Primary Care Coding Alert

Question: Our FP recently performed removal of the inflamed tissue adjacent to the nail along both sides of a toenail. Since the procedure was done on both sides, we reported two units of 11765. The payer denied the claim saying that the payment for two units has been wrongly reported. Our clinician is asking us to appeal the claim. Are we correct, or should we only report one unit of the code?

Vermont Subscriber

Answer: Since your FP performed the procedure on only one toenail, you should report the procedure with only one unit of 11765 (Wedge excision of skin of nail fold [e.g., for ingrown toenail]), even though the procedure was done on both the sides of the same toenail.

If the procedure was done on more than one toenail, you could report it with additional units of the code along with an appropriate modifier to indicate which of the toenails your clinician operated upon.

You should use these HCPCS site modifiers to let the payer know exactly which toenail your clinician is treating:

• TA -- Left foot, great toe
• T1 -- ...second digit
• T2 -- ... third digit
• T3 -- ... fourth digit
• T4 -- ... fifth digit
• T5 -- Right foot, great toe
• T6 -- ... second digit
• T7 -- ... third digit
• T8 -- ... fourth digit
• T9 -- ... fifth digit.