healthguide.

 

Rehnquist, J., (2002). Medicare payments for nail debridement services. Department of Health and Human Services, Office of the Inspector General.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD NAIL DEBRIDEMENT