Billing and Coding: Nail Debridement

This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33922 Nail Debridement provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to the LCD for reasonable and necessary requirements and limitations. The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD. Coding Guidelines For nail debridement not related to symptomatic mycotic nails but associated with a systemic condition, refer to the Routine Foot Care LCD L33941. Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. The provider of the service(s) must document the affected nail(s), including the clinical evidence of mycosis, and the manner in which and to what extent the nail(s) were debrided. Use of appropriate anti-fungal treatment or the contraindication of such treatment must also be documented. In addition, a description of the qualifying symptoms for debridement of toenail(s) must be documented. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Compliance with the provisions in LCD L33922, Nail Debridement may be monitored and addressed through post payment data analysis and subsequent medical review audits.