Nail Debridement Decision Tree
This set of questions will assist with review of documentation requirements:
1. Does all documentation meet signature requirements and include the name, signature and credentials of the person performing the service?
2. Are ALL the following present in the documentation?
Treatment of mycotic nails in absence of systemic condition, the following criteria must be met:
- Ambulatory patients:
- Clinical evidence of mycosis of toenail, and
- Marked limitation of ambulation, pain, and/or secondary infection resulting from thickening and dystrophy of infected toenail plate
- Non-ambulatory patients:
- Clinical evidence of mycosis of toenail, and
- Patient suffers from pain and/or secondary infection resulting from thickening and dystrophy of infected toenail plate
- Onychogryphosis with marked limitation of ambulation, pain, and/or secondary infection where nail plate is causing symptomatic indentation of or minor laceration of affected distal toe; and/or Onychauxis with marked limitation of ambulation, pain, and/or secondary infection that causes symptoms
- Physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in patient record, in order for routine foot care services to be reimbursable:
Class A findings
Non-traumatic amputation of foot or integral skeletal portion thereofClass B findings
Absent posterior tibial pulseAdvanced trophic changes as evidenced by any three of the following:
- hair growth (decrease or increase)
- nail changes (thickening)
- pigmentary changes (discoloring)
- skin texture (thin, shiny)
- skin color (rubor or redness); and absent dorsalis pedis pulse
Class C findings
Claudication
Temperature changes (e.g., cold feet)
Edema
Paresthesias (abnormal spontaneous sensations in the feet)
BurningPresumption of coverage may be applied when physician rendering routine foot care has identified:
- Class A finding
- Two Class B findings; or
- One Class B and two Class C findings
- Medical record should contain description of each nail which requires debridement. This should include, but is not limited to, size (including thickness) and color of each affected nail. In addition, local symptomatology caused by each affected nail resulting in the need for debridement must be documented along with precise physical findings and services (e.g., left great toe, or right foot, 4th digit.)
Yes No
3. When reporting debridement of mycotic nails if coverage based on qualifying systemic condition, is the appropriate modifier appended?
- HCPCS mod Q7 = 1 Class A finding
- HCPCS mod Q8 = 2 Class B findings
- HCPCS mod Q9 = 1 Class B finding and 2 Class C findings
Yes No
4. If reporting debridement of mycotic nails verify primary diagnosis representing patient's dermatophytosis of nail. Does secondary diagnosis represent systemic condition? In absence of systemic condition does primary diagnosis support dermatophytosis and one of the diagnosis codes which indicates secondary infection or pain?
Yes No
5. Does documentation indicate claim is for routine foot care services performed in the absence of localized illness, injury, or systemic disease involving the foot?
Yes No
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