LCD Reference Article Response To Comments Article

Response to Comments: Surgical Treatment of Nails

A58960

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
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Article ID
A58960
Original ICD-9 Article ID
Not Applicable
Article Title
Response to Comments: Surgical Treatment of Nails
Article Type
Response to Comments
Original Effective Date
12/16/2021
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The following are the comment summaries and contractor responses for First Coast Service Options, Inc. Proposed Local Coverage Determination (LCD) DL33833, Surgical Treatment of Nails , which was posted for comment on 7/29/2021, and presented at the 8/12/2021 JN Open Meeting. All comments were reviewed and incorporated into the final LCD where applicable.

Response To Comments

Number Comment Response
1

A letter with multiple comments was received from the American Podiatric Medical Association (APMA) and the American Academy of Dermatology Association (AADA). The associations agree with the statements and support the limitations:

  1. Nail debridement or removing small chips or wedges of the nail and/or skin that does not require local anesthesia does not constitute surgical treatment of a nail.
  2. Trimming, cutting, or clipping of the distal unattached nail margins does not constitute surgical treatment of a nail.
  3. Surgical treatment of asymptomatic conditions.

The associations further stated this is consistent with education APMA and AADA have previously provided to our membership and APMA and AADA plan to continue to provide this guidance, especially to our First Coast providers should this proposal be finalized.

The APMA and the AADA provided comments regarding limitation 4. Repeat nail avulsion on the same toe or finger following a complete nail avulsion performed more frequently than every 8 months (32 weeks) for toenails or 4 months (16 weeks) for fingernails. The commenters noted that CPT code 11730 does not differentiate between a partial nail avulsion and a complete nail avulsion and providers have no way to indicate with CPT coding or modifiers if a partial or complete nail avulsion was performed. Also, providers have no way to indicate with CPT coding or modifiers if the medial, lateral or both borders were treated. In addition, the commenters stated while the references in the Proposed LCD speak to how long it may take a toenail to grow from the matrix to the distal tip of the toe, there is no peer-reviewed literature that speaks to how long it may take for an ingrown toenail to occur at the most proximal aspect of a medial or lateral nail border following complete nail avulsion.

The APMA and the AADA provided comments regarding limitation 5. Repeat nail excision on the same toe or finger following a complete nail excision for permanent removal. The commenters noted that CPT code 11750 does not differentiate between a partial nail permanent removal and a complete nail permanent removal and providers have no way to indicate with CPT coding or modifiers if a partial nail permanent removal or a complete nail permanent removal was performed. Also, the commenters stated that providers have no way to indicate with CPT coding or modifiers if the medial, lateral or both borders were treated. In addition, they stated as shared in this Proposed LCD, a Cochrane systematic review found that one in 25 patients experience recurrence following nail avulsion with phenolization (permanent removal).

Thank you for your support for the proposed LCD limitations 1, 2, and 3.

In response to the concerns regarding limitations 4 and 5, the billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits. 

2

A comment was received regarding limiting coverage to symptomatic patients. The commenter noted that patients with peripheral neuropathy or radiculopathy with loss of sensation can present with no pain.

Thank you for your comments. Symptoms of nail disease requiring surgical treatment are not limited to pain. Other symptoms include but are not limited to edema/swelling, erythema, drainage, infection, ulceration, and granulation tissue. 

3

A comment was received regarding LCD limitation 4. Repeat nail avulsion on the same toe or finger following a complete nail avulsion performed more frequently than every 8 months (32 weeks) for toenails or 4 months (16 weeks) for fingernails. The commenter noted recurrence of a symptomatic pathology can occur within a few months after treatment is performed and although not common, 2-3 months is possible.  

Thank you for your comments. The billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits.

4

A comment was received regarding LCD limitation 5. Repeat nail excision on the same toe or finger following a complete nail excision for permanent removal. The commenter noted that permanent removal is not an absolute and there is a percentage of reoccurrence with surgical intended permanent procedures.

Thank you for your comments. The billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits. 

5

A comment was received regarding the use of local anesthesia. The commenter noted that patients with a diagnosis of loss of protective sensation/numbness do not require local anesthesia for nail surgeries. 

Thank you for your comment. The billing and coding article documentation requirement 4 allows for providers to document in the medical record the reason for not using local anesthesia. 

6

Comments were received regarding language in the proposed LCD History/Background and/or General Information section.

Thank you for your comment. The History/Background and /or General information section was revised to remove the acronym PNF and spell out “proximal nail fold” where it appears in the text. Also, the language in multiple paragraphs was revised for clarification. The last sentence in the second paragraph under the History/Background and /or General information section, was revised to include the verbiage: “include but are not limited to” those with uncontrolled diabetes mellitus, ...” Revision was made to the last sentence of the third paragraph to clarify that surgical treatments are “typically” used in moderate and severe cases. In the fourth paragraph, additional language to include that “comorbidities or risk factors for complications” may be considered for the treatment of subungual hematoma was added. The fifth paragraph was revised to include the language “or other conditions” that may be indicated as an underlying cause of Onychauxis or the thickening of the nail plate. In the seventh paragraph, language was added to clarify all options of matrixectomy performed when treating ingrown toenails. In the eighth paragraph, the description of wedge excision was revised to read more consistent with Current Procedural Terminology coding.

7

Comments were received regarding covered indications 3 and 8. The commenter noted that periungual tumors and acquired forms of nail dystrophy may require nail surgery.

Thank you for your comments. The LCD indication 3 was revised to include periungual tumors and indication 8 was revised to include acquired nail dystrophies. 

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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