07/18/2024    Michael G. Warshaw, DPM, CPC

Noridian CMS Audit for CPT 11730

CPT code 11730 is defined as the following:
Avulsion of nail plate, partial or complete,
simple; single. Unfortunately, it is one of the
most frequently audited CPT/procedure codes due to
the improper performance and documentation of this
procedure.

Here are the important facts regarding the
performance and documentation of CPT code 11730:

1. Documentation must describe the symptoms and
complaints which establish medical necessity for
the treatment.
2. Nail or Nail border must be separated and
removed to and under the eponychium.
3. Local anesthetic (type and quantity) must be
documented. If not used, provide
rationale (i.e. Neuropathic patient, patient
refused, medical contraindications).
4. Post-operative instructions and follow-up care
should be documented.
5. If the medial and the lateral borders are
removed on the same nail, only one service can be
billed.
6. Cannot bill an I&D and avulsion or partial
avulsion on the same nail.
7. CPT codes 11730 and 11732 for nail avulsion will
be denied if billed for the same finger less than 4
months (16 weeks) or the same toe less than 8
months (32 weeks) following a previous avulsion.
8. For a reasonable and necessary repeat nail
avulsion on the same finger less than 4 months (16
weeks) or the same toe less than 8 months (32
weeks) following a previous avulsion, the KX
modifier must be appended to the claim. The medical
record documentation must be specific as to the
indication, such as ingrown nail of the opposite
border or new significant pathology on the same
border recently treated.

With respect to the request from Noridian for 4
Medicare patient medical records, specifically for
CPT code 11730, the fact that the office notes are
handwritten should not be an issue if an exact copy
of the medical records in question are typed and
accompany the handwritten records when they are
submitted.

If the medical records in question are “not in the
great detail CMS guidelines suggest,” it would be
highly inappropriate to alter or change the
documentation, especially since the procedures were
performed “last year.” If the office notes include
the chief complaint/HPI, the objective findings and
the treatment, specifically that local anesthetic
was injected and the nail border in question was
avulsed to and under the eponychium, hopefully this
will pass the test.

This is my opinion.

Michael G. Warshaw, DPM, CPC, Mount Dora, FL

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