Nail services review

September 1, 2007

I receive many questions about how to bill for various nail services.

I receive many questions about how to bill for various nail services.

In this article, I will provide information to answer some of these frequently asked questions.

There are many Local Medical Review Policies (LMRPs) and Local Carrier Decisions (LCDs) regarding various aspects of nail treatment, so make sure that if your practice is providing nail services you carefully monitor your carriers' Web site for rules and regulations.

1. In the definition above, separate procedure means that you can bill this code only once for each nail you biopsy - whether the biopsy is from the plate, bed, matrix, hyponychium, proximal or lateral nail fold of each nail.

a. Some Medicare carriers require the use of modifiers 59 or 51 instead of modifier 76 when identical services are billed. Check the local carrier policy for billing guidelines.

b. Do not bill these codes in units.

2. CPT code 11755 is subject to the multiple surgery reduction rule. In the above example, the carrier would reduce the second and third nail biopsies by 50 percent.

3. If you bill a nail biopsy on the same date of service as a skin biopsy, the skin biopsy (CPT code 11100) will be reduced by 50 percent.

Modifier 59 would be required on CPT code 11755 as the skin biopsy and nail biopsy are bundled per Version 13.2 of Medicare's Correct Coding Initiative.

4. This code may be appropriate when a portion of the nail is obtained and sent to the pathologist for PAS staining. Since a pathology service is performed and a pathology report is obtained, the use of CPT code 11755 in this situation should be acceptable. You may wish to verify this coding scenario with your local carrier, although this is the commonly accepted way to bill for this service in the dermatologic community.

5. Even if you only have one diagnosis, as long as the evaluation and management (E/M) visit is properly documented for the level of care billed, you can charge the new patient E/M service for new patient encounters. Be sure to use modifier 25 on the E/M visit.

6. The Medicare allowable (national average) for this code is $114.07.

7. This code has zero global postoperative days.

Nail avulsion

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

11732: each additional nail plate

(List separately in addition to code for the primary procedure)

(Use CPT code 11732 in conjunction with code 11730)

Note: Triple your charge for CPT code 11732 since you are billing three units. (In this example, 11732 was billed at $40.)