How familiar are you with different nail removal procedural codes? You might be surprised, but it is quite common for healthcare providers to mistakenly use the simple nail avulsion CPT code for a nail excision with matrixectomy. The common reason for this confusion is the similarity between the two procedures at first glance.
The result of this coding error? Claim denial or underpayment! You don’t have to face the same issue. You can easily avoid this mistake by understanding each code in detail. That’s why, today, we are discussing CPT code 11750.
CPT Code 11750 – Description
You may have already gathered that CPT code 11750 specifies nail excision. But to be more specific, it refers to the complete or partial removal of a problematic toe or fingernail, including:
- The visible part (nail plate),
- The hidden part (nail matrix), and
- Sometimes the partially visible lunula (the half-moon-shaped area at the base of the nail).
During this procedure, a podiatrist removes the offending nail plate (the hard part of the nail) to access the active tissue underneath (the nail matrix). The matrix is part of the nail bed and is responsible for producing the cells that form the nail plate.
To prevent regrowth, the podiatrist uses phenol to destroy this portion of the nail chemically. The primary purpose of this matrixectomy? To resolve recurring nail-related issues, including ingrown nails, fungal infections, or deformities.
Scenarios Where CPT Code 11750 is Applicable
Need some visualization to understand this code better? Here are three specific scenarios for CPT code 11750:
Recurrent Ingrown Toenail in a Diabetic Patient
Around 20 out of 100 people who visit their healthcare providers for foot problems have an ingrown toenail. Did you know that diabetes can significantly impact the development and severity of this condition?
So, for our first example, let’s consider a 58-year-old diabetic man with onychocryptosis (ingrown toenail). He arrives at the nearest podiatry clinic with an infected, ingrown right toenail. The patient complains of severe pain, swelling, and pus coming from the affected area. The podiatrist examines the nail and reviews the patient’s medical history.
He learns that the patient has previously had multiple nail avulsions on the same toe, but the issue keeps coming back. To address this recurring problem, the provider partially removes the nail plate and performs a matrix excision using phenol to prevent regrowth. He then reports the procedure using CPT code 11750.
Chronic Nail Deformity after Door Crush Injury
Nail bed injuries are quite common. Approximately 25% of these injuries occur due to people accidentally jamming their toes in doors, most often car doors. Let’s look at this scenario!
Suppose a 27-year-old woman slammed her right big toe into a car door a year ago. She now visits a podiatrist after enduring chronic pain and discomfort. Upon inspection, the doctor notes that her nail plate is splitting, and the nail is dystrophic (thick, oddly shaped, or colored).
After asking a few questions, he learns the patient also experiences painful nail growth and has difficulty wearing shoes due to persistent pain. To correct the deformity, the podiatrist performs a matrixectomy to remove the permanently damaged matrix. His billing team then uses CPT code 11750 to bill for the procedure.
Medication-Resistant Fungal Nail Infection
Severe fungal nail infections can be quite painful, and let’s not forget, contagious! Did you know that toenail fungus, medically known as onychomycosis or tinea unguium, affects approximately 6 to 7 million people in the United States?
So, for our final scenario, consider a 45-year-old man with tinea unguium (a highly common yet difficult-to-treat infection) in his left little toenail. He visits a podiatrist after taking multiple rounds of oral antifungal medications. The doctor notes minimal improvement despite consistent treatment.
He then evaluates the patient, considering his symptoms and the current condition of the nail. Given the resistance to medication, the podiatrist decides to perform a matrixectomy under local anesthesia to resolve the issue permanently. He then files a claim using CPT code 11750.
Applicable Modifiers for CPT Code 11750
You cannot report certain codes without modifiers. CPT code 11750 is one such code, requiring you to use anatomical modifiers (for fingers and toes). The primary reason? Insurance companies want to know the exact location of the procedure, in this case, a specific finger or toenail, to process the claim correctly.
Here are several applicable modifiers with CPT code 11750:
TA, T1 to T9 Modifiers
Want to specify exactly which toenail you performed the matrixectomy on? You can use the following modifiers to avoid duplicate claims and denials.
| Toe Modifiers | Location |
|---|---|
| TA | Great toe of the left foot |
| T1 | Second digit of the left foot (left long toe) |
| T2 | Third digit of the left foot (left middle toe) |
| T3 | Fourth digit of the left foot (left ring toe) |
| T4 | Fifth digit of the left foot (left little toe) |
| T5 | Great toe of the right foot |
| T6 | Second digit of the right foot (right long toe) |
| T7 | Third digit of the right foot (right middle toe) |
| T8 | Fourth digit of the right foot (right ring toe) |
| T9 | Fifth digit of the right foot (right little toe) |
FA, F1 to F9 Modifiers
Did you perform the matrixectomy on a fingernail? Specify the exact location of that nail with the following modifiers:
| Finger Modifiers | Location |
|---|---|
| FA | Thumb of the left hand |
| F1 | Second digit of the left hand (left index finger) |
| F2 | Third digit of the left hand (left middle finger) |
| F3 | Fourth digit of the left hand (left ring finger) |
| F4 | Fifth digit of the left hand (left pinky) |
| F5 | Thumb of the right hand |
| F6 | Second digit of the right hand (right index finger) |
| F7 | Third digit of the right hand (right middle finger) |
| F8 | Fourth digit of the right hand (right ring finger) |
| F9 | Fifth digit of the right hand (right pinky) |
Modifier 59
Use modifier 59 with CPT code 11750 if the matrixectomy was distinct and separately identifiable from other services you performed on the same day. For example, if you performed a simple nail avulsion (CPT code 11730) on the left little toe and matrixectomy on the right big toe, use modifier 59 with CPT code 11750 to indicate it as distinct.
CPT Code 11750 – Billing & Reimbursement Guidelines
So, what is the right way to bill this code? If you want to avoid claim denials and rework due to basic mistakes, follow these billing and reimbursement guidelines for CPT code 11750:
Do Not Confuse Code 11750 with 11730
This is a common mistake. To avoid billing confusion, remember that CPT code 11730 specifies simple nail avulsion (the complete or partial removal of a finger or toenail from the nailbed). In simple terms? It does not include matrix removal.
On the other hand, CPT code 11750 refers to a permanent nail removal procedure, matrixectomy.
Justify the Medical Necessity with Complete Documentation
All insurance payers, including Medicare, require complete documentation with CPT code 11750. Therefore, you should diligently record everything about the procedure, such as:
- Diagnosis with the relevant ICD-10 code (L60.0 for ingrown nail, B35.1 for tinea unguium or L60.3 for nail dystrophy)
- Medical necessity (why the previous treatment failed)
- Anesthesia used
- Nail removed (complete or partial)
- Nail matrix excision or destruction method (phenol or any other process)
- Lunula (if it was removed)
Understand the Global Period
CPT code 11750 has a 10-day global period. You know what that means? Avoid separate billing of follow-up evaluation and management (E/M) services. Otherwise, insurance companies will deny your claim.
Apply the Appropriate Finger or Toe Modifiers
Let us reiterate! You need to specify the exact finger or toenail on which you performed the procedure. The best way to do that is through finger (FA, F1 to F9) and toe (TA, T1 to T9) modifiers.
Summary
You no longer need to second guess whether a nail procedure is a simple avulsion or matrixectomy! Use CPT code 11750 confidently to secure complete payments. This code covers a permanent nail removal procedure (matrixectomy) to manage recurrent problems, like ingrown nails, fungal infections, or medicine-resistant nail deformities. We have discussed CPT code 11750 quite comprehensively, so you can avoid basic mistakes like billing the follow-up E/M services separately, not using the appropriate anatomical modifier, or filing a claim with incomplete documentation. But if coding is still not your cup of tea, you can always hire a billing expert. Many local and national billing companies cover coding in their podiatry billing services.
