Wiki 11730 avulsion nail plate partial/complete

[amylynn911]

We have filed with Medicare 99212.25 and 11730 Diagnosis L60.1 onycholyis and S69.82XA other specified injuries of left hand etc. Medicare has denied the 11730, I was told to do a medical review to Medicare. I had thought that the procedure would have to billed alone, that Medicare would pay for one or the other but not both. Any help would be great. Thank you

 

[ellzeycoding]

Did you use a digit modifier for the nail avulsion code?

Also, keep in mind the E/M is paypable only if its for a separate and identifiable service (i.e., unrelated to) the nail avulsion.

Left Finger/Toe

FA/TA Left, thumb/great toe
F1/T1 Left, second digit
F2/T2 Left, third digit
F3/T3 Left, fourth digit
F4/T4 Left, fifth digit

Right Finger/Toe

F5/T5 Right, thumb/great toe
F6/T6 Right, second digit
F7/T7 Right, third digit
F8/T8 Right, fourth digit
F9/T9 Right, fifth digit

 

[amylynn911]

We did, this is the response I got from Medicare:
CO-50 : These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 09/20/2009

I can do a medical review to show that is was deemed medical necessity.

 

[boomba003]

11730 avulsion

This denial remark is usually due to either a Local Coverage Determination (LCD) or the leading diagnosis was wrong. L60.0 for example (ingrowing nail) as the leading diagnosis would have paid the claim. We bill this all the time for toes and have no problems. Because this was apparently an injury, the leading diagnosis should have probably been the injury code.

Billing the E/M with this procedure should also be reviewed. The diagnosis aside, the claim was billed properly, but it may have been over billed. This appears to be a Problem Focused encounter with an establish patient that may not be significant enough to warrant an office visit code. If the patient had other conditions that were examined, the E/M would be fine, if documented. Medicare unlikely would have not denied this claim since they would not know if the E/M was significant or not unless they recalled the medical records.

Check your local MAC's LCDs to see if this code is listed.

wklyn@roadrunner.com