A Closer Look at an Updated CMS Policy for Surgical Treatment of Nails
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.
Last year, the Centers for Medicare and Medicaid Services (CMS) implemented a nationwide policy concerning the surgical treatment of nails. This policy establishes utilization parameters regarding the use of CPT® 11730 and 11732.1 The policy states:
A medically reasonable and necessary repeat CPT 11730/11732 of the same nail within 32 weeks of a previous avulsion will be considered upon redetermination.
This policy previously contained utilization parameters regarding use of CPT® 11750 that have since been retracted following multiple communications between CMS and the American Podiatric Medical Association (APMA) where APMA asked for modifications to or rescinding of this policy.
The current policy provides examples of why a repeat avulsion of the same nail may be medically necessary, and the two examples provided are “ingrown nail of the opposite border or a new significant pathology on the same border recently treated.” Two of the Part B Medicare Administrative Contractors (MACs), Novitas Solutions, Inc.2 and First Coast Service Options, Inc.,3 have released policies that reflect this guidance.
It is important to note that these “repeat” (as defined by CMS) procedures will be considered for payment if they are medically reasonable and necessary. It is recommended that providers document the medical necessity of “repeat” avulsions or excisions when performed.
Furthermore, when these medically reasonable and necessary “repeat” procedures are denied, it is important to submit redetermination requests as outlined in the CMS policy. One method that CMS uses to determine the magnitude of an issue is to track the number of redetermination requests it receives. A high volume of reconsideration requests submitted to CMS is expected to help in the effort to overturn or modify this policy.
Advocacy efforts remain underway, led by the American Podiatric Medical Association.
Dr. Lehrman operates Lehrman Consulting, LLC and is a Certified Professional Coder and Certified Professional Medical Auditor. Follow him on Twitter @DrLehrman
References
1. 2023 CPT Professional Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983–2022 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
2. Centers for Medicare and Medicaid Services. L34887. Surgical treatment of nails.
3. Centers for Medicare and Medicaid Services. L33833. Surgical treatment of nails.
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
