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Applying modifiers correctly is the key to successful payment on this claim.

Surgeries for ingrown toenails are a common occurrence that you鈥檒l likely come across in your podiatry coding. These procedures are so prevalent that many podiatrists carry out around five of them daily in their practice.

Scenario: A patient came into the office for follow-up treatment of an ingrown toenail. The podiatrist found that the patient鈥檚 continued discomfort was due to them having two ingrown toenails 鈥� one on the big toe of each foot. The podiatrist removed both and performed silver nitrate cauterizations to keep them from recurring. The visit lasted a total of 47 minutes, including the procedure time.

Let鈥檚 review the given scenario above and determine how to appropriately select the correct CPT^庐 and ICD-10-CM codes for this claim.

Calculate E/M Level First

Because we do not know the exact amount of time spent between the practitioner discussing the patient鈥檚 concerns/gathering information and conducting the procedure, let鈥檚 review our options for office visit codes below.

If you are determining the office/outpatient evaluation and management (E/M) level based on total time, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded) could only be correct if the total time of the E/M component of the encounter minus the time taken for the procedures fell within the parameters of total time for the code (30-39 minutes). If it did, then you could select the code that way; if it did not, you would have to select another level of E/M.

This is because the total time of the visit cannot include the time taken for the two toenail excision procedures if they are coded separately using 11750 (Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal). Per CPT^{庐&苍产蝉辫;}office/outpatient E/M guidelines, total E/M time 鈥渄oes not include any time spent in the performance of other separately reported service(s).鈥�

You can still establish an E/M level for this encounter based on total time, however, or you can calculate the E/M level based on medical decision making (MDM). If total E/M time minus procedure time is greater than 10 minutes and less than or equal to 19 minutes, you could go ahead and code 99212 (鈥�10 minutes must be met or exceeded.); if total E/M time minus procedure time is greater than 20 minutes and less than or equal to 29 minutes, you can decide to use code 99213 (鈥� 20 minutes must be met or exceeded.). If you decide to go this route, make sure your documentation contains detailed notes of the time your podiatrist spent evaluating the patient and the time spent on the actual procedures.

But if the total time for the E/M does not fall within any of these parameters (i.e., it is less than 10 minutes, but not greater than 39 minutes), your other option would be to choose the E/M level based on MDM. Given that the two ingrown toenails represent two self-limited or minor problems, and the excision procedures represent a low risk of morbidity to the patient from treatment, that would give you a low level of MDM, which translates to a 99213 office/outpatient E/M.

Coding the Ingrown Toenail Removals

Then, you should report each ingrown toenail removal separately: 11750 for the first removal and 11750 for the second removal, appending modifier 59 (Distinct procedural service) to the second removal to tell the payer that the podiatrist performed a second ingrown toenail removal on a different toe.

Add Your Modifiers

Be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99212 to indicate the podiatrist performed a significant, separate E/M service from the single ingrown toenail removal that was originally planned.

Why? The E/M service (evaluation of the toe pain and ingrown toenails, including the history taking and decision making) involves two separate and significant services: the evaluation and management of the ingrown toenail and the evaluation and management of the injury, which were significant and separate services to the ingrown toenail removal procedure. Because of this, you would append modifier 25 to the E/M service to indicate to the payer that the procedures and the E/M were distinct and occurred on the same day.

You will also want to make sure you are adding the anatomical modifiers T5 (Right foot, great toe) and TA (Left foot, great toe) to prove to the payer that ingrown toenails were removed from two separate locations on two different feet.

Find Your ICD-10-CM Code

Although it may seem confusing, the code for ingrown toenail will be found under the term 鈥渋ngrowing,鈥� not 鈥渋ngrown.鈥� To find code L60.0 (Ingrowing nail) for an ingrown toenail in the ICD-10-CM code book, you should start by looking in the Alphabetic Index. Search for the main term 鈥淚ngrowing,鈥� and under this term, you should find the subterm 鈥渘ail.鈥� Next to 鈥渘ail,鈥� you will see the code L60.0. To confirm this is the correct code, you should then go to the Tabular List. Locate the L60.- category for 鈥淣ail Disorders,鈥� and under this category, you鈥檒l find the specific code, L60.0, for 鈥淚ngrowing nail.鈥�

Note: The ICD-10-CM code set doesn鈥檛 feature a separate distinction or code for toenails versus fingernails.

Putting the Claim Together

For this encounter, you should report the following codes:

• 11750-T5
• 11750-59-TA
• 99212-25
• L60.0.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC