General Surgery Coding Alert

Question: During an appointment for an ingrown toenail surgery, the surgeon finds that the patient has another ingrown toenail on the other foot, and removes both nails. What procedure code(s) should I report, and can I claim a separate E/M?

Iowa Subscriber

Answer: You should report two units of 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown ordeformed nail] for permanent removal).

It may be appropriate to bill an E/M service as well. Depending on the physician’s documentation, you may be able to bill for the work in assessing the patient’s other foot and making the plan to excise both ingrown nails during the same encounter. If you do bill for an E/M service, don’t forget to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)to indicate that this was a separate service.

Modifiers can help: You can use anatomic modifiers to emphasize the two separate nails, such as 11750-T5 (Right foot, great toe) and11750-59-TA (Distinct procedural service, Left foot, great toe).