Response to Comments: Surgical Treatment of Nails

The proposed LCD DL39258 identifies several limitations that are considered not covered and are considered not medically reasonable and necessary including:

• Repeat nail excision on the same toenail or fingernail following a complete nail excision for permanent removal;
• When a complete nail avulsion is performed, a repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails, is considered to be not medically reasonable and necessary.^1,13,14,16

I do not agree with these two limitations and the assertion that it would not be reasonable or necessary to have these services performed more often than these exclusions specify.

In preparation for my response to this LCD, I downloaded and read all the references cited including the Cochrane review and all the studies that it cited. I have not found that any of the articles or studies corroborate the statements in the proposed LCD. In fact, the references cite significant recurrence of nail problems after nail procedures. One of the main studies in the Cochrane review had 30% of participants who had prior procedures and still there was recurrence after the author's procedure.

I did learn about the epidemiology of nail problems. The "Review of onychocryptosis: epidemiology", by Geizhals and Lipner states, "The 1990 US National Health Survey reported increased prevalence in advanced age, in those earning less than $10,000 per year, and in residents of the southern US." (Which is the Palmetto region.)

Below is an overview of findings and questions regarding coding.

Overview:

Unguis incarnatus, commonly known as ingrown toenail or onychocryptosis, is a frequently encountered condition of the elderly. It is a condition where the nail acts as a foreign body and can lead to a cascade of events including pain, inflammation, edema, and infection. As noted in one of the references used in the proposed LCD, partial avulsion (border of the nail) or partial matrixectomy (border of nail) for permanent removal is the more common procedure and often the preferred procedure. Removal of one border does not prevent the other border from becoming ingrown or painful. Often the condition does not warrant an entire nail avulsion or entire nail matrixectomy. Often the patient will choose to have the thinnest portion of nail possible to be removed, both for decreased healing and cosmetic result.

Onychocryptosis, the bending of the nail matrix, is a progressive condition. The nail border does not have to regrow for the remaining portion of the nail to become involved, ingrown, painful, and/or infected. When performing matrixectomies on the elderly, a risk- benefit consideration is made for beneficiaries with contributing factors such as circulatory impairment and diabetes. Some patients who would truly benefit from having the nail permanently removed can not do so due to risk factors of healing. They are destined to have nail debridements and avulsions repeatedly to prevent infection. Others of less risk may have matrixectomies but need less of a cauterization of the matrix to prevent a complication. This could lead to recurrence in some cases.

With the aging population and onychocryptosis being a progressive condition, more incidence of need for nail procedures will be occurring. Better understanding of the condition, its progressiveness, and the morbidity it can cause would clarify the need for rapid intervention without barriers to access of care. Without interventions, the elderly who develop ingrown nails will develop cellulitis, abscess, osteomyelitis, gangrenous digits, amputations, and hospitalizations. The benefits of this simple procedure are profound, and barriers to its access are unfounded by the articles cited.

Coding and Coverage Dilemmas with Proposed LCD DL39258

1.) 11730 & 11750 are used for a procedure on a nail border (i.e TA)

1. 1. How do you code which border that was done?
   2. How do you code if the other border is done at a later date?

2.) If 11750 is performed on a border and the remaining portion of the nail becomes painful/ingrown/in need of repeat procedure:

1. 1. How does the provider code the new condition occurring on the same side or same toe?

3.) If an entire nail matrixectomy is performed and the nail recurs as seen in 30% of participants of the Cochrane Review (Eekhof et al., 2012):

1. 1. How do we code for this?
   2. Does the patient sign an ABN for standard charges?

4.) If the beneficiary has an 11730 or a 11750 by another provider and the same toe has need for a procedure not covered by the LCD:

1. 1. Does the beneficiary sign an ABN for standard charge?

I have also attached a summary of the references used and my findings.

References were provided for review.

Palmetto GBA appreciates your informed comments. Palmetto GBA recognizes that nail avulsions (partial or complete) and excisions of the nail and nail matrix (partial or complete) for permanent removal may need repeating. We also recognize that coding convention does not differentiate between a medial or lateral border avulsion or excision for permanent removal. Upon review of the policy, the LCD was revised to include the statement, “A medically necessary repeat nail avulsion on the same finger less than 16 weeks or the same toe less than 32 weeks following a previous avulsion will be considered on a redetermination. A medically necessary repeat excision of the nail and nail matrix for permanent removal on the same finger or the same toe following a previous excision of the nail and nail matrix for permanent removal will be considered on a redetermination. 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”.

The references noted in the policy speak to the finding that the normal nail plate growth rate of fingernails averages 3 mm/month and that of toenails averages 1 mm/month. After the age of 25, this rate tends to decrease approximately 0.5% per year.

On behalf of dermatologists in the Palmetto GBA regions, we would like to respectfully share the dermatology perspective and our concern regarding the Proposed Local Coverage Determination (LCD): Surgical treatment of Nails (DL39258).

In the “Limitations” section of the Proposed LCD, Limitation #5: 

Repeat nail excision on the same toenail or fingernail following a complete nail excision for permanent removal.

In the “Limitations” section of this proposed LCD, Limitation #6:

When a complete nail avulsion is performed, a repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails, is considered to be not medically reasonable and necessary.

The Dermatologic Medicare Contractor Advisory Committee has the following concerns with these proposed limitations.

While it is possible for both medial and lateral nail borders to present ingrown at the same time, it is much more likely that only one border is ingrown on presentation. Pathology of one border of a toenail is normally unrelated to pathology that exists on the other border of that same toenail. When a removal of either a medial or lateral border of a toenail is performed, CPT code 11730 (Avulsion of nail plate, partial or complete, simple; single) nor 11750 (Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent removal) differentiate between a medial or lateral border avulsion. Furthermore, there are no CPT Modifiers that allow providers to indicate which border was avulsed when a medial or lateral nail border avulsion is performed. The partial nail avulsion of one border of a toe has no impact on the behavior of the other border of the same toenail. Should the contralateral aspect of the nail become symptomatic requiring avulsion in less than eight months, it would result in another submission of one of these CPT codes. As Proposed, Palmetto GBA would have no way of knowing whether this second CPT 11750 was for the same medial border previously removed or for an unrelated lateral border without performing a manual record review, which would be terribly inefficient and introduce tremendous burden to both Palmetto GBA providers and Palmetto GBA staff.

Palmetto GBA provides multiple references in the proposed LCD that describe how long it takes for an entire nail to grow. This typically refers to how long it takes for a nail to grow from the matrix to the distal aspect of the finger or toe. However, ingrown and diseased toenails may become symptomatic and require either complete or partial avulsion can occur without the toenail being fully grown to the distal edge of the toe. Ingrown toenails that can cause infection can occur anywhere proximal to distal along the medial and lateral nail grooves, including the most proximal aspect of the nail groove. While it may take 8 months for a toenail to grow from the matrix to the distal edge of the toe, it may take only one month for a toenail to grow 1/8 of the way from the matrix to the distal edge of the toe. With only this amount of nail growth, an ingrown toenail requiring avulsion may occur at the most proximal aspect of the medial or lateral nail border.

Therefore, there is grave danger in finalizing this proposed limitation. 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. Recurrence of ingrown toenails following complete nail avulsion happens. If the recurrent ingrown toenail offends the skin at the most proximal aspect of the medial or lateral nail border, this can occur in much less than 8 months following complete nail avulsion. Denying Palmetto beneficiaries’ coverage for this needed service may lead beneficiaries to delay seeking care, increasing the risk for infection and amputation.

For these reasons and to ensure patient access to quality dermatologic care, we encourage Palmetto GBA to remove Limitations #5 and #6 from this LCD when it is finalized.

We appreciate the opportunity to share our concerns about this proposed LCD change.

Palmetto GBA appreciates your informed comments. Palmetto GBA recognizes that nail avulsions (partial or complete) and excisions of the nail and nail matrix (partial or complete) for permanent removal may need repeating. We also recognize that coding convention does not differentiate between a medial or lateral border avulsion or excision for permanent removal. Upon review of the policy, the LCD was revised to include the statement, “A medically necessary repeat nail avulsion on the same finger less than 16 weeks or the same toe less than 32 weeks following a previous avulsion will be considered on a redetermination. A medically necessary repeat excision of the nail and nail matrix for permanent removal on the same finger or the same toe following a previous excision of the nail and nail matrix for permanent removal will be considered on a redetermination. 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”.

The American Podiatric Medical Association (APMA), the American Academy of Dermatology Association (AADA), the American Society of Plastic Surgeons (ASPS), and the American Society for Surgery of the Hand (ASSH), together respectfully submit the below support, concerns, and recommendations in response to Proposed Local Coverage Determination (LCD): Surgical Treatment of Nails (DL39258) and Proposed Local Coverage Article (LCA): Surgical Treatment of Nails (DA59028).

In the “Limitations” section of the Proposed LCD, the following indications are listed as non- covered:

• Trimming, cutting, clipping or debridement of nails;
• Removing small chips or wedges of the nail or skin that does not require local anesthesia;
• Simple treatment of ingrown toenails (e.g., trimming, cutting, clipping of the distal unattached nail margins);
• Surgical treatment of asymptomatic conditions

The undersigned associations agree with the proposal to consider these indications to be non- covered. This is consistent with education we have previously provided to our membership and plan to continue to provide this guidance, especially to our Palmetto providers should this proposal be finalized.

In the “Limitations” section of the Proposed LCD, this indication is proposed to be non-covered and not medically reasonable and necessary:

     Repeat nail excision on the same toenail or fingernail following a complete nail excision for permanent removal

We do not agree with this proposal and list our reasons for this disagreement below:

Inability To Enforce

CPT^® 11750 - Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent removal

CPT 11750 does not differentiate between a partial nail permanent removal and a complete nail permanent removal. A partial nail permanent removal occurs when a single border of a toenail or fingernail, either medial or lateral, is permanently removed. A complete nail permanent removal occurs when an entire toenail or fingernail is permanently removed. Partial nail permanent removals are performed much more frequently than complete nail permanent removals. We are concerned that under this proposal, any submission of CPT 11750 will disallow coverage of another CPT 11750 submitted for the same toe or finger for the indefinite future. This would be inappropriate as Palmetto providers have no way to indicate with CPT coding, including available CPT Modifiers, whether CPT 11750 is being submitted for a partial nail permanent removal or a complete nail permanent removal. Furthermore, Palmetto has no way of knowing whether a submitted CPT 11750 represents a partial nail permanent removal or a complete nail permanent removal. The only way for Palmetto to determine this would be manual record review, which would be terribly inefficient and introduce tremendous burden to both Palmetto providers and Palmetto staff. Worst of all, we fear this inefficiency could delay care to Palmetto beneficiaries for a condition (ingrown toenail) which can cause infection, amputation, and even death.

Medial Versus Lateral Border Ingrown Nails

CPT^® 11750 - Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent removal

Ingrown toenails and fingernails typically occur along either a medial or lateral nail border. While it is possible for both medial and lateral borders to present ingrown at the same time, it is much more likely that only one border is ingrown on presentation. Pathology of one border of a nail is normally unrelated to pathology that exists on the other border of that same nail. When a permanent removal of either a medial or lateral border of a nail is performed, CPT 11750 does not differentiate between a medial or lateral border permanent removal. Furthermore, there are no CPT Modifiers that allow providers to indicate which border was permanently removed when a medial or lateral nail border permanent removal is performed. The permanent removal of one border of a nail has no impact on the behavior of the other border of the same nail. For example, if a permanent removal of a medial border of a right hallux is performed, represented by CPT 11750 – T5 Modifier, the lateral border of the same right hallux could require permanent removal one year later. This would result in another submission of CPT 11750 – T5 Modifier. As proposed, Palmetto would have no way of knowing whether this second CPT 11750 was for the same medial border previously removed or for an unrelated lateral border without performing a manual record review, which would be terribly inefficient and introduce tremendous burden to both Palmetto providers and Palmetto staff. As noted previously, we fear this inefficiency could delay care to Palmetto beneficiaries for a condition (ingrown toenail) which can cause infection, amputation, and even death.

Recurrence Happens

As shared in this Palmetto Proposed LCD, a Cochrane systematic review found that one in 25 patients experience recurrence following nail avulsion with phenolization (permanent removal). This is an incredibly high rate of recurrence. There is tremendous risk involved with limiting coverage for a pathology that occurs this frequently. We ask that this limitation (Repeat nail excision on the same toenail or fingernail following a complete nail excision for permanent removal) be removed from this LCD when it is finalized for the three reasons listed above.

Alternatively, Palmetto may consider mirroring the guidance of its colleagues at Novitas Solutions, Inc. and First Coast Services Options, Inc. by adding this guidance to this policy:

For a medically necessary repeat nail excision on the same finger or toe, use 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). 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.

In the “Limitations” section of the Proposed LCD, this indication is proposed to be non-covered and not medically reasonable and necessary:

When a complete nail avulsion is performed, a repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails

We do not agree with this proposal and list our reasons for this disagreement below:

Inability To Enforce

CPT^® 11750 – Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent removal

CPT 11730 does not differentiate between a partial nail avulsion and a complete nail avulsion. A partial nail avulsion occurs when a single border of a nail, either medial or lateral, is avulsed. A complete nail avulsion occurs when an entire nail is removed. Partial nail avulsions are performed much more frequently than complete nail avulsions. APMA and AADA are concerned that any submission of CPT 11730 will trigger this 8-month (32 week) limitation should this limitation be finalized. This would be inappropriate as Palmetto providers have no way to indicate with CPT coding, including available CPT Modifiers, whether CPT 11730 is being submitted for a partial nail avulsion or a complete nail avulsion. Furthermore, Palmetto has no way of knowing whether a submitted CPT 11730 represents a partial nail avulsion or a complete nail avulsion. The only way for Palmetto to determine this would be manual record review, which would be terribly inefficient and introduce tremendous burden to both Palmetto providers and Palmetto staff. Worst of all, APMA and AADA fear this inefficiency could delay care to Palmetto beneficiaries for a condition (ingrown toenail) which can cause infection, amputation, and even death.

Rate of Recurrence

In the Proposed LCD, Palmetto provides multiple references that speak to how long it takes for an entire toenail to grow. This typically refers to how long it takes for a toenail to grow from the matrix to the distal aspect of the toe. However, ingrown and diseased toenails that require either complete or partial avulsion can occur without the toenail being fully grown to the distal edge of the toe. Ingrown toenails that can cause infection can occur anywhere proximal to distal along the medial and lateral nail grooves, including the most proximal aspect of the nail groove. While it may take 8 months for a toenail to grow from the matrix to the distal edge of the toe, it may take only one month for a toenail to grow 1/8 of the way from the matrix to the distal edge of the toe. With only this amount of nail growth, an ingrown toenail requiring avulsion may occur at the most proximal aspect of the medial or lateral nail border.

Therefore, there is grave danger in finalizing this proposed limitation. 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. Recurrence of ingrown toenails following complete nail avulsion happens. If the recurrent ingrown toenail offends the skin at the most proximal aspect of the medial or lateral nail border, this can occur in much less than 8 months following complete nail avulsion. Denying Palmetto beneficiaries coverage for this needed service may lead beneficiaries to delay seeking care, increasing the risk for infection and amputation.

Medial Versus Lateral Border Ingrown Toenails

CPT^® 11730 - Avulsion of nail plate, partial or complete, simple; single

Ingrown nails typically occur along either a medial or lateral border of a nail. While it is possible for both medial and lateral nail borders to present ingrown at the same time, it is much more likely that only one border is ingrown on presentation. Pathology of one border of a nail is normally unrelated to pathology that exists on the other border of that same nail. When a partial nail avulsion of either a medial or lateral border of a nail is performed, CPT 11730 does not differentiate between a medial or lateral border avulsion. Furthermore, there are no CPT Modifiers that allow providers to indicate which border was avulsed when a medial or lateral nail border avulsion is performed. The partial nail avulsion of one border of a toe has no impact on the behavior of the other border of the same toenail. For example, if an avulsion of a medial border of a right hallux nail is performed, represented by CPT 11730 – T5 Modifier, the lateral border of the same right hallux could become ingrown three weeks later, requiring a partial nail avulsion. This would result in another submission of CPT 11730 – T5 Modifier three weeks after the same CPT code with same Modifier was submitted. As proposed, Palmetto would have no way of knowing whether this second CPT 11730 was for the same medial border that was just performed three weeks ago or for an unrelated lateral border avulsion without performing a manual record review, which would be terribly inefficient and introduce tremendous burden to both Palmetto providers and Palmetto staff. Worst of all, the undersigned associations fear this inefficiency could delay care to Palmetto beneficiaries for a condition (ingrown toenail) which can cause infection, amputation, and even death.

We ask that this limitation (When a complete nail avulsion is performed, a repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails) be removed from this LCD when it is finalized for the three reasons listed above.

Alternatively, Palmetto may consider mirroring the guidance of its colleagues at Novitas Solutions, Inc. and First Coast Services Options, Inc. by adding this guidance to this policy:

For a medically necessary repeat nail avulsion on the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion, use 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). 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.

Conclusion

In summary, for the reasons listed herein, APMA, AADA, ASSH, and ASPS support the four limitations listed in page 1 of this letter and ask that those limitations:

• Repeat nail excision on the same toenail or fingernail following a complete nail excision for permanent removal
• When a complete nail avulsion is performed, a repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails

either not be finalized and instead be removed from this LCD when it is finalized or be allowed with the use of Modifiers as suggested above.

Thank you for the opportunity to provide feedback on this Palmetto Proposed LCD and LCA.

References and Images were provided for review.

Palmetto GBA appreciates your informed comments. Palmetto GBA recognizes that nail avulsions (partial or complete) and excisions of the nail and nail matrix (partial or complete) for permanent removal may need repeating. We also recognize that coding convention does not differentiate between a medial or lateral border avulsion or excision for permanent removal. Upon review of the policy, the LCD was revised to include the statement, “A medically necessary repeat nail avulsion on the same finger less than 16 weeks or the same toe less than 32 weeks following a previous avulsion will be considered on a redetermination. A medically necessary repeat excision of the nail and nail matrix for permanent removal on the same finger or the same toe following a previous excision of the nail and nail matrix for permanent removal will be considered on a redetermination. 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”.

I am a podiatrist practicing in South Carolina. I am the immediate past president of the South Carolina Podiatric Medical Association. I serve on the executive board and I am the PIAC/CAC representative. I am submitting reasons why not only myself but my the SCPMA opposes the proposed LCD for surgical treatment of ingrown toenails.

We disagree specifically with the proposed change that repeat removal of partial or complete ingrown toenails are medically unnecessary if done within 8 months.

One reason we oppose this proposed change is because an ingrown nail can occur at along the entire medial or lateral nail plate from proximal to distal so it can reoccur proximally well within that time on the argument of nail growth. When you look at the anatomy of the nail plate, an ingrown nail can occur from not only the most distal aspect of the nail but also along the most proximal aspect of the nail plate.

Also, when billing for a 11730 or 11750 it doesn’t specify whether the lateral or medial ingrown nail is removed and it is common for patients to present with a symptomatic ingrown on the medial border one week and a few weeks later, the lateral border could then be ingrown and symptomatic.

Lastly, ingrown toenails are not only very painful for our patients but they can lead to a moderate skin and soft tissue infections that can progress to the bone causing osteomyelitis which could lead to amputation of the toe or a more distal amputation. Skin and soft tissue infections are more prominent in our diabetic patients in South Carolina as well as our neighboring states in our Palmetto MAC. Columbia, South Carolina, our capital, is unfortunately leading the nation in diabetic amputations and amputations are a leading cause of mortality for our patients, particularly those who have diabetes. We as podiatrist fear that this proposed LCD will only further worsen that statistic. Please let’s work providing more adequate care and not limiting it for our patients.

Palmetto GBA appreciates your comments. Upon review of the policy, the LCD was revised to include the statement, “A medically necessary repeat nail avulsion on the same finger less than 16 weeks or the same toe less than 32 weeks following a previous avulsion will be considered on a redetermination. A medically necessary repeat excision of the nail and nail matrix for permanent removal on the same finger or the same toe following a previous excision of the nail and nail matrix for permanent removal will be considered on a redetermination. 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”.

I am president of the South Carolina Podiatric Medical Association. I have been practicing podiatric medicine for over 13 years with 10 of those years being in South Carolina. The purpose of this email is to voice a concern about the proposed LCD concerning surgical treatment of nails. While I agree with many of the limitations placed on nail avulsions, there is one that is problematic for several reasons.

The CPT code 11730 does not differentiate between partial and full nail avulsions. Therefore, it would be difficult to enforce the limitation when there is no code or modifier currently that would let you know that a partial is being done.

Ingrown toenails usually occur at the proximal nail fold. This area can become painful and inflamed well before 8 months. Eight months is the average time it takes a full nail to regrow. The area closest to the cuticle regrows in a matter of weeks.

Lastly, there is no modifier currently that differentiates between medial and lateral borders of the same nail. This would be important as usually a patient comes in with an ingrown nail/paronychia of one border, not both. We treat the offending border, not both. The opposite border may or may not have a separate problem within 8 months, but the ability to treat it and be compensated is important.

I work with largely elderly (fixed income) and diabetic patients within mixed socioeconomic areas. Many of them are already making difficult choices between daily needs and healthcare. If there is a coverage issue for a procedure, they may choose not to delay or not have the procedure. This decision can lead to further complications such as severe infection, amputation, and/or death.

Please consider these comments when finalizing the proposed LCD. Thank you for the opportunity to provide feedback.

Palmetto GBA appreciates your comments. Upon review of the policy, the LCD was revised to include the statement, “A medically necessary repeat nail avulsion on the same finger less than 16 weeks or the same toe less than 32 weeks following a previous avulsion will be considered on a redetermination…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”.

I have a few comments regarding the LCD "surgical treatment of nails " DL 39258.

It is not reasonable to limit nail avulsion with chemical matrixectomy 11750 to only once per toe because normal toe anatomy is inclusive of two nail borders on each toe. The medial and lateral nail borders. The patient may appear on 2 different occasions and demonstrate medical necessity for excision of the medial nail border on one occasion and in the future, present with medical necessity for excision of the lateral nail border.

Another reason why this is not reasonable is because not every excision of the nail with chemical matrixectomy is successful. The patient may experience regrowth of the previously resected nail, or experience regrowth of a portion of the previously resected nail. If the regrowth is painful or causes infection, then it would certainly be medically necessary to excise the same nail or nail border on the same toe.

I do not have a problem with the LCD be written as above but disallowing 77 modifier is a problem for the reasons listed above. I submit that the circumstances listed above do not occur frequently however, they do occur and therefore the 77 modifier should be accepted with a repeat procedure on the same toe.

Palmetto GBA appreciates your comments. Upon review of the policy, the LCD was revised to include the statement, “… A medically necessary repeat excision of the nail and nail matrix for permanent removal on the same finger or the same toe following a previous excision of the nail and nail matrix for permanent removal will be considered on a redetermination. 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”.