LCD Reference Article Response To Comments Article

Response to Comments: Surgical Treatment of Nails

A58961

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Source Article ID
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Article ID
A58961
Original ICD-9 Article ID
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Article Title
Response to Comments: Surgical Treatment of Nails
Article Type
Response to Comments
Original Effective Date
12/16/2021
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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:

  1. 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.
  2. Trimming, cutting, or clipping of the distal unattached nail margins does not constitute surgical treatment of a nail.
  3. 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.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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