Primary Care Coding Alert

Question: An established patient complaining of pain in toes on both feet reports to the physician with a swollen, red left pinky toe and a swollen right big toe. The physician conducts a level-two E/M, and diagnoses two ingrown toenails. She then performs partial nail excision on both toes. Can I report a code for each nail trimming?

Minnesota Subscriber

Answer: Because the trimmings occurred on different feet, you should be able to report a removal code for each.

T modifiers are vital: On your toenail care claims, it is important to include the appropriate T modifiers to show payers which toes the physician treated. The inside cover of the CPT manual has a list of all the T modifiers. On the claim, report the following:

- 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown or deformed nail] for permanent removal) for the left toe trimming with modifier T4 (Left foot, fifth digit) to indicate the location of the procedure.

- 11750 for the right toe trimming with modifier T5 (Right foot, great toe) to indicate the location of the procedure.

- modifier 59 (Distinct procedural service) appended to the second 11750 entry to show that the procedures were separate.

- 703.0 (Ingrowing nail) linked to 11750 and 11750-59 to represent the patient's toenail problems.

- 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M.

- 729.5 (Pain in limb) linked to 99212 to represent the patient's foot pain.

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99212 to show that the nail excision and E/M were separate services.

Payer exceptions: Some Medicare carriers will not want to see modifier 59 appended to the second 11750. Medicare in Florida, for example, wants to see modifier 51 (Multiple procedures) on this claim, because the physician performed pre- and postoperative services once. Other Medicare carriers consider the T modifiers evidence that the trimmings happened on different toes; you might not need modifier 59 for these payers.