Debridement of Nails

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for beneficiaries receiving outpatient therapy services. 

eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized Debridement of Nails services results log on to eServices. 

Medicare Coverage of Routine Foot-Care Services (Overview of Debridement of Nails Services) 
Did you know that Medicare has a National Coverage Determination (NCD) for Routine Foot Care? Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section §290 (PDF) is where you can find the entire national policy for routine foot care and mycotic nail debridement. The term mycotic is the infection with a fungus or a disease caused by a fungus. Mycotic nails are also known as onychmycosis. The disease presents as brittle or crumbly nails that appear abnormal in shape and texture. The nails appear yellow or brown and are thick and discolored. They may even separate from the nail bed, loosening or lifting from their normal position and may have debris trapped underneath. Toenails or fingernails may be affected, but it is more common for toenails.

Medicare coverage of debridement of nail services must be supported by the documentation. For each service encounter for debridement of mycotic nails, the medical record should contain a description of each debrided nail that reflects clinical descriptors consistent with mycotic nails. If appropriate the clinical descriptor may encompass multiple nails with the same findings. (e.g., the nail for toes 1, 3, 5 are yellow, brittle, thickened, etc.). Definitive treatment of mycotic nails involves the appropriate use of effective antifungal pharmacologic agents with or without periodic debridement of dystrophic nail plates. Medicare will cover debridement of mycotic nails as an adjunct to pharmacologic treatment with a prescription antifungal agent indicated per its Food and Drug Administration (FDA) label for the treatment of fungal nail infections.

Although CPT® coding does not exclusively apply CPT® codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT® codes usually used to code for services related to debriding mycotic nails Billing and Coding: Routine Foot Care A56680.

The nail debridement procedure codes (11720–11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined in the LCD for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care, they must meet the same criteria as all other routine foot care services to be considered for payment.

Before submitting/billing for this service review the following questions and develop a checklist to assist your practice with meeting the Medicare requirements for billing and reimbursement:

• Do you have a covered primary diagnosis?
• Do you have a covered secondary diagnosis?
• Does the patient’s record include identification (by number or name) and description of all nails treated?
• Is there a description of the debridement procedure beyond simple statements such as “nail(s) debrided?”
• Does the record demonstrate the necessity of debridement of each debrided nail considering the patient’s usual activities?
• Was the order dated and issued by the supervising physician prior to mycotic nail debridement services being rendered?
• Does the order meet he criteria for medically necessary services to address a specific patient complaint or physical finding?

Documentation must comply with all legal and regulatory requirements applicable to Medicare claims. 

CMS works to eliminate improper payments in the Medicare Program and protect the Medicare Trust Fund, as well as beneficiaries from medically unnecessary services or supplies and their associated costs. CMS calculates a national Medicare fee-for-service (FFS) improper payment rate and improper payment rates by claim type and publishes the review results annually.

Methods
The metrics reviewed in this eCBR are the proportion of billing for claims denied for 11720 and 11721 versus all therapy-billed claims for comparisons performed for your peers within the state and jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing at each level compared to your peers in Jurisdictions J and M.