05/24/2022    Bryan C. Markinson, DPM

Nail Changes Should Be Biopsied: MI Podiatrist

Oftentimes, common parlance used to describe
procedures does not align with the exact
definition or even intent of the procedure. It is
in that vein that I feel compelled to make a
statement regarding what my colleagues routinely
call a “nail biopsy.” The procurement of a sample
of nail plate and subungual tissue by a clinician
for analysis under a microscope is NOT A BIOPSY.
On the laboratory end, although they may call it a
biopsy or mention the word biopsy in the report,
the pathology billing is under the domain of the
laboratory procedures and is in no way connected
to the procedure done in the podiatry office.

There has been discussion (and passionate
disagreement) about this for a few years now, with
many a word to the wise about calling the
submission of nail tissue samples a biopsy. It is
not. Even though the CPT descriptor of the nail
biopsy, CPT 11755, would seem to indicate that
what I am saying is incorrect, and is the cause of
considerable debate on the issue, I assure you
that the procurement of samples as described above
is not included in the definition of that code,
especially when interpreted by those looking into
coding abuse and/or fraud.

Likewise, a proper biopsy of the nail unit DOES
NOT have to include all anatomical parts of the
nail unit listed in the descriptor, as some
billing experts have contended.

In addition, the submission of nail plate to a lab
after the performance of a nail avulsion for a
garden variety nail infection for the sole purpose
of supporting that the procedure was in fact done
MAY be deemed abuse by CMS. I was involved in
review of one such case. On the other hand, a
noted and charted irregularity in the appearance
of the tissues raising suspicion of a neoplasm
certainly meets all the requirements for the code
to be billed.

Lastly, the ongoing ambiguity of code descriptors,
and impotence of practitioners and their
associations to get any kind of resolution of that
ambiguity, is more likely to work against you than
for you if any impropriety is thought to be
occurring.

Bryan C. Markinson, DPM, NY, NY

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