Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27487

Debridement of Mycotic Nails

L27487

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Medicare Benefit Policy Manual - Pub. 100-02, Chapter 15, Section 290

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Fungal disease of the toenails is a comparatively benign condition, but difficult to eradicate due to a high recurrence rate. A superficial variety of fungal infections produce little or no symptomatology beyond white opacities on the nails. However, deep infections may result in dystrophic nails, with subsequent pain and/or limitation of ambulation, and/or secondary infection. The definitive treatment may involve a short-term use of oral agents, long term use of topical agents and/or periodic debridement of the dystrophic fungal nails with thinning of the nail plates (manual or electric).

Debridement of nails is a temporary reduction in the size or girth of an abnormal nail plate, short of avulsion. It is performed most commonly without anesthesia to accomplish any or all of the following objectives:

• Relief of pain
• Treatment of infection (bacterial, fungal, and viral)
• Temporary removal of an anatomic deformity such as onychauxis (thickened nail), or certain types of onychocryptosis (ingrown nail)
• Exposure of subungual conditions for the purpose of treatment as well as diagnosis (biopsy, culture, etc)
• As a prophylactic measure to prevent further problems, such as a subungual ulceration in an insensate patient with onychauxis.

Debridement of mycotic nails is considered to be routine foot care.

Indications

Whether by manual method or by electrical grinder, debridement is a modality used as part of the definitive antifungal treatment of onychomycosis.

Payment may be made for the debridement of a mycotic nail (whether by manual method or by electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met:

I. In the absence of a systemic condition, the following criteria must be met:

1. Clinical evidence of mycosis of the toenail AND

2. Marked limitation of ambulation, pain, and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

1. Clinical evidence of mycosis of the toenail AND

2. The patient suffers from pain and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

II. For patients with a systemic condition and clinical evidence of mycosis of the toenail, but who do not meet the above criteria, refer to Local Coverage Determination: Routine Foot Care.

Medicare does not routinely cover fungus cultures and KOH preparations performed on toenail clippings in the doctor’s office. Identification of cultures of fungi in the toenail clippings is medically necessary only:

• When it is required to differentiate fungal disease from psoriatic nails.

• When a definitive treatment for a prolonged period of time is being planned involving the use of a prescription medication.

Limitations

Whirlpool treatment prior to the debridement of mycotic nails to soften the nails or the skin is not eligible for separate reimbursement.

Debridement codes should not be used to report the simple trimming, cutting, or clipping of the distal nail plate.

Foot Care

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. For each service encounter, the medical record should contain a description of each nail, which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local pathology caused by each affected nail resulting in the need for debridement must be documented. For CPT code 11720 documentation of at least one nail will be accepted. For CPT code 11721 complete documentation must be provided for at least 6 nails.
   
   
5. Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral or topical antifungal therapy has been planned. If cultures are performed and billed, documentation of cultures and the need for prolonged oral or topical antifungal therapy must be in the patient record and available to Medicare upon request.
   
   
6. The medical record must clearly document which nails were treated at every visit.
   
   
7. Services for debridement of more than five nails in a single day may be subject to special review. Documentation to support the medical necessity of such services must be in the patient's record and available to Medicare upon request.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Routine foot care services provided more often than every 60 days will be denied.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27487

07/31/2008

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