Nail Debridement

LCD Information Document Information Source LCD ID N/A LCD ID L33922 Original ICD-9 LCD ID Not Applicable LCD Title Nail Debridement Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 11/28/2019 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Nail Debridement. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Nail Debridement and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. Internet Only Manual (IOM) Citations: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 Foot Care Chapter 16, Section 30 Foot Care CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD Social Security Act (Title XVIII) Standard References: 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. Federal Register References: Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 411.15(l) Foot care Coverage Indications, Limitations, and/or Medical Necessity Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 Foot Care for indications and limitations in coverage for treatment of mycotic nails. Covered Indications Medicare will consider the treatment of fungal (mycotic) infection of the nails a covered service when the medical record substantiates: Clinical evidence of mycosis of the nail, by generally accepted clinical findings such as discoloration, onycholysis, subungual debris, thickening, or secondary skin infection; In addition one of the following must be documented for mycotic toenails: the ambulatory patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s); or the non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s). Appropriate anti-fungal treatment is necessary to qualify nail debridement as a medically necessary and reimbursable service unless contraindicated. If an anti-fungal treatment is not used, the contraindication must be documented in the medical record. Patients need not have an underlying systemic condition to be covered for mycotic nail care. Limitations As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual , Chapter 15, Section 290 Foot Care for indications and limitations in coverage for treatment of mycotic nails. Covered Indications Medicare will consider the treatment of fungal (mycotic) infection of the nails a covered service when the medical record substantiates: Clinical evidence of mycosis of the nail, by generally accepted clinical findings such as discoloration, onycholysis, subungual debris, thickening, or secondary skin infection; In addition one of the following must be documented for mycotic toenails: the ambulatory patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s); or the non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s). Appropriate anti-fungal treatment is necessary to qualify nail debridement as a medically necessary and reimbursable service unless contraindicated. If an anti-fungal treatment is not used, the contraindication must be documented in the medical record. Patients need not have an underlying systemic condition to be covered for mycotic nail care. Limitations As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual , Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.