Podiatry Coding & Billing Alert

Question: Is there a code you would charge for seeing a patient and doing a clipping of the nail, then sending it to pathology for analysis for fungus? Can I bill 11755 along with an E/M?

Utah subscriber

Answer: In your case, code 87101 (Culture, fungi [mold or yeast] isolation, with presumptive identification of isolates; skin, hair, or nail) seems more appropriate.

You are bound by E/M rules when obtaining nail clippings or nail bed scrapings for purposes of performing a fungal culture, KOH preparation, stain or test, or PAS stain as these activities are part of an evaluation and management visit involving the medical management of the nail condition. When medically appropriate, separate nail trimming and/or nail debridement services should be indicated with the specific codes. If your provider only performed a nail clipping for obtaining the sample that would be a part of the service then no separate E/M can be reported.

For example, you cannot report E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…) + 87101 as no separate procedure code is allowed with lab 87101-87102 (…other source [except blood]). However, if he did a routine foot care (RFC), you can bill 11719 (Trimming of nondystrophic nails, any number) + 87101.

If it was actually a biopsy, then depending upon the extent of removal, you can also report a separate procedure, e.g., 11730 (Avulsion of nail plate, partial or complete, simple; single) + 11755 (Biopsy of nail unit [e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds] [separate procedure]).

So, to answer the question directly: no, according to your description, the nail clipping was removed for a culture and not a biopsy as reported by 11755. You can report 11755 only if the physician removes a portion of the nail unit for a biopsy sample. The physician may obtain the portions from the hard nail itself, the nail bed, lateral skin, or underlying soft tissue. The physician then excises (and does not just clip) the specimen by clippers or with a scalpel.