L29318-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Surgical Treatment of Nails (L29318)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29318

LCD Title

Surgical Treatment of Nails

Contractor's Determination Number 11730

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart

D]. In addition, an administrative law judge may not review an NCD. See § 1869(f)(1)(A)(i) of the Social Security

Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Medicare Carriers Manual, Part 3, Chapter IV, Section 4120.2

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will consider the surgical treatment of ingrown nails to be medically appropriate and reasonable for an ingrown toenail in the advanced stage in which the lateral nail fold buldges over the nail plate causing erythema, edema, and tenderness, and granulation of the epithelium inhibits serous drainage and precludes any chance of elevating the nail edge from the dermis of the lateral skin fold.

Limitations

The following are considered routine foot care and are not included in the surgical treatment of ingrown nails:

• cutting small chips of the nail

• excising less than the full length of the affected nail

• simple nonsurgical treatment of ingrown nails (e.g., trimming, cutting, lifting and clipping of the distal unattached nail margins)

• simple wedge excision of tissue or nail borders not requiring local anesthesia

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE

11732 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

11750 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL;

11765 WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)

ICD-9 Codes that Support Medical Necessity

110.1 DERMATOPHYTOSIS OF NAIL

681.00 UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER

681.02 ONYCHIA AND PARONYCHIA OF FINGER

681.10 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE

681.11 ONYCHIA AND PARONYCHIA OF TOE

681.9 CELLULITIS AND ABSCESS OF UNSPECIFIED DIGIT

686.1 PYOGENIC GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE

703.0 INGROWING NAIL

703.8 OTHER SPECIFIED DISEASES OF NAIL

703.9 UNSPECIFIED DISEASE OF NAIL

757.5 SPECIFIED CONGENITAL ANOMALIES OF NAILS

785.4 GANGRENE

816.2 CLOSED FRACTURE OF DISTAL PHALANX OR PHALANGES OF HAND

816.3 CLOSED FRACTURE OF MULTIPLE SITES OF PHALANX OR PHALANGES OF HAND

816.12 OPEN FRACTURE OF DISTAL PHALANX OR PHALANGES OF HAND

816.13 OPEN FRACTURE OF MULTIPLE SITES OF PHALANX OR PHALANGES OF HAND

826.1 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT

826.2 OPEN FRACTURE OF ONE OR MORE PHALANGES OF FOOT

883.1 OPEN WOUND OF FINGERS WITHOUT COMPLICATION

883.2 OPEN WOUND OF FINGERS COMPLICATED

883.3 OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT

893.1 OPEN WOUND OF TOE(S) WITHOUT COMPLICATION

893.2 OPEN WOUND OF TOE(S) COMPLICATED

893.3 OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT

923.3 CONTUSION OF FINGER

924.3 CONTUSION OF TOE

927.3 CRUSHING INJURY OF FINGER(S)

928.3 CRUSHING INJURY OF TOE(S)

959.5 OTHER AND UNSPECIFIED INJURY TO FINGER

959.7 OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT

991.1 FROSTBITE OF HAND

991.2 FROSTBITE OF FOOT

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

For procedure codes 11730, 11732, 11750, and 11765, the following information must be clearly documented in the patient’s medical record and submitted upon request for review.

1. Complete detailed description of the pre-operative findings.

2. Procedure being performed (making note to the nail margin involved).

3. Method of obtaining anesthesia (if not used, the reason for not using it).

4. A complete detailed description of the procedure.

5. Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).

6. Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).

Appendices

Utilization Guidelines Nail avulsions usually offer only temporary relief for ingrown toenails. The nail often grows back to its original thickness and the offending margin again may become problematic, resulting in another nail avulsion. Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Rounding C., Bloomfield S. Surgical Treatment for Ingrowing Toenails (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Zuber, T. (2002, June). Ingrown Toenail Removal [Electronic version]. American Family Physician, Volume 65, Number 12, 2547-2550.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29318) replaces LCD L13859 as the policy in notice. This document (L29318) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

11732 descriptor was changed in Group 1 11765 descriptor was changed in Group 1

Reason for Change