Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, is conducting post-payment review of claims for Medicare Part B billed on dates of service from January 1, 2022, through December 31, 2023. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Nail avulsion is the removal of all or part of the nail from the nail bed of the finger or toe, due to traumatic injury or systemic disease. This procedure is commonly performed for both diagnostic and/or therapeutic indications. Removal of the nail plate allows for the examination of the matrix for the presence of injury or other pathology. Removal of the nail plate allows for the examination of the matrix for the presence of injury or other pathology.

Podiatry services are covered by Medicare Part B for treatment of injuries, disease, or other medical conditions affecting the foot, ankle, or lower leg when medically necessary. Routine footcare services are generally not covered for services such as cutting or removal of corns and calluses, or trimming, cutting, clipping, or debridement of nails to reduce nail thickness. Routine footcare services are considered reasonable and necessary and covered by Medicare Part B if they are performed (1) as a necessary and integral part of an otherwise covered service; (2) for the treatment of warts on the foot; (3) in the presence of a systemic condition; or (4) treatment of a toenail that is infected.

For Stage II and Stage III ingrown nails, surgical intervention is considered. Ingrown nails are staged by signs and symptoms of infection. Stage II ingrown nails have increased pain, discharge, and inflammation. Stage III ingrown nails contain abnormal granulation around the nail area, and may present with pain, edema, and purulent drainage. Due to the abnormal fit of the nail groove, Stage II and Stage III ingrown nails require removal of more than a fourth of the nail laterally, as these simple nail avulsions are considered unnecessary and are associated with high recurrence rates. Nail avulsions are generally performed under local anesthesia.

Evaluation and Management (E/M) services billed by the same provider that performed the nail avulsion service on the same day are not covered, unless the E/M service is a significant, separately identifiable service, and appended with modifier 25 indicating a significant, separately identifiable E/M service by the same physician or other qualified health care profession on the same day of the procedure.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with CPT codes 11730 and 11732 with or without modifier 59, in addition to select E/M codes billed with modifier 25 for dates of service January 1, 2022, through December 31, 2023.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. History and Physical exam
2. A complete detailed description of the pre-operative findings. Include the patient’s symptoms, indications, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale for why a surgical treatment is being selected over other treatment options
3. Medical necessity requirements for nail avulsions per applicable LCD or LCA
4. Office visit or E&M documentation, if billed on same date of service under medical review
5. Debridement of nails with E&M
6. Detailed operative/procedure report
7. Anesthesia records (including pre- and post-anesthesia) If no anesthesia used, the reason for not using it
8. Identify the specific digit(s) including the nail margin(s) involved on which the procedure was performed
9. Post-operative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied)
10. Post-operative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments)
11. All documentation to support the necessity of the services billed, including documentation for one-year prior to the date of service on review, if previous nail avulsion was completed. If previous nail avulsions occurred one year before the date of service under review, documentation to support necessity of repeated procedures.
12. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
13. Any other supporting or pertinent documentation
14. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
15. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
16. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering or referring provider to ensure medical necessity criteria have been met

References

Social Security Act (SSA), Title XI

• §1135. Authority to Waive Requirements During National Emergencies

SSA, Title XVIII

• §1815(a). Payment to Providers of Services
• §1833(e). Payment of Benefits
• §1862(a)(1)(A), (a)(7), (a)(13)(C). Exclusions from Coverage and Medicare as Secondary Payer
• §1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

42 Code of Federal Regulations (CFR)

• §411.15(l). Particular services excluded from coverage-Foot care
• §424.5. Basic Conditions
• §482.24. Condition of participation: Medical record services

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 15, §100. Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
• Ch. 16. General Exclusion from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 1. General Billing Requirements
• Ch. 12, §30.6. Evaluation and Management Service Codes – General (Codes 99201 – 99499)
• Ch. 20, §100. General Documentation Requirements
• Ch. 30, §50. Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3. Verifying Potential Errors and Taking Corrective Actions
• Ch. 13, §13.5.4. Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• American Academy of Professional Coders (AAPC). 99202-99215: Office/Outpatient E/M Coding in 2021. January 2021. Retrieved from Evaluation and Management (E/M) Code Changes 2021 – AAPC

• National Correct Coding Initiative (NCCI) Edits. NCCI Policy Manual for Medicare Services. §§2021, 2022, and 2023
• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 1, Section D. Evaluation and Management (E/M) Services
• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 1, Section E. Modifiers and Modifier Indicators
• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 11, Section U. Evaluation & Management Services

Local Coverage Determination (LCDs)

• L33833 Surgical Treatment of Nails. Effective October 1, 2015
• L34887 Surgical Treatment of Nails. Effective October 1, 2015
• L39258 Surgical Treatment of Nails. Effective March 5, 2023

Other

• American Medical Association (AMA). Evaluation and Management (E/M) Services Guidelines. January 1, 2023. Retrieved from 2023 CPT E/M descriptors and guidelines (ama-assn.org)
• The Centers of Medicare and Medicaid Services (CMS). Medical Learning Network (MLN) 006764. Evaluation and Management Services. August 2023. Retrieved from MLN006764 | CMS
• CMS. MLN SE1113. Foot Care Coverage Guidelines. Retrieved from se1113 (hhs.gov)
• CMS. MLN 1783722. Proper Use of Modifiers 59, XE, XP, XS & XU. Retrieved from 1783722 (hhs.gov)

Last Updated Jun 11, 2024