Nail that code
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, December 1, 2016
After examining a patient’s tender, ulcerated papule located on the left thumb lateral nail fold you biopsy it. You are tempted to code for the procedure with an 11755 nail unit biopsy CPT® code. However, is that the optimal code to use?
One should use the most specific diagnostic and procedural codes for any entity and service. The CPT features a code section dedicated to nail procedures (11719 –11765). This includes a code specific to biopsies of a nail unit. The CPT defines a nail unit biopsy as: “Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure).” Does that qualify a nail fold biopsy as a “nail unit” biopsy? Although one may be tempted to rigidly interpret a nail unit biopsy as stipulating the presence of all of the above components in a biopsy specimen, one realizes that it would be the rare biopsy indeed that would contain all of those nail unit features. Including all of them in a specimen would require a rather radical resection of tissue. In reality, by CPT convention, each entity listed within the confines of parentheses qualified by an “eg,” stands on its own as satisfying its pertinent code definition. Thus, biopsy of a nail fold, which is a component of the nail unit, satisfies the criterion for a CPT 11755 “Biopsy of nail unit” code.
Well, then, empowered with the above interpretation one may be tempted to bill an 11755 nail unit biopsy code for the sampling of dystrophic nail for KOH wet mount or fungus culture examination. Would that be correct? No! The CPT Assistant, October 2004, indicates that the nail unit biopsy code is not to be used for obtaining nail clippings or nail bed scrapings of tissue processed for KOH examination with or without a component stain, for fungal culture, or for PAS staining. The obtaining of the nail or subungual debris scraping is considered to be part of the evaluation and management (E/M) service. One would separately code and bill for a KOH fungal wet mount or for a fungus culture and interpretation (CPT code 87220 or Medicare’s code: Q0112 – Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)).
How about billing CPT 11719, “Trimming of nondystrophic nails, any number?” That is not appropriate, either, for two reasons: First, the CPT Assistant has specifically prohibited such coding as part of the rationale discussed above; second, the 11719 code pertains to nondystrophic nails, and nails trimmed for a laboratory examination are more likely dystrophic.
Example 1: You avulse a portion of a nail plate to gain access to a painful subungual suspected glomus tumor that you then biopsy. You bill CPT 11732 for the avulsion and 11755 for the biopsy.
Answer: Incorrect. “When a biopsy of the nail bed is performed after avulsion of the nail plate, it is inclusive of the avulsion procedure and is not coded separately” (CPT Assistant, December, 2002). Note that the nail unit biopsy code states, in parentheses, “(separate procedure).” This indicates that the biopsy would have to be a separately identifiable procedure not related to another nail unit procedure. In the above vignette the biopsy is a secondary procedure related to the nail plate avulsion, and as such, does not constitute a separate procedure. Only 11732 should be billed.
Example 2: A patient with dystrophic, thickened, yellowed toenails and copious subungual debris has a portion of the hyperkeratotic nail bed scraped or curetted for the purpose of obtaining material for a KOH wet mount examination. CPT 11055, Paring or curetting of benign hyperkeratotic lesion (eg, corn or callus), single lesion, is billed for the specimen production.
Answer: Incorrect. A CPT Assistant October 2004 article on nail procedures disallowed billing nail unit biopsy codes for nail bed scrapings, stating that scraping is integral to the evaluation and management care. Consequently, code 11055 is not appropriate. Notice, also, that in this scenario the intent is to obtain subungual scale for a KOH examination, rather than to therapeutically pare a lesion. This is similar to the process of scraping non-subungual skin, or a molluscum lesion, or a suspected herpetic lesion for wet mount slide processing and examination. The obtaining of the scraped tissue is a component of the evaluation and management. One codes for the laboratory procedure and interpretation only.
Example 3: While barefoot one opens a freezer to fetch a frozen chicken for dinner cooking. However, as a final revenge for plastic package encasement and freezing, the chicken slips out and tumbles onto the unprepared cook’s left great toe, partially avulsing the nail and leaving a stellate nail bed defect. The patient hobbles into your office for help. You avulse the great toenail and suture the nail bed defect shut. You bill CPT 11760 for the nail bed repair.
Answer: Correct. CPT 11760 specifies a nail bed repair, including a nail plate removal. Thus, CPT 11730, nail avulsion, partial or complete, simple; single, would not be billed along with the repair code. The nail bed repair includes any reflection of the proximal nail fold for the purpose of accessing a laceration in that location. If the falling chicken were to have lacerated toe skin beyond that of the nail bed a repair of that area would be specified by the appropriate simple, intermediate, or complex repair CPT codes.
Example 4: You trim a lateral nail fold nail spicule that catches on clothing but otherwise is asymptomatic. You bill CPT 11719, trimming of nondystrophic nails, any number.
Answer: Technically correct, as this procedure was done. However, if this were a Medicare patient, the service would not be covered and would be considered to be a component of an evaluation and management service. Consequently, billing CPT 11719 to Medicare for this situation would result in a non-covered service rejection. Unless the patient had signed an appropriate Advance Beneficiary Notice prior to the service, no payment would be recoverable from the patient. Check your Medicare Administrative Contractor’s website for any local coverage determinations dealing with nail treatment and care, as some have published specific criteria for coverage.
Example 5: A bilateral matricectomy is done on a Texas Medicare patient’s bilaterally ingrown toenail. CPT 11750, Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal is billed once.
Answer: Correct. A nail avulsion is a component of the matricectomy code, so one would not bill a nail avulsion code, 11730, separately. Although bilateral matricectomies, with a preservation of the central nail, were done, one bills only a single unit of code 11750 for the procedure. The Texas Medicare Administrative Contractor’s local coverage article, Surgical Treatment of Nails (A52998), specifies that only one matricectomy code should be reported when done bilaterally on a single nail unit.
