The Centers for Medicare and Medicaid Services (CMS) has implemented a nationwide policy concerning the surgical treatment of nails. This policy establishes utilization parameters regarding the use of CPT® 1 11730 and 11732, and 11750.
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.
The policy goes on to provide examples of why a repeat procedure 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 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 a problematic issue is to track the number of redetermination requests it receives.
This policy is being contested by multiple stakeholders, including the American Podiatric Medical Association. Success of this contest may, in part, depend on the volume of redetermination requests submitted by providers.
References:
12023 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).
