The Centers for Medicare and Medicaid Services (CMS) has implemented a nationwide policy concerning the surgical treatment of nails. This policy establishes utilization parameters regarding the use of CPT®1 11730 and 11732*. The policy states:

A medically reasonable and necessary repeat CPT 11730 / 11732 of the same nail within 32 weeks of a previous avulsion will be considered upon redetermination.*

When is a Repeat Procedure Medically Necessary?

The policy goes on to provide examples of why a repeat procedure of the same nail may be medically necessary.  The two examples provided are:

  1. Ingrown nail of the opposite border, or
  2. A new significant pathology on the same border was recently treated.

Two of the Part B Medicare Administrative Contractors (MACs), Novitas Solutions, Inc.2 and First Coast Service Options, Inc.3, have released policies that reflect this guidance.

What Does This Mean for Your Practice?

It is important to note that these “repeat” (as defined by CMS) procedures will be considered for payment if they are medically reasonable and necessary. It is recommended that providers document the medical necessity of “repeat” avulsions or excisions when performed. Furthermore, when these medically reasonable and necessary “repeat” procedures are denied, it is important to submit redetermination requests as outlined in the CMS policy. One method that CMS uses to determine the magnitude of an issue is to track the number of redetermination requests it receives.

This policy is being contested by multiple stakeholders, including the American Podiatric Medical Association.

*ADDENDUM

Since this post was first written, following advocacy efforts from the American Podiatric Medical Association and others, CMS is now allowing medically reasonable and necessary repeat submissions of CPT® 11750 for the same toe without the need to submit for redetermination. The Novitas and First Coast Service Options Surgical Treatment of Nails Billing and Coding Local Coverage Articles both now instruct providers to report modifier KX for a medically reasonable and necessary repeat nail excision (CPT 11750) on the same toe. In this situation, the medical record must be specific as to the indication, such as an ingrown nail of the opposite border or new significant pathology on the same border recently treated.

References

  1. 2023 CPT Professional Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983–2022 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
  2. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34887&ver=44&contractorName=6&updatePeriod=968&sortBy=updated&bc=13
  3. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33833&ver=20