LCD/NCD Portal

L29318

 

SURGICAL TREATMENT OF NAILS

 

 

02/11/2013

 

 

Indications and Limitations of Coverage and/or Medical Necessity

• This LCD describes conditions under which the coverage of nail avulsion/excision may be considered.

• Treatment of simple uncomplicated or asymptomatic ingrown nail such as removal of a nail spicule may be considered to be routine foot care as are other trimming, cutting, clipping and debriding of a nail distal to the eponychium.

o Routine foot care is covered only when certain systemic conditions are present. (Refer to LCD: Routine Foot Care).

• The following surgical procedures represent the options used to treat a complicated/symptomatic ingrown nail(s):

o Avulsion of a nail (CPT codes 11730 and 11732) involving separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium).

 A nail avulsion usually requires injected local anesthesia except in instances wherein the digit is devoid of sensation or there are other extenuating circumstances for which injectable anesthesia is not required or is medically contraindicated.

o Excision of the nail and the nail matrix (CPT code 11750) performed under local anesthesia (unless the digit is devoid of sensation, which should be documented) requiring separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium) followed by destruction or permanent removal of the associated nail matrix.

o Wedge excision of the nail fold hypertrophic granulation tissue with removal of the offending portion of the nail (CPT code 11765).

• Nail avulsions usually offer only temporary relief for ingrown toenails.

o The nail often grows back to its original thickness and the offending margin again may become problematic, resulting in another nail avulsion.

o Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails.

• The surgical treatment of nails is also covered for the following indications:

o Subungual abscess.

o Contusion injuries of nails.

o Crushing injuries of the toes.

o Crushing injuries of the fingers.

o Paronychia.

o Complicated wounds of the toes involving nail components.

o Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

 

 

Limitations

• The following are considered routine foot care (refer to LCD: Routine Foot Care)and are not included in the surgical treatment of ingrown nails:

o cutting small chips of the nail

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

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

Limitations specifically related to nail avulsion (CPT codes 11730, 11732)

o When a complete nail avulsion is performed done, another avulsion should not be required for at least 12 weeks on the same digit. Services performed more often than every 12 weeks on the same digit are not considered to be not reasonable and necessary and will be denied.

o In the unusual circumstance of a repeat partial avulsion of the same digit, within a 12-week period of time, the medical record must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated.

o Partial nail avulsion of separate borders of the same nail is considered a single procedure.

o Both avulsion and routine trimming/debridement will not be allowed on the same nail on the same day.

 

 

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

816.02 CLOSED FRACTURE OF DISTAL PHALANX OR PHALANGES OF HAND

816.03 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

826.0 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT

826.1 OPEN FRACTURE OF ONE OR MORE PHALANGES OF FOOT

883.0 OPEN WOUND OF FINGERS WITHOUT COMPLICATION

883.1 OPEN WOUND OF FINGERS COMPLICATED

883.2 OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT

893.0 OPEN WOUND OF TOE(S) WITHOUT COMPLICATION

893.1 OPEN WOUND OF TOE(S) COMPLICATED

893.2 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

 

 

Documentation 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.

o Complete detailed description of the pre-operative findings.

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

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

o A complete detailed description of the procedure.

 Identifying the specific digit(s) on which the procedure was performed.

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

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

Utilization Guidelines

• Nail avulsions usually offer only temporary relief for ingrown toenails.

o The nail often grows back to its original thickness and the offending margin again may become problematic, resulting in another nail avulsion.

o Another nail avulsion should not be required for at least 12 weeks for the same digit.

o Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails.

• A complete nail avulsion performed more often than every 12 weeks on the same digit is not considered reasonable and necessary and will be denied.

o When avulsion of the nail plate, partial or complete is performed it represents all services performed on that nail for that date of service.

o Partial nail avulsion of separate borders of the same nail is considered a single procedure (refer to the “Coding Guidelines” attachment).

o Both avulsion and routine trimming/debridement will not be allowed on the same nail on the same day.

• For the same nail, on the same day, it is only necessary to perform one of the following procedures:

o Partial or complete avulsion (CPT codes 11730, 11732)

o Excision of nail and nail matrix (CPT code 11750)

o Wedge resection of skin of nail fold (CPT code 11765)]

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

 

 

Treatment Logic

• An ingrown nail is growth of the nail edge into the surrounding soft tissue that may result in pain, inflammation or infection.

o This condition most commonly occurs in the great toes and may require surgical management. Other conditions may also require avulsion of part or all of a nail.

• The surgical treatment of ingrown nails is considered to be medically appropriate and reasonable for an ingrown toenail in the advanced stage in which the lateral nail fold bulges 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.

 

 

Sources of Information and Basis for Decision

 

A. Martinez-Nova et al; “A New Omychocryptosis Classification and Treatment Plan”, Journal of the American Podiatric Medical Association, Sept./Oct. 2007;Volume 97, Number 5, 389-393.

 

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

 

S Yaemsiri et al; “Growth rates of human fingernails and toenails in healthy American young adults”, Journal of the European Academy of Dermatology and Venereology; April, 2010; 24(4):420-423

 

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

 

02/11/2013

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 SURGICAL TREATMENT OF NAILS