Podiatry Coding & Billing Alert

Use these 3 questions and answers to spot the difference between medically necessary toe treatment and routine foot care.

Podiatrists are in the crosshairs for routine foot care in 2017, but you can’t sacrifice patient care by avoiding providing the needed procedures or dishing out unnecessary ABNs. Learn these toenail codes back and forth so you can code with precision to provide full care and report for full reimbursement.

Routine or Nah?

Certain ingrown toenail treatments are considered part of routine foot care, and thus billable only with G0127 (Trimming of dystrophic nails, any number), 11719 (Trimming of nondystrophic nails, any number), and 11720-11721 (Debridement of nail[s] by any method[s]…) for some payers.

According to Medicare’s fact sheet on podiatry services, for procedure codes 11730, 11732, 11750, and 11765, an operative report or complete detailed description of the procedure being performed is required. Failure to include the following information in the patient’s medical record could result in denial of the claim.

• The patient’s chief complaint (e.g., painful toe)  
• Procedure being performed (making note to the nail margin involved)
• Method of obtaining anesthesia (if not used, the reason for not using it)
• A complete detailed description of the procedure 
• Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied)
• Postoperative instructions given to the patients and any follow-up care (e.g., soaks, antibiotics, follow-up appointments)

The medical record must be available upon request. “The items stated are required to be in the notes,” says Dr. Arnold Beresh, DPD, CPC. “If not, your claim may be denied or rescinded on audit.”

3 Q&As: Know How to Differentiate the Codes

1. Question: So my podiatrist treated a patient’s ingrown toenail by removing the affected toenail and the inflamed skin. He packed it with gauze. How would I code for this?

Answer: In this case, you would code 11765 (Wedge excision of skin of nail fold [e.g., for ingrown toenail]). A wedge excision is a quick and dirty excision of the lateral nail fold limited to the “ingrown part.”

Because your physician just removed the inflamed tissue adjacent to the nail and a section of the nail itself, along the whole length of the nail. It’s called a wedge because the incision just removes the soft tissue from the nail margins that are affected.

Your physician will administer local anesthesia, then cut out the nail and make a triangular incision that just removes the affected skin.

2. Question: We had a patient present with two severely ingrown toenails on the right foot, the big toe and the second toe, and then one on the greater toe on the left foot. The physician’s notes indicate that he removed the nail plate. How do I code these? Are they all codes together?

Answer: This is a bit trickier.

The basic code is 11730 (Avulsion of nail plate, partial or complete, simple; single) and 11732 (…each additional nail plate [List separately in addition to code for primary procedure]).

It involves cutting away the nail plate from the bed, and can be either partial or complete. A standard digital block is performed, and a nail elevator or iris scissors are used to separate the nail plate from the nail bed.

Since 11730 covers either all or part of the nail, you don’t need to indicate “bilateral” sides of a single nail.

Include modifier 59 (Distinct procedural service) for the second and third toes your podiatrist treated. And since the modifiers for toes include the foot, you only need to indicate the toes themselves:

• 11730-T5 (Right foot, great toe)
• 11730-T6-59 (Right foot, second digit)
• 11730-TA-59 (Left foot, great toe).

3. Question: We have a patient who came to our office reporting pain from an ingrown small toenail on each foot. He said they’ve always bothered him, and upon looking at the physician sees that they’re deformed. He removed and cauterized them. How do we code for this?

Answer: If the toenail is being removed permanently, you’ll need to code 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown or deformed nail], for permanent removal). This includes removal of the nail plate, matrix, and lunula.

Because the goal is to stop a new nail from forming and continuing the problem, your doctor will also take steps to destroy the nail matrix.

You should code each toenail removal. Report 11750 for the first complete removal and 11750 for the second removal and append 50 to tell the insurer that the pediatrician performs the toe removal as a bilateral procedure.

You don’t need to report the cauterization, since it’s included in 11750.

• 11750
• 11750-50

To read further on what qualifies as routine foot care, please visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicarePodiatryServicesSE_FactSheet.pdf.