S91.255D — Open bite of left lesser toe(s) with damage to nail, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Document complete detailed preoperative findings including symptoms, physical exam documenting severity of nail infection, injury, or deformity, and an assessment/plan with rationale for selecting surgical treatment over other options.
Key Coverage Criteria
- Report CPT 11730 for simple avulsion of a nail plate (partial or complete) when removing part or the entire nail plate for a single digit on a single date of service.
- Report CPT 11732 as the add-on code for every subsequent nail avulsion on a different nail during the same date of service; append the appropriate identifying digit modifier and report one unit of service for the add-on.
- Report CPT 11750 for excision of the nail and nail matrix (partial or complete) designated for permanent removal when the full length or entire nail plate is removed and the matrix is destroyed or permanently removed by any means.
- Report CPT 11765 for excision of a wedge of skin of the nail fold from the involved side of the toe (nail fold wedge excision) when the procedure includes the required wedge excision.
- When an avulsion, excision, or nail-fold procedure is performed on different nails during the same date of service, report the procedure with one unit of service and append the appropriate identifying-digit modifiers to identify each digit.
- When CPT codes 11730, 11732, or 11750 are reported for a digit, the single code represents all services performed on that specific nail for that date of service.
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