LCD Reference Article Response To Comments Article

Response to Comments: Surgical Treatment of Nails

A58961

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Novitas Solutions, Inc.	A and B MAC	04111 - MAC A	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04112 - MAC B	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04211 - MAC A	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04212 - MAC B	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04311 - MAC A	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04312 - MAC B	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04411 - MAC A	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04412 - MAC B	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04911 - MAC A	J - H	Colorado New Mexico Oklahoma Texas
Novitas Solutions, Inc.	A and B MAC	07101 - MAC A	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07102 - MAC B	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07201 - MAC A	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07202 - MAC B	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07301 - MAC A	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	07302 - MAC B	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	12101 - MAC A	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12102 - MAC B	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12201 - MAC A	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12202 - MAC B	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12301 - MAC A	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12302 - MAC B	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12401 - MAC A	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12402 - MAC B	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12501 - MAC A	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12502 - MAC B	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12901 - MAC A	J - L	Delaware District of Columbia Maryland New Jersey Pennsylvania

Article Information

General Information

Article ID
A58961

Article Title
Response to Comments: Surgical Treatment of Nails

Article Type
Response to Comments

Original Effective Date
12/16/2021

Retirement Date
N/A

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Article Guidance

Article Text

The following are the comment summaries and contractor responses for Novitas Solutions Proposed Local Coverage Determination (LCD) DL34887, Surgical Treatment of Nails, which was posted for comment on 7/29/2021, and presented at the 8/13/2021 JH JL Open Meeting. All comments were reviewed and incorporated into the final LCD where applicable.

Response To Comments

Number	Comment	Response
1	A letter with multiple comments was received from the American Podiatric Medical Association (APMA) and the American Academy of Dermatology Association (AADA). The associations agree with the statements and support the limitations: Nail debridement or removing small chips or wedges of the nail and/or skin that does not require local anesthesia does not constitute surgical treatment of a nail. Trimming, cutting, or clipping of the distal unattached nail margins does not constitute surgical treatment of a nail. Surgical treatment of asymptomatic conditions. The associations further stated this is consistent with education APMA and AADA have previously provided to our membership and APMA and AADA plan to continue to provide this guidance, especially to our Novitas providers should this proposal be finalized. The APMA and the AADA provided comments regarding limitation 4. Repeat nail avulsion on the same toe or finger following a complete nail avulsion performed more frequently than every 8 months (32 weeks) for toenails or 4 months (16 weeks) for fingernails. The commenters noted that CPT code 11730 does not differentiate between a partial nail avulsion and a complete nail avulsion and providers have no way to indicate with CPT coding or modifiers if a partial or complete nail avulsion was performed. Also, providers have no way to indicate with CPT coding or modifiers if the medial, lateral or both borders were treated. In addition, the commenters stated while the references in the Proposed LCD speak to how long it may take a toenail to grow from the matrix to the distal tip of the toe, there is no peer-reviewed literature that speaks to how long it may take for an ingrown toenail to occur at the most proximal aspect of a medial or lateral nail border following complete nail avulsion. The APMA and the AADA provided comments regarding limitation 5. Repeat nail excision on the same toe or finger following a complete nail excision for permanent removal. The commenters noted that CPT code 11750 does not differentiate between a partial nail permanent removal and a complete nail permanent removal and providers have no way to indicate with CPT coding or modifiers if a partial nail permanent removal or a complete nail permanent removal was performed. Also, the commenters stated that providers have no way to indicate with CPT coding or modifiers if the medial, lateral or both borders were treated. In addition, they stated as shared in this Proposed LCD, a Cochrane systematic review found that one in 25 patients experience recurrence following nail avulsion with phenolization (permanent removal).	Thank you for your support for the proposed LCD limitations 1, 2, and 3. In response to the concerns regarding limitations 4 and 5, the billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits.
2	Multiple comments were received regarding limiting coverage to symptomatic patients. The commenters noted that patients with peripheral neuropathy or radiculopathy with loss of sensation can present with no pain.	Thank you for your comments. Symptoms of nail disease requiring surgical treatment are not limited to pain. Other symptoms include but are not limited to edema/swelling, erythema, drainage, infection, ulceration, and granulation tissue.
3	Multiple comments were received regarding LCD limitation 4. Repeat nail avulsion on the same toe or finger following a complete nail avulsion performed more frequently than every 8 months (32 weeks) for toenails or 4 months (16 weeks) for fingernails. The commenters noted that the procedures are frequently performed to remove either medial or lateral borders and there is no mechanism within current billing procedures to differentiate which borders are being treated and the other nail border may become symptomatic/infected within the time frames being proposed. Also, the commenters stated that an ingrown nail, while it does take time to regrow, can in fact regrow and become symptomatic and/or infected far sooner than 8 months. This may happen when the nail regrows in an incurvated pattern as soon as 2 months and create symptoms which need to be addressed.	Thank you for your comments. The billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits.
4	Multiple comments were received regarding limitation 5. Repeat nail excision on the same toe or finger following a complete nail excision for permanent removal. The commenters noted that although the expected outcome is to not have nail plate regrowth, there is a rate of recurrence often cited as 1/25 (1/25=4% Cochrane systematic review cited in the LCD evidence). Also, since there is no mechanism within current billing procedures to identify nail borders, a patient who may have had a medial permanent procedure and then requires a lateral permanent procedure.	Thank you for your comments. The billing and coding article has been revised to allow the use of modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional) for medically necessary repeat procedures. The medical record documentation must be specific as to the indication, such as ingrown nail of opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits.
5	Comments were received regarding language in the proposed LCD History/Background and/or General Information section.	Thank you for your comment. The History/Background and /or General information section was revised to remove the acronym PNF and spell out “proximal nail fold” where it appears in the text. Also, the language in multiple paragraphs was revised for clarification. The last sentence in the second paragraph under the History/Background and /or General information section, was revised to include the verbiage: “include but are not limited to” those with uncontrolled diabetes mellitus, ...” Revision was made to the last sentence of the third paragraph to clarify that surgical treatments are “typically” used in moderate and severe cases. In the fourth paragraph, additional language to include that “comorbidities or risk factors for complications” may be considered for the treatment of subungual hematoma was added. The fifth paragraph was revised to include the language “or other conditions” that may be indicated as an underlying cause of Onychauxis or the thickening of the nail plate. In the seventh paragraph, language was added to clarify all options of matrixectomy performed when treating ingrown toenails. In the eighth paragraph, the description of wedge excision was revised to read more consistent with Current Procedural Terminology coding.
6	Comments were received regarding covered indications 3 and 8. The commenter noted that periungual tumors and acquired forms of nail dystrophy may require nail surgery.	Thank you for your comments. The LCD indication 3 was revised to include periungual tumors and indication 8 was revised to include acquired nail dystrophies.

Coding Information

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-PCS Codes

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Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Additional ICD-10 Information

Bill Type Codes

Code	Description

Revenue Codes

Code	Description

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

N/A

Associated Documents

Related Local Coverage Documents
Articles
A52998 - Billing and Coding: Surgical Treatment of Nails
LCDs
L34887 - Surgical Treatment of Nails
DL34887 - Surgical Treatment of Nails (MCD Archive Site)

Updated On	Effective Dates	Status
12/10/2021	12/16/2021 - N/A	Currently in Effect	You are here

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Response to Comments: Surgical Treatment of Nails

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Note History

Contractor Information

Article Information

General Information

CMS National Coverage Policy

Article Guidance

Response To Comments

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

ICD-10-PCS Codes

Group 1

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Group 1

Coding Table Information

Revision History Information

Associated Documents

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