AmeriHealth has updated its coverage positions, documentation and billing requirements, and covered diagnosis codes in the policy on toe nail debridement. Medical Policy #11.08.17g: Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails was posted as a Notification on June 29, 2017, and will go into effect September 27, 2017.

Added coverage positions

As part of the update, coverage positions are being added for:

• debridement of mycotic toe nails in the presence of systemic conditions or severe peripheral involvement;
• debridement of mycotic and non-mycotic hypertrophic nails after the acute symptoms (e.g., limitation of ambulation, pain, and/or secondary infection) have abated and in the absence of a qualifying covered systemic condition;
• debridement of six or more nails during a single encounter in the absence of a qualifying systemic condition and supporting documentation.

Updated documentation and billing requirements

Documentation and billing requirements are being updated to clarify reporting requirements related to:

• description of diseased nail(s);
• symptomatology;
• number of nails treated;
• rationale for provision of care by a professional provider;
• necessity for primary and secondary diagnosis codes and Q7, Q8, and Q9 modifier reporting requirements;
• identification of the professional provider responsible for treating the underlying systemic condition, when applicable.

Updated covered diagnosis codes

The covered diagnosis codes for debridement of non-mycotic hypertrophic toe nails (L60.8 Other nail disorders) have been updated in the coding table. Attachments A through E have been added to include the diagnosis codes for mycotic toe nails (B35.1 Tinea unguium).

Claims submitted should follow these requirements:

• For debridement (CPT^® codes 11720 or 11721) of non-mycotic hypertrophic toe nails: Claims must include the primary diagnosis code (L60.8 Other nail disorders) and secondary diagnosis code representing secondary infection, pain, or difficulty in ambulation, which are listed within the coding table of this policy.
• For debridement (CPT codes 11720 or 11721) of mycotic toe nails: Claims must include the primary diagnosis code (B35.1 Tinea unguium) and one of the following:
• – secondary diagnosis code representing secondary infection, pain, or difficulty in ambulation, which are listed within the attachments to the policy;
• – secondary diagnosis representing a systemic condition resulting in peripheral neuropathy, which are listed within the attachments to the policy;
• – Q modifier for the Class finding representing the sequela(ae) of severe peripheral involvement.

For more information

To view the Notification for this updated policy, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial under Active Notifications.

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