Independence has updated its coverage positions, documentation and billing
requirements, and covered diagnosis codes in the policies on toe nail
debridement. The following policies were posted as Notifications on June 29,
2017, and will go into effect September 27, 2017.
- Commercial: #11.08.17g: Debridement of Mycotic and
Symptomatic Non-Mycotic Hypertrophic Toe Nails
- Medicare Advantage: #MA11.014c: Debridement of Mycotic and
Symptomatic Non-Mycotic Hypertrophic Toe Nails
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 Notifications for the updated policies, visit our Medical Policy Portal and select Accept and Go to
Medical Policy Online. Then select Commercial or Medicare
Advantage under Active Notifications.
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