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Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.014g

Policy

MEDICALLY NECESSARY

DEBRIDEMENT OF MYCOTIC TOENAILS
Debridement of mycotic toenails is considered medically necessary and, therefore, covered every 60 days when the individual has clinical evidence and documentation of mycosis and one of the following criteria are met:

The individual has qualifying systemic illnesses represented by one or more of the diagnoses listed below that is causing a peripheral neuropathy:
  • Amyotrophic lateral sclerosis (ALS)
  • Arteriosclerosis obliterans (ASO) (e.g., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
  • Arteritis of the feet
  • Buerger's disease (thromboangiitis obliterans)
  • Chronic indurated cellulitis
  • Chronic thrombophlebitis*
  • Chronic venous insufficiency
  • Diabetes mellitus*
  • Intractable edema, secondary to a specific disease (e.g., congestive heart failure, kidney disease, hypothyroidism)
  • Lymphedema, secondary to a specific disease (e.g., Milroy disease, malignancy)
  • Peripheral neuropathies involving the feet:
    • Associated with malnutrition and vitamin deficiency*
      • Malnutrition (general, pellagra)
      • Alcoholism
      • Malabsorption (celiac disease, tropical sprue)
      • Pernicious anemia
    • Associated with carcinoma*
    • Associated with diabetes mellitus*
    • Associated with drugs and toxins*
    • Associated with multiple sclerosis*
    • Associated with uremia (chronic kidney disease)*
    • Associated with traumatic injury
    • Associated with leprosy or neurosyphilis
    • Associated with hereditary disorders
      • Hereditary sensory radicular neuropathy
      • Amyloid neuropathy
      • Angiokeratoma corporis diffusum (Fabry disease)
  • Peripheral vascular disease
  • Raynaud's disease
    *NOTE: When the individual's condition is one of those designated by an asterisk (*), nail debridement is covered only if the individual is under the active care of professional provider who documents the condition.
The individual has clinical findings that indicative severe peripheral involvement and meets one of the following criteria:
  • A Class A finding of a nontraumatic amputation of foot or integral skeletal portion thereof
  • Two of the following Class B findings:
    • Absent posterior tibial pulse
    • Absent dorsalis pedis pulse
    • Advanced trophic changes (at least three of the following are required):
      • Hair growth (decrease or absence)
      • Nail changes (thickening)
      • Pigmentary changes (discoloration)
      • Skin texture (thin, shiny)
      • Skin color (rubor or redness)
  • One Class B finding (see above) and two of the following Class C findings:
    • Claudication
    • Temperature changes (e.g., cold feet)
    • Edema
    • Paresthesias (abnormal spontaneous sensations in the feet)
    • Burning
The individual does not have a qualifying systemic illness and one of the following criteria is met:
  • For ambulatory individuals, there must be a marked limitation of ambulation, pain, and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
  • For nonambulatory individuals, there must be evidence of pain and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
The performance of fungi cultures and potassium hydroxide (KOH) with nail clippings is considered medically necessary and, therefore, covered when one of the following criteria are met:
  • The culture is required to differentiate fungal disease from psoriatic nails or other nail pathology.
  • A definitive antifungal treatment involving the use of a prescription medication for a prolonged period of time that could pose health issues is being planned.
DEBRIDEMENT OF NON-MYCOTIC HYPERTROPHIC TOENAILS
Debridement of symptomatic non-mycotic hypertrophic toenails is considered medically necessary and, therefore, covered every 60 days when the following criteria are met:
  • When the clinical evidence and documentation of symptomatic non-mycotic hypertrophic conditions of the nail are provided, and when one of the following criteria is met:
    • For ambulatory individuals, there must be a marked limitation of ambulation, pain, and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
    • For nonambulatory individuals, there must be evidence of pain and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
NOT MEDICALLY NECESSARY

Debridement of symptomatic mycotic and non-mycotic hypertrophic nails performed more often than every 60 days is considered not medically necessary and, therefore, not covered unless documentation (e.g., nail size, color, thickness) is provided in the medical record to substantiate the increased frequency.

Debridement of mycotic and non-mycotic hypertrophic nails after the acute symptoms have abated and in the absence of a qualifying covered systemic condition is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.

Debridement of six or more mycotic and/or non-mycotic hypertrophic nails in the absence of a qualifying systemic condition and in a single encounter is considered not medically necessary and, therefore, not covered unless documentation (e.g., nail size, color, thickness) is provided in the medical record to substantiate the increased service.

Whirlpool treatment to soften the nails or skin, and performed for individuals with a systemic condition and clinical evidence of mycosis, prior to the debridement of mycotic and symptomatic non-mycotic hypertrophic nails, is considered part of routine foot care services and, therefore, not eligible for separate reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

For each service encounter, the medical record must contain the number of nails debrided and a description of each nail, which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local pathology caused by each affected nail resulting in the need for debridement must be documented. When debriding 6 or more nails, complete documentation must be provided for at least 6 nails. (In situations where several nails are identical in characteristics, it may be appropriate to combine those nails into the description.)

For nail debridement of symptomatic mycotic and non-mycotic hypertrophic nails in the absence of a qualifying covered systemic condition, the medical record must contain a description of the specified condition beyond mention that the particular condition is present (e.g., painful nails, limited ambulation, infection).

For nail debridement of mycotic nails in the presence of qualifying covered systemic conditions, the medical record must contain a sufficiently detailed description of the feet to support that non-professional performance of the service is hazardous to the individual. Furthermore, the following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the individual’s medical record. The professional provider rendering the nail debridement has identified, in addition to a primary condition, either (1) the Class A finding (Q7); (2) two of the Class B findings (Q8); or (3) one Class B and two Class C findings (Q9).

BILLING REQUIREMENTS

Claims submitted for debridement (CPT codes 11720 or 11721) of non-mycotic hypertrophic toenails must include:
  • A primary diagnosis code (International Classification of Disease [ICD] ICD-10 diagnosis code L60.8 Other nail disorders ) AND
  • A secondary diagnosis code representing secondary infection, pain, or difficulty in ambulation, which are listed within the coding table of this policy
Claims submitted for debridement (CPT codes 11720 or 11721) of mycotic toenails must include:
  • A primary diagnosis code (ICD-10 diagnosis code B35.1 Tinea unguium) AND
  • One of the following:
    • A secondary diagnosis code representing secondary infection, pain, or difficulty in ambulation, which are listed within the coding table of this policy
    • A secondary diagnosis representing a systemic condition resulting in peripheral neuropathy, which are listed within the coding table of this policy
    • A Q modifier for the Class finding representing the sequela(ae) of severe peripheral involvement
Debridement codes should not be used to report the simple trimming, cutting, or clipping of the distal nail plate.

When reporting one of the ICD-10-CM codes that fall under the "active care requirement", the date that the individual was last seen by the professional provider responsible for treating the underlying condition must be reported in line 19 of the CMS-1500 claim form or the electronic equivalent.

Guidelines

This policy is consistent with Medicare's coverage determination. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, debridement of mycotic and symptomatic non-mycotic hypertrophic nails is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. Additional visits for routine foot care may be available based on the members evidence of coverage.

Description

Symptomatic non-mycotic hypertrophic toenails, or excessively thick nails, may be the result of aging, trauma, or individual predisposition, and are not related to fungal disease. The nails undergo changes in their rate of growth, color, thickness, shape, surface texture, and composition. Periodic debridement of symptomatic non-mycotic hypertrophic nails may be done manually or with the aid of electrical grinders.

Fungal disease of the toenails is usually a relatively benign condition, although its high recurrence rate makes complete elimination difficult. Fungal infections may be either superficial or deep, with minor to significant dystrophic change to the nails, according to the degree of infection. Antifungal therapy for mycotic nails may involve the short-term use of oral agents and/or the long-term use of topical agents. Periodic debridement of symptomatic dystrophic fungal nails may also be used in combination with oral or topical agents. Definitive treatment of a mycotic nail includes debridement by either manual or electrical grinder method, and may be combined with the use of antifungal therapy.

The debridement of nails is the partial or complete removal of nail substance that is causing local pathology. Debridement temporarily reduces the size or girth of a portion of an abnormal nail plate; it does not remove the entire nail plate. Debridement is most commonly performed without anesthesia for one or more of the following purposes:
  • Relief of pain
  • Treatment of infection (e.g., bacterial, fungal, and/or viral)
  • Temporary removal of an anatomic deformity (e.g., onychauxis [thickened nail] or certain types of onychocryptosis [ingrown nail])
  • Exposure of conditions below the nail for treatment and/or diagnosis (e.g., biopsy, culture)
  • Prophylaxis to prevent further complications (e.g., ulceration under the nail in an individual with lack of sensation and onychauxis)

References

American Podiatric Medical Association (APMA). Nail problems. [APMA Web site]. 2013. Available at: http://www.apma.org/files/ProductPDFs/Nail_Problems.pdf. Accessed April 04, 2024.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. §290 : Foot Care. [CMS Web site].02/08/2024. Available at:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed April 04, 2024.


Goldstein AO, Bhatia N. Onychomycosis: Epidemiology, clinical features, and diagnosis. 01/20/2023. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed April 04, 2024.

Goldstein AO, Bhatia N. Onychomycosis: Management. 09/08/2022. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed April 04, 2024.

Gupta A. Onychomycosis in the elderly. Drugs Aging. 2000;16(6):397-407.

Loo DS. Onychomycosis in the elderly: drug treatment options. Drugs Aging. 2007;24(4):293-302.

Mozena JD, Mitnick JP. Emerging concepts in treating onchomycosis. Podiatry Today. 2009;22(10):46-51.

Novitas Solutions, Inc. A52996: Routine foot care (article). [Novitas Solutions Web site]. 10/01/2019. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52996&ver=26. Accessed April 04, 2024.

Novitas Solutions, Inc. A56640: Debridement of Mycotic Nails (article). [Novitas Solutions Web site]. 10/01/2019. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56640&ver=16. Accessed April 04, 2024.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35138: Routine foot care. [Novitas Solutions Web site]. 01/01/2024. Available at:https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35138&ver=43&Date=06/11/2020&SearchType=Advanced&DocID=L35138&bc=KAAAAAgAAAAA&. Accessed April 04, 2024.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35013: Debridement of mycotic nails. [Novitas Solutions Web site]. 09/12/2019. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35013&ver=36&bc=0. Accessed April 04, 2024.

Poulin Y, Thomas R, Gupta AK. Brief treatment guide for onychomycosis. J Cutan Med Surg. 2006;10:Suppl2:S39-S43.

Rich P. Overview of nail disorders. 05/09/2022. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed April 04, 2024.

Spelman D. Lymphangitis. Up to Date. 01/29/2024. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed April 04, 2024.

Coding

CPT Procedure Code Number(s)
11720, 11721, 87101, 87102, 87220
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
THE FOLLOWING DIAGNOSIS CODE IS USED TO REPRESENT SYMPTOMATIC NON-MYCOTIC HYPERTROPHIC TOE NAILS

L60.8 Other nail disorders

DEBRIDEMENT OF NON-MYCOTIC HYPERTROPHIC TOE NAILS IS MEDICALLY NECESSARY WHEN REPORTED WITH L60.8 OTHER NAIL DISORDERS AND ANY OF THE FOLLOWING DIAGNOSIS CODES USED TO REPRESENT SECONDARY INFECTION, PAIN, OR DIFFICULTY IN AMBULATION:

B37.2 Candidiasis of skin and nail

L02.611 Cutaneous abscess of right foot

L02.612 Cutaneous abscess of left foot

L02.619 Cutaneous abscess of unspecified foot

L03.031 Cellulitis of right toe

L03.032 Cellulitis of left toe

L03.039 Cellulitis of unspecified toe

L03.041 Acute lymphangitis of right toe

L03.042 Acute lymphangitis of left toe

L03.049 Acute lymphangitis of unspecified toe

L60.0 Ingrowing nail

M79.604 Pain in right leg

M79.605 Pain in left leg

M79.606 Pain in leg, unspecified

M79.661 Pain in right lower leg

M79.662 Pain in left lower leg

M79.671 Pain in right foot

M79.672 Pain in left foot

M79.673 Pain in unspecified foot

M79.674 Pain in right toe(s)

M79.675 Pain in left toe(s)

M79.676 Pain in unspecified toe(s)

M79.669 Pain in unspecified lower leg

R26.2 Difficulty in walking, not elsewhere classified

R26.89 Other abnormalities of gait and mobility

R26.9 Unspecified abnormalities of gait and mobility

THE FOLLOWING CODE IS USED TO REPRESENT MYCOTIC TOE NAILS

B35.1 Tinea unguium

DEBRIDEMENT OF MYCOTIC TOE NAILS IS MEDICALLY NECESSARY WHEN REPORTED WITH B35.1 TINEA UNGUIUM AND ANY OF THE FOLLOWING DIAGNOSIS CODES USED TO REPRESENT SECONDARY INFECTION, PAIN, DIFFICULTY IN AMBULATION, OR SYSTEMIC CONDITIONS RESULTING IN PERIPHERAL NEUROPATHY

See Attachments A, B, C, D, and E.

HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A

Modifiers

Q7 One Class A finding

Q8 Two Class B findings

Q9 One Class B and 2 Class C findings

Coding and Billing Requirements

Policy History

10/1/2021
10/1/2021
5/1/2024
MA11.014
Medical Policy Bulletin
Medicare Advantage
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No