07/19/2023    Lawrence Rubin, DPM

Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Ralph Zicherman, DPM)

Dr. Zicherman's response to my post regarding
Medicare's past revision of utilization guidelines
for CPT coded nail avulsion procedures questioned
the authority of the Office of the Inspector
General (OIG) to require Medicare to curb "abusive"
billing by podiatrists. The following link to the
OIG website explains this ability:
https://www.ftc.gov/office-inspector-general/what-
you-need-know-about-office-inspector-general

It is also important to know that since 2002,
podiatrists have been at high risk of audits and
punitive actions for what the OIG considers abusive
billing for debridement of onychomycosis. Read more
about this here:
https://oig.hhs.gov/oei/reports/oei-04-99-00460.pdf

The reality of all this is that Medicare claims
from podiatrists that involve toenail avulsion
and/or debridement are under close monitoring by
Medicare. They are among the most common services
that subject a podiatrist to an audit.

I strongly advise all podiatrists who submit
Medicare claims for nail avulsion and debridement
services to follow the advice of the OIG itself:
Implement the Office of the Inspector General (OIG)
Individual and Small Group Practice Compliance
Program that evidences your adherence to published
CMS-Medicare utilization guidelines.

The OIG states that, even if there is a suspicion
of abusive billing following a Medicare audit,
having a practice compliance program, "will be a
mitigating factor" against punitive action. In my
past and present work involving Medicare compliance
issues, I have found this OIG statement to be true.

Here are the details about the OIG Individual and
Small Group Compliance Program Act:
https://oig.hhs.gov/documents/compliance-
guidance/801/physician.pdf

Lawrence Rubin, DPM, Las Vegas, NV

Other messages in this thread:

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07/12/2023    Jack Ressler, DPM

Medicare Simple Partial Nail Avulsion Guidelines Unproven, Unnecessary, Unsafe (Ralph Zicherman, DPM)

I totally agree with everything Dr. Zicherman has
concisely written. To understand Medicare's
reasoning is as simple as Goggling "The goose and
the golden eggs". Sadly it tells a story of a
countryman who possessed a wonderful goose that
laid golden eggs. Every day he would visit the nest
to find one golden egg which he would take into
town to sell. He began to get rich but as greed
took over, he wasn't getting rich fast enough. He
decided to cut open the goose to remove all of the
golden eggs, obviously killing the goose.

While in podiatry school in the early ‘80s, I
shadowed a podiatrist during his visit to a nursing
home. He must have seen around 30 patients that
day. As he would see a patient, he would utter the
phrase "bilateral bilateral" to his assistant as he
debrided the patients nails. A brief clean-up was
then done, sometimes followed by applying topical
antibiotic ointment. This was done on around 70% of
the patients he treated. Curiously, I asked him,
what does bilateral bilateral mean. His reply was
that he did a simple nail excision procedure on
both borders of both great toes. Enough said. The
11730 procedure code has been the golden egg in
many podiatry practices. Unfortunately, it became a
code that has been highly abused and closely
scrutinized by Medicare.

As stated in other posts, I actually went through
what I would call a silent Medicare audit based on
the high frequency I used this code. Medicare
actually showed up at two of my patients homes that
I did a 11730 procedure on. They asked my patients
two questions, did your toe hurt before the
procedure and did the doctor inject local
anesthesia. I would have had a mess on my hands had
I not gone by Medicare's guidelines with this
procedure. I do think Medicare's requirements on
this procedure could be overkill but that is what
we as a profession have created. We haven't yet
removed all the golden eggs, but the goose is
definitely on life support.

Jack Ressler, DPM, Boca Raton, FL