Nail it

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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A prospective patient opens a top freezer door, reaches for ice cream, but in the process dislodges a frozen chicken that tumbles out, falling directly upon a bare big toe. A painful subungual hematoma leads to a frantic visit to you, the patient’s established dermatologist. Lacking a drill but being well stocked with paper clips, you unwind a paper clip, heat its tip with a lighter used for KOH slide preps, and gently burn through the nail plate, liberating a geyser of dark blood and immediately relieving the pain. You then bill for the procedure with Current Procedure Terminology (CPT) code 10140, “Incision and drainage of hematoma, seroma or fluid collection”. You did an exquisitely effective therapeutic procedure, but did you bill correctly?

The CPT indicates that one should select a code that most accurately specifies, rather than approximates, a performed service. One finds that the CPT has a section devoted to nail procedures: CPT 11720 11765, which lists the following code: 11740, Evacuation of subungual hematoma. Thus, the more precise code 11740, rather than 10140, should have been used to characterize the hematoma extrusion in the above vignette.

The “Nails” section of the CPT lists nail-specific procedural codes. The following is a list extracted from the CPT®.

11720 Debridement of nail(s) by any method(s); 1-5

11721              6 or more

11730 Avulsion of nail plate, partial or complete, simple; single

11732              each additional nail plate (List separately in addition to code for primary procedure)

11740 Evacuation of subungual hematoma

11750 Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent removal;

11752              with amputation of tuft of distal phalanx

11755 Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail fold(s) (separate procedure)

11760 Repair of nail bed

11762 Reconstruction of nail bed with graft

11765 Wedge excision of skin of nail fold (eg, for ingrown toenail)

Example 1: You obtain a smear swab from the proximal nail fold area of an exudative paronychia on a commercially insured patient and do an in-office KOH processing and examination of the specimen for the presence or absence of Candidal organisms. You bill CPT 87220 for the KOH examination.

Answer: Incorrect. The CPT lists two potential codes for KOH processing. CPT 87220 is for skin, hair, or nails tissue KOH slide examination. In this case the specimen is of a wet mount smear of exudate, rather than of actual tissue. Consequently, the more appropriate CPT code is 87210, “wet mount for infectious agents (e.g., saline, India ink, KOH preps).”

Example 2: You obtain the same swab specimen as in Example 1, but from a Medicare insured patient. You bill the Medicare Administrative Contractor the Healthcare Common Procedure System (HCPCS) code Q0112, as Medicare preferentially recognizes this code, published in the HCPCS manual.

Answer: Correct. HCPCS code Q0112 is defined as: “All potassium hydroxide (KOH) preparations”. This should be used for Medicare patients instead of the CPT code. Note that there is another HCPCS code, Q0111, defined as, “Wet mounts, including preparations of vaginal, cervical or skin specimens.” As in this example a KOH examination was done, code Q0112 is the appropriate choice. [pagebreak]

Example 3: A patient’s great toenail contains white spots of uncertain cause. Are they caused by white superficial onychomycosis, or are they leukonychia due to trauma? You use nail nippers to remove a portion of the affected nail plate and submit it for histologic processing and PAS staining for fungus identification. You bill CPT 11755 for the nail biopsy and 88312-26 for the professional component of interpretation and report of a Group I for microorganisms PAS special stain.

Answer: Incorrect. CPT code 11755 describes “Biopsy of nail unit (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure).” The October 2004 CPT Assistant, page 14, indicates that this biopsy procedure code is not appropriate for reporting the production of nail clippings or scrapings for fungal cultures, KOH preps, or stains including PAS. Obtaining pieces of nail is included in the evaluation and management process and is not separately billable. Histologic processing, including the preparation of PAS stained nail on a microscope slide and interpretation, are separately billable with CPT 88312 global, appended TC for the technical component only, or appended 26 for the professional component, including the generation of a report.

Example 4: You relieve pain and tenderness caused by thick, yellowed, dystrophic great toe nails by debriding and trimming the nails with nail nippers, process some of the clippings for KOH prep examination, and send others for a fungal culture. You then bill CPT 11720 for the debridement and 87220 (or HCPCS Q0112 for Medicare patients) for the KOH prep.

Answer: Correct. CPT 11720 indicates “Debridement of nail(s) by any method(s); 1 to 5.” This includes the debridement of fungal infected nails, hypertrophic nails, and dystrophic nails. This code does not relate to what is done with the removed nail portions. However, if those are sent for further examination, such as KOH prep processing, then the appropriate code for the laboratory procedure should be specified.

Example 5: You remove the entire lateral longitudinal length of a painful ingrown toenail and cauterize the nail matrix of the removed portion of nail with phenol. You bill CPT 11750, “Excision of nail and nail matrix, partial or complete,” for the nail removal and matrixectomy.

Answer: Correct. Although the procedure that was done did not include an actual excision of the matrix, CPT code 11750 is appropriate. This is corroborated in the CPT Assistant, December 2002, page 4, which states that code 11750 includes a destruction of the matrix with surgical, laser, electrocautery, or chemical techniques.

Example 6: Your dear friend with excellent insurance pops in with a traumatic partial nail avulsion and laceration of the distal dorsal finger extending into the nail bed. You remove the nail and meticulously sew together the nail bed as well as the laceration on the adjoining proximal finger. You bill CPT 11760, repair of nail bed, to insurance.

Answer: Partially Correct. In addition to repairing the nail bed, specified with CPT 11760, you also repaired the dorsal finger skin beyond that of the nail unit. It is appropriate to separately code for this procedure with a simple, intermediate, or complex repair code corresponding to the complexity and measured length of the repair.

As in all cases, the assignment of a CPT code does not guarantee reimbursement, as individual insurance company coverage criteria must be met in order to qualify for payment. Some Medicare Administrative Contractors maintain Local Coverage Determinations (LCD) specifically dealing with nail debridement.

Example 7: You avulse the nail in order to expose a nail bed lesion and do an incisional biopsy that you suture shut. You bill CPT 11730 for the nail plate avulsion and 11755 for the nail unit biopsy.

Answer: Incorrect. Only CPT 11755 should be billed, as the nail plate avulsion (and replacement, if done) is included in the 11755 code descriptor, which also includes suturing of the biopsied tissue (CPT Assistant, October 2004).