Local Coverage Article Billing and Coding

Billing and Coding: Debridement of Mycotic Nails

A56640

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Contractor Information

Article Information

General Information

Article ID
A56640
Article Title
Billing and Coding: Debridement of Mycotic Nails
Article Type
Billing and Coding
Original Effective Date
07/11/2019
Revision Effective Date
09/12/2019
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

Please refer to the related LCD, L35013.

Article Guidance

Article Text

Refer to the Novitas Local Coverage Determination (LCD) L35013, Debridement of Mycotic Nails, for reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

CPT codes 11720 and 11721 will not be reimbursed more often than once every 60 days.

CPT codes 11720 and 11721 may be limited to 6 sessions per beneficiary, per 12 months. Refer to the Utilization Guidelines in the related LCD for information related to this limitation.

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
11720 Debride nail 1-5
11721 Debride nail 6 or more

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(17 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. 

Medicare is establishing the following limited coverage for CPT/HCPCS codes 11720 and 11721.

Note
: ICD-10-CM code B35.1 must appear on each claim in addition to one of the other ICD-10-CM codes below that indicates secondary infection, pain, or difficulty in ambulation.

Group 1 Codes
CodeDescription
B35.1 Tinea unguium
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L60.0 Ingrowing nail
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.661 Pain in right lower leg
M79.662 Pain in left lower leg
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
R26.2 Difficulty in walking, not elsewhere classified
R26.89 Other abnormalities of gait and mobility
R26.9 Unspecified abnormalities of gait and mobility

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
083x Ambulatory Surgery Center
085x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
09/12/2019 R2

In addition to the update below, due to system changes, the coding section of this Article has been reorganized and a new section for modifiers has been added.

09/12/2019 R1

Article revised and published 9/12/2019. CPT code 11721 has been added to the article text to be consistent with the LCD language. 

Associated Documents

Related Local Coverage Documents
LCDs
L35013 - Debridement of Mycotic Nails
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
09/06/2019 09/12/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A