CPT 11719 – When is nail trimming billable?

[Bored Snorlax]

Curious how others approach billing for CPT 11719 (nail trimming, non-dystrophic). I know it’s usually considered routine and not covered, but becomes reimbursable if there’s a systemic condition (like DM or PVD) and the patient can’t safely perform self-care (low vision, sciatica, etc). Anyone have tips on documentation or examples of what’s worked in practice? Also wondering how often you actually get reimbursed. Appreciate any insights. Thanks!

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[Hybrocure]

Q codes are your best friend. Most people unable to trim their own nails in my experience (particularly the older population) don’t have pedal hair. Have some sort of edema. The legs feel cool. Maybe the PT pulse is hard to palpate.

Also keep in mind most people in this population don’t have non-dystrophic nails. They tend to be thickened, discolored etc. that’s a different code.


🦞👑

 

[air bud]

I don't even know what 11719 is and never billed in my life.

The other day I had a new MA and she called a few diabetic foot exam referrals. Figured out they were looking for RFC. Said Dr. air Bud doesn't do that and got them off my schedule. I didn't even tell her to. I just discussed diabetic foot care with her and how rarely covered and she took it upon herself. I think I am in love.

 

[Hybrocure]

I don't even know what 11719 is and never billed in my life.

The other day I had a new MA and she called a few diabetic foot exam referrals. Figured out they were looking for RFC. Said Dr. air Bud doesn't do that and got them off my schedule. I didn't even tell her to. I just discussed diabetic foot care with her and how rarely covered and she took it upon herself. I think I am in love.

Send em my way

 

[DYK343]

Curious how others approach billing for CPT 11719 (nail trimming, non-dystrophic). I know it’s usually considered routine and not covered, but becomes reimbursable if there’s a systemic condition (like DM or PVD) and the patient can’t safely perform self-care (low vision, sciatica, etc). Anyone have tips on documentation or examples of what’s worked in practice? Also wondering how often you actually get reimbursed. Appreciate any insights. Thanks!

11719 pays 0.1 wRVU and unless a seperate identifiable complaint cant routinely bill office visits.

Pays about $5 (not sure in private practive amount paid).

No thickness its a hard no. Cut them yourself

Convincing the PCP that a stable non neuropathic diabetic doesnt need their nails trimmed by a podiatrist is another story.
Thats the hardest part about turning them down. You turn down future (non nail) referrals.

 

[heybrother]

1. If they are a Q you can bill it. ie. systemic diagnosis + 1A, 2B, B&Cs + met the asterisk requirement + 61 days
2. Its worth $13 where I am. If you are seeing people and billing just 11719 and nothing else you are going to go out of business. A 99212 on Medicare is worth $50+ and involves running your eyes over the patient's foot and saying "looks good" as you walk backwards out of the room that you never full entered. You can combine 1105X with 11719-21. I suppose if you were already going to trim a callus and they ask you to cut a nail you should put the $13 in your pocket and buy some hobo wine with it to drown your sorrows. You can also combine 11720 and G0217 which turns a $30 visit into a $50 visit and is still less than a 99212 I bet - yep, just checked. 99212 > 11730+g0127. The PCP who sent them to you and didn't lift a finger is billing a 99214 +G2211 and the G2211 is worth more than the 11719. Think about that.
3. I have no idea what the ICD-10 code that matches it is. G0127 pairs to onychogryphosis.
4. Medicare probably pays if you get the ICD-10 to CPT right. A lot of Medicare Advantage plans will not pay for nails with a callus and will claim the services were bundled. Before I dropped Humana I once realized that I had like 60+ denied 1172Xs sitting in my coding mailbox. Some PP pod posted a story once on IPED claiming they'd followed hundreds of nails through to a ALJ and finally been paid for them against Humana. Dear Lord. We're fighting for our tiny coins.
5. Non-qualifying routine foot care is statutorily uncovered and you can set your own price structure.
6. Where I am - there is no 50% reduction on the 2nd "procedure" if the first was some sort of trimming/debridement. ie. 11720+G0127 - the G0127 is full value. 11056+ a 11721/1170 - the nail debridement isn't 50% reduced so you still get your $30-40. Exception to this is Aetna

You are far better off trying to put yourself in a position where all of the above is trash to you. ie. being RVU based.

 

[air bud]

11719 pays 0.1 wRVU and unless a seperate identifiable complaint cant routinely bill office visits.

Pays about $5 (not sure in private practive amount paid).

No thickness its a hard no. Cut them yourself

Convincing the PCP that a stable non neuropathic diabetic doesnt need their nails trimmed by a podiatrist is another story.
Thats the hardest part about turning them down. You turn down future (non nail) referrals.

Be the only option in town..think about it guy meme.

 

[air bud]

11719 pays 0.1 wRVU and unless a seperate identifiable complaint cant routinely bill office visits.

Pays about $5 (not sure in private practive amount paid).

No thickness its a hard no. Cut them yourself

Convincing the PCP that a stable non neuropathic diabetic doesnt need their nails trimmed by a podiatrist is another story.
Thats the hardest part about turning them down. You turn down future (non nail) referrals.

Be the only option in town..think about it

1. If they are a Q you can bill it. ie. systemic diagnosis + 1A, 2B, B&Cs + met the asterisk requirement + 61 days
2. Its worth $13 where I am. If you are seeing people and billing just 11719 and nothing else you are going to go out of business. A 99212 on Medicare is worth $50+ and involves running your eyes over the patient's foot and saying "looks good" as you walk backwards out of the room that you never full entered. You can combine 1105X with 11719-21. I suppose if you were already going to trim a callus and they ask you to cut a nail you should put the $13 in your pocket and buy some hobo wine with it to drown your sorrows. You can also combine 11720 and G0217 which turns a $30 visit into a $50 visit and is still less than a 99212 I bet - yep, just checked. 99212 > 11730+g0127. The PCP who sent them to you and didn't lift a finger is billing a 99214 +G2211 and the G2211 is worth more than the 11719. Think about that.
3. I have no idea what the ICD-10 code that matches it is. G0127 pairs to onychogryphosis.
4. Medicare probably pays if you get the ICD-10 to CPT right. A lot of Medicare Advantage plans will not pay for nails with a callus and will claim the services were bundled. Before I dropped Humana I once realized that I had like 60+ denied 1172Xs sitting in my coding mailbox. Some PP pod posted a story once on IPED claiming they'd followed hundreds of nails through to a ALJ and finally been paid for them against Humana. Dear Lord. We're fighting for our tiny coins.
5. Non-qualifying routine foot care is statutorily uncovered and you can set your own price structure.
6. Where I am - there is no 50% reduction on the 2nd "procedure" if the first was some sort of trimming/debridement. ie. 11720+G0127 - the G0127 is full value. 11056+ a 11721/1170 - the nail debridement isn't 50% reduced so you still get your $30-40. Exception to this is Aetna

You are far better off trying to put yourself in a position where all of the above is trash to you. ie. being RVU based.

I still don't understand and refuse to learn anything other than 11721 and 11720. I refuse to do those codes. Everybody can refuse..... This is the way

11721 is .5RVU so 25ish bucks for most people
1172p is .3RVU so 15ish bucks. Hard F***ing No. Anyone in an RVU based model who has admin thinking doing that is a good idea works for moar rons. Sure you are going to get some establish visits out of it with "new problems"....but it's not worth it. No matter what @DYK343 tells you.

 

[Bored Snorlax]

Appreciate all the input. Super helpful as I try to wrap my head around how this actually works in the real world. Glad we confirmed it's actually billable. From what I’ve seen in clinic, patients requesting nail care often can’t do it themselves, and they usually have something else going on e.g. old age, chronic conditions, poor vision, etc. Even if the nails look “non-dystrophic,” they still struggle with basic foot care.

I completely agree 11719 isn’t something to chase alone, but if it’s bundled into a visit or layered with other services e.g. 992xx, it’s not totally useless. $13 might not sound like much, but it adds up and could realistically help cover ancillary staff costs or be built into a workflow that keeps the clinic efficient. Cutting non-dystrophic nails probably takes a minute at most. We're not resecting a calcified lobster claw off a diabetic rocker bottom mid-crisis. If that quick task keeps the schedule flowing and the MA engaged with a little bonus incentive, seems like an easy win.

Another thing is the patient experience. Sometimes it’s the small stuff that keeps them happy and coming back. If they feel cared for and respected, even for something as simple as nail care, they’re more likely to return for diabetic foot checks, wounds, or other real pathology down the road. Thanks again for all the great feedback. Learning a ton from this thread.

 

[air bud]

Appreciate all the input. Super helpful as I try to wrap my head around how this actually works in the real world. Glad we confirmed it's actually billable. From what I’ve seen in clinic, patients requesting nail care often can’t do it themselves, and they usually have something else going on e.g. old age, chronic conditions, poor vision, etc. Even if the nails look “non-dystrophic,” they still struggle with basic foot care.

I completely agree 11719 isn’t something to chase alone, but if it’s bundled into a visit or layered with other services e.g. 992xx, it’s not totally useless. $13 might not sound like much, but it adds up and could realistically help cover ancillary staff costs or be built into a workflow that keeps the clinic efficient. Cutting non-dystrophic nails probably takes a minute at most. We're not resecting a calcified lobster claw off a diabetic rocker bottom mid-crisis. If that quick task keeps the schedule flowing and the MA engaged with a little bonus incentive, seems like an easy win.

Another thing is the patient experience. Sometimes it’s the small stuff that keeps them happy and coming back. If they feel cared for and respected, even for something as simple as nail care, they’re more likely to return for diabetic foot checks, wounds, or other real pathology down the road. Thanks again for all the great feedback. Learning a ton from this thread.

Repeat this to yourself and to the patient. Medicare doesn't cover lots of things. Eyes, ears, teeth...toenails


Just because they can't reach them doesn't mean you, a doctor, needs to do it.

Also, as @619 always says ...you don't want people coming back. You want new patients. You need availability on your schedule. The people who want you to cut their nails are not wanting surgery. Stop with the crap about oh their kids or neighbors might come to you. Stop with all of it. It's not profitable for you. It's not different than any other business.

Oh yeah as long as we are talking about useless stuff....annual diabetic foot exams. All of these exist because there isn't enough real work to be done.

 

[air bud]

Appreciate all the input. Super helpful as I try to wrap my head around how this actually works in the real world. Glad we confirmed it's actually billable. From what I’ve seen in clinic, patients requesting nail care often can’t do it themselves, and they usually have something else going on e.g. old age, chronic conditions, poor vision, etc. Even if the nails look “non-dystrophic,” they still struggle with basic foot care.

I completely agree 11719 isn’t something to chase alone, but if it’s bundled into a visit or layered with other services e.g. 992xx, it’s not totally useless. $13 might not sound like much, but it adds up and could realistically help cover ancillary staff costs or be built into a workflow that keeps the clinic efficient. Cutting non-dystrophic nails probably takes a minute at most. We're not resecting a calcified lobster claw off a diabetic rocker bottom mid-crisis. If that quick task keeps the schedule flowing and the MA engaged with a little bonus incentive, seems like an easy win.

Another thing is the patient experience. Sometimes it’s the small stuff that keeps them happy and coming back. If they feel cared for and respected, even for something as simple as nail care, they’re more likely to return for diabetic foot checks, wounds, or other real pathology down the road. Thanks again for all the great feedback. Learning a ton from this thread.

Take me around the shed and shoot me now.

 

[HardRoadPaved]

useless stuff....annual diabetic foot exams

Nothing is worse than having to "educate" and explain the big bad wolf of diabetic complications to patients clearly compliant enough to get their foot examined with an A1c of 6.2% for the past 15 years.

 

[pod squad]

From a PP standpoint, 11720+G0127+11056 x4 visits per year pays as much as a bunion. It is what it is. Now, 11719 is a different story. Tell these people to go to a nail salon.

 

[heybrother]

Appreciate all the input. Super helpful as I try to wrap my head around how this actually works in the real world. Glad we confirmed it's actually billable. From what I’ve seen in clinic, patients requesting nail care often can’t do it themselves, and they usually have something else going on e.g. old age, chronic conditions, poor vision, etc. Even if the nails look “non-dystrophic,” they still struggle with basic foot care.

I completely agree 11719 isn’t something to chase alone, but if it’s bundled into a visit or layered with other services e.g. 992xx, it’s not totally useless. $13 might not sound like much, but it adds up and could realistically help cover ancillary staff costs or be built into a workflow that keeps the clinic efficient. Cutting non-dystrophic nails probably takes a minute at most. We're not resecting a calcified lobster claw off a diabetic rocker bottom mid-crisis. If that quick task keeps the schedule flowing and the MA engaged with a little bonus incentive, seems like an easy win.

Another thing is the patient experience. Sometimes it’s the small stuff that keeps them happy and coming back. If they feel cared for and respected, even for something as simple as nail care, they’re more likely to return for diabetic foot checks, wounds, or other real pathology down the road. Thanks again for all the great feedback. Learning a ton from this thread.

At some point that mentality will burn you out. You at first will think - "I'm doing the right thing". Then you'll think "its good for business - I see a $10, I pick it up". And then at some point you realize that every visit is just click, click, click adding on little charges trying to stay in business and turn $50 into $70 or what not. You'll review the billing and realize your office didn't get a referral for the VA patient for the last 3 visits and the

99212, 11056, 11720 - (cause it was the first visit of the year and you wanted to get your "yearly diabetes education" E&M charge in)
and the 11056, 11720, g0127 (yeah, you knew the g0127 was only worth $10 when its a 3rd CPT, but it pays for part of an MA)

didn't get paid for and the patient is never going to pay. And you'll realize that you are doing something you don't really enjoy just clicking boxes and you aren't even getting paid to do it.

Also, "can't cut", "can't bend", "can't reach" - doesn't qualify.

 

[heybrother]

From a PP standpoint, 11720+G0127+11056 x4 visits per year pays as much as a bunion. It is what it is. Now, 11719 is a different story. Tell these people to go to a nail salon.

This is something I've always been amused by in the past. The Medicare fee schedule keeps changing but historically a 11056 + 11720 is worth more than a commercial insurance 99214.

The real problem for a lot of PP is that everything keeps being degraded in value and for me at least most commercial insurance pays less than Medicare even if they pay CPT at higher.

The other day I somehow convinced a small insurance company to pay 160% of Medicare for everything. I realized afterwards that this contract is the closest thing I have to being paid like a hospital employed doctor. A 99203 at $168/2 is $84 and hospital people at $50 an RVU get like $80 for a 99203. $53 an RVU gets you $84. I have almost no other contracts like this. So for a PP doctor to match an RVU doctor they need a contract that pays like $50-60 more $ a visit and they need to keep at least 50% of collections.

 

[Adam Smasher]

To answer @Bored Snorlax 's question, you can bill a 11719 at the same time as any other nail code: if the patient has (1) LOPS or if the patient has (2) signs of PAD (needs a Q modifier as @Hybrocure noted). Per my LCD, it's not billable against "pain in toe" but somehow I've gotten paid anyway. It's a useful line 2 code after your 11720 if you don't feel like embellishing to bill the G0127. For auditing purposes, Medicare expects you to bill a 11719 every now and then as a lone procedure so I suppose don't not use it. Example, quadriplegic medicare beneficiaries whose family members/aides are afraid to trim their nails. Yes, RFC is covered under icd-10 code G52.8x

That's when you CAN bill 11719. When SHOULD you be billing 11719s is: almost never. Agree with commenters above that this code should not be actively pursued, do not build your practice around these patients. As I noted in another thread, you need to actively manage your schedule. If your admin people will do this for you, that's great. If not, it's incumbent on you to leave designated slots for real patients so you are not caught up in a dust storm of keratin

 

[dtrack22]

I bill it with 11720. In a previous MAC, 11720 + 11719 was the same reimbursement as 11721 by itself. Your mileage may vary. I also don’t do much nail care and am hospital employed so I haven’t paid any attention to these codes in 4 years, i.e. don’t listen to me.

 

[DYK343]

Be the only option in town..think about it

I still don't understand and refuse to learn anything other than 11721 and 11720. I refuse to do those codes. Everybody can refuse..... This is the way

11721 is .5RVU so 25ish bucks for most people
1172p is .3RVU so 15ish bucks. Hard F***ing No. Anyone in an RVU based model who has admin thinking doing that is a good idea works for moar rons. Sure you are going to get some establish visits out of it with "new problems"....but it's not worth it. No matter what @DYK343 tells you.

Again, only accept train wrecks. True people that actually need their nails cut. Not just anyone.

Trainwrecks 80% of the time have a 99213 attached in which its just under 2RVU and >2RVU if calluses.

A good % of these people come in with an active wound. 99214 + debridement+ nails. Love those visits.

Book 5 of these an hour and it's easy work. I do my note in the room before I leave and run to the next room. All templates.

It's also a bit of a mental break. I literally don't use my brain.

Where I practice there is a lot of well-trained DPMs. Its competitive. I wasn't filling my outpatient schedule all the days I could be in clinic. So I set some hours (4hrs a week) aside to do nails only to pad my schedule. Its been pretty profitable. Since accepting nails I have easily added 150-200 RVU a month to my total. My plan is working. My non nail days are much more full. No gaps because I condensed my schedule. Might open a whole day for nails to further condense. Im hitting 800ish RVU a month now.

But I do agree. Have to have new patients rolling through. Which is why I limit my nail care hours.

 

[air bud]

Nothing is worse than having to "educate" and explain the big bad wolf of diabetic complications to patients clearly compliant enough to get their foot examined with an A1c of 6.2% for the past 15 years.

Yeah meant to tag you on this one. Churn patients.

 

[Bored Snorlax]

Totally agree 11719 is not worth chasing by itself. But let’s be real, most patients are not showing up just to get their healthy nails trimmed. If they are asking, I'm assuming they cannot do it themselves. Could be limb weakness, balance issues, limited reach, low vision, tremor, anything that makes it medically justifiable to bill. As long as it is documented and paired with a qualifying condition, I don't really see how an audit could overturn it. And honestly, there is usually something else going on anyway like diabetes, neuropathy, mobility issues, or early signs of pathology.

Kinda wild that 11719 only requires one non-dystrophic nail. One nail for $13. That's less effort than finding parking in Philly. These visits often turn into legit 99212 or 99213s because you're checking pulses, sensation, pain, maybe catching early vascular issues.

What's been interesting is how differently people handle it. Some avoid it completely. Others block off nail care hours and walk away with 150-200 extra RVUs a month by streamlining visits and filtering high-risk patients.

If you say no to trimming, there is a good chance that patient doesn't come back. And that might've been your shot at catching something early or setting up a real 992xx-level encounter. And if I am trimming them anyway, might as well get reimbursed for it.

 

[air bud]

Totally agree 11719 is not worth chasing by itself. But let’s be real, most patients are not showing up just to get their healthy nails trimmed. If they are asking, I'm assuming they cannot do it themselves. Could be limb weakness, balance issues, limited reach, low vision, tremor, anything that makes it medically justifiable to bill. As long as it is documented and paired with a qualifying condition, I don't really see how an audit could overturn it. And honestly, there is usually something else going on anyway like diabetes, neuropathy, mobility issues, or early signs of pathology.

Kinda wild that 11719 only requires one non-dystrophic nail. One nail for $13. That's less effort than finding parking in Philly. These visits often turn into legit 99212 or 99213s because you're checking pulses, sensation, pain, maybe catching early vascular issues.

What's been interesting is how differently people handle it. Some avoid it completely. Others block off nail care hours and walk away with 150-200 extra RVUs a month by streamlining visits and filtering high-risk patients.

If you say no to trimming, there is a good chance that patient doesn't come back. And that might've been your shot at catching something early or setting up a real 992xx-level encounter. And if I am trimming them anyway, might as well get reimbursed for it.

You don't get it. That's ok.....10 nails at 13 bucks a pop....to get at best 99204.

See @DYK343 I told you that you were going to give others false hope .

 

[DYK343]

Totally agree 11719 is not worth chasing by itself. But let’s be real, most patients are not showing up just to get their healthy nails trimmed. If they are asking, I'm assuming they cannot do it themselves. Could be limb weakness, balance issues, limited reach, low vision, tremor, anything that makes it medically justifiable to bill. As long as it is documented and paired with a qualifying condition, I don't really see how an audit could overturn it. And honestly, there is usually something else going on anyway like diabetes, neuropathy, mobility issues, or early signs of pathology.

Kinda wild that 11719 only requires one non-dystrophic nail. One nail for $13. That's less effort than finding parking in Philly. These visits often turn into legit 99212 or 99213s because you're checking pulses, sensation, pain, maybe catching early vascular issues.

What's been interesting is how differently people handle it. Some avoid it completely. Others block off nail care hours and walk away with 150-200 extra RVUs a month by streamlining visits and filtering high-risk patients.

If you say no to trimming, there is a good chance that patient doesn't come back. And that might've been your shot at catching something early or setting up a real 992xx-level encounter. And if I am trimming them anyway, might as well get reimbursed for it.

No, you missed the point. Train wrecks only. PAD, Neuropathy, Stasis dermatitis, Edema, diabetic shoe rx, tinea pedis farm, want to talk about nail fungus treatment each time, gabapentin/pain management, cellulitis, wounds, etc etc.

The people coming in for a nail trim are not going to have a 99213. They will be the most picky nail people alive for a whopping 0.1rvu with no E&M. Do not accept this type of work.

Nearly all the of the nails I treat come from the wound center (Mine plus other non DPM providers refer to me). They have to have neuropathy as a diagnosis, hx stasis ulcers, etc or I wont see them.

 

[heybrother]

Everyone at some point believes they know something that no one else does.

There is no free lunch.

 

[Feli]

This kid hasn't even started residency yet... he will figure it out.

I've never billed 11719 ... what is the point? ($20???)

As said, you don't want to turn ppl away, but make those ppl who have no qualifiers/need/fungus cash pay for nail care. Don't be shy.

...People will always do what pays them:

Hospital pod guys find creative ways to refuse nails and make a TMA get them 55wRVU.
That doesn't work at all in PP as those patients have crap/no insurance and/or the payers deny most codes.

PP guys find ways to make money off nail care and OTC stuff and look for other pathology/DME on those pts too.
That doesn't work for hospital pods on wRVU models as they want surgery pts (wRVU on RFC are pathetic).

 

[Hybrocure]

This kid hasn't even started residency yet... he will figure it out.

I've never billed 11719 ... what is the point? ($20???)

As said, you don't want to turn ppl away, but make those ppl who have no qualifiers/need/fungus cash pay for nail care. Don't be shy.

...People will always do what pays them:

Hospital pod guys find creative ways to refuse nails and make a TMA get them 55wRVU.
That doesn't work at all in PP as those patients have crap/no insurance and/or the payers deny most codes there... plus they don't want to work eve/weekends.

PP guys find ways to make money off nail care and OTC stuff and look for other pathology/DME on those pts too.
That doesn't work for hospital pods on wRVU models as they want surgery pts (wRVU on RFC are pathetic).

Oh man the TMA codes are ****ing hilarious.

Almost as crazy as scopes

 

[air bud]

This kid hasn't even started residency yet... he will figure it out.

I've never billed 11719 ... what is the point? ($20???)

As said, you don't want to turn ppl away, but make those ppl who have no qualifiers/need/fungus cash pay for nail care. Don't be shy.

...People will always do what pays them:

Hospital pod guys find creative ways to refuse nails and make a TMA get them 55wRVU.
That doesn't work at all in PP as those patients have crap/no insurance and/or the payers deny most codes.

PP guys find ways to make money off nail care and OTC stuff and look for other pathology/DME on those pts too.
That doesn't work for hospital pods on wRVU models as they want surgery pts (wRVU on RFC are pathetic).

I feel seen

 

[heybrother]

What's funny is wRVUs for nailcare essentially reimburses at "PP" levels. With the exception of calluses - if you take the nailcare codes (I looked at 11721, 11720, g0127) wRVUs at about $50 they essentially match up with the dollar value of 50% overhead on nails. Calluses are obviously lower which is sort of hilarious since calluses are the only thing that make nails worthwhile for PP. Busting a crumbly is hospital pods way to see how the other 90% live.

 

[DYK343]

I've never billed 11719 ... what is the point? ($20???)

Went to a lecture once where Jeffrey Lehrman (DPM also certified coder - speaks a lot) said if you debride <5 nails and trim the rest you are suppost to bill a 11720 and a 11719

 

[Bored Snorlax]

This kid hasn't even started residency yet... he will figure it out.

I've never billed 11719 ... what is the point? ($20???)

As said, you don't want to turn ppl away, but make those ppl who have no qualifiers/need/fungus cash pay for nail care. Don't be shy.

...People will always do what pays them:

Hospital pod guys find creative ways to refuse nails and make a TMA get them 55wRVU.
That doesn't work at all in PP as those patients have crap/no insurance and/or the payers deny most codes.

PP guys find ways to make money off nail care and OTC stuff and look for other pathology/DME on those pts too.
That doesn't work for hospital pods on wRVU models as they want surgery pts (wRVU on RFC are pathetic).

Definitely not trying to claim I’ve cracked the code before even starting residency. It makes sense that in high-volume PP or RVU-driven hospital systems, 11719 barely moves the needle. Totally get that this isn’t where the real money or surgical cases come from. Anyway, not here to romanticize nail care. Just trying to understand how people use it differently depending on their model.

Went to a lecture once where Jeffrey Lehrman (DPM also certified coder - speaks a lot) said if you debride <5 nails and trim the rest you are suppost to bill a 11720 and a 11719

Curious how often that’s actually done in practice or if most just simplify it to 11720 to avoid red tape.

 

[MicroPod]

This thread started as nails but it’s funny how every thread eventually makes its way to discussing nails (and podiatry saturation).

 

[DYK343]

Curious how often that’s actually done in practice or if most just simplify it to 11720 to avoid red tape.

I dont want to misquote him because it was awhile ago. He talks fast too.

But I believe it was more so you dont get audited. If youre always debriding (not trimming) 10 nails medicare could find this suspicious. Even if you debride 9 and trim 1 nail I believe he said to bill a 11721 (debride >6) and 11719 (trim any number).

I dunno. I never bill the 11719 even though i sat through that billing/coding lecture

 

[heybrother]

I dont want to misquote him because it was awhile ago. He talks fast too.

But I believe it was more so you dont get audited. If youre always debriding (not trimming) 10 nails medicare could find this suspicious. Even if you debride 9 and trim 1 nail I believe he said to bill a 11721 (debride >6) and 11719 (trim any number).

I dunno. I never bill the 11719 even though i sat through that billing/coding lecture

Another podiatrist in my town told me the exact same story / rationale and I think I've sat through said lecture also.

We joke about it, but I do add G0127's onto 11720 if appropriate because it is an extra $20.

I recently sat through a Lehrman lecture where he essentially says we need to beef up our documentation for x-rays. Haven't heard anyone talking about that on here before but I've enlarged my x-ray templates and ulcer debridement templates based on his recommendation. I've read the ulcer LCDs and my documentation was definitely light compared to what the LCD said and what Lehrman recommended. I haven't searched for the x-ray LCD, but I get what he's saying. Its just sort of a feeling of never ending more and more documentation.

 

[DYK343]

Another podiatrist in my town told me the exact same story / rationale and I think I've sat through said lecture also.

We joke about it, but I do add G0127's onto 11720 if appropriate because it is an extra $20.

I recently sat through a Lehrman lecture where he essentially says we need to beef up our documentation for x-rays. Haven't heard anyone talking about that on here before but I've enlarged my x-ray templates and ulcer debridement templates based on his recommendation. I've read the ulcer LCDs and my documentation was definitely light compared to what the LCD said and what Lehrman recommended. I haven't searched for the x-ray LCD, but I get what he's saying. Its just sort of a feeling of never ending more and more documentation.

G0127

Ive never billed this. I dont really know what it is.

It pays 0.17 RVU so I dont plan to use it.

 

[Feli]

Went to a lecture once where Jeffrey Lehrman (DPM also certified coder - speaks a lot) said if you debride <5 nails and trim the rest you are suppost to bill a 11720 and a 11719

He's a dude who sells lectures to pay for travel and to attract more lecture bookings.

The problem with prac mgmt "guru" lectures is the people "teaching" seldom even see any appreciable number of patients (often zero)... they make income from selling books, lectures, appraisals, training, etc. Lehrmann is the current captain of clinic and wounds, and before that it was Goldsmith who could tell everyone about surgery coding - yet his own surgery skill and exp was basically nil.

Sure, there can be good info in the lectures, but they usually don't practice what they preach (because they don't practice at all).

...I believe it was more so you dont get audited. If youre always debriding (not trimming) 10 nails medicare could find this suspicious...

Theoretically, sure.
But I have a hard time believing that me seeing 16-20/d for 4 days/wk with maybe average of 3-5 of them being RFC is going to be a huge MCR audit target. I could be wrong, lol. CMS reviewers (what fraction of them DOGE didn't lay off?) probably has their sights more on the amnio accumulators and the DPMs who are top 5 or 10% in terms of nail procedures.

I do the very rare 11720 (for pts with contralat BKA and 5 or fewer fungal nails).
But 11719 is not even worth the time to document or type in the codes. Jmo.

...at the end of the day, anyone worth their salt in PP (or hospital) knows that with education costing $400k at 8% interest, the RFC patients are basically just schedule fillers. They are people you can help, but they don't pay the bills (hence so much fraud on RFC). They are a bit of a break from more demanding pts/path and RFC pts are mainly a way to look for them having DME need, flexor tendonotomies, blisters, biopsies, injects, calluses, wounds, deformity, XR or u/s, and other DME or procedures that actually make appreciable money.

The goal for many, myself included, is to get through the RFC quick and well (give them a funny story or DM exam or whatever they need)... but the patients that pay the bills come largely from procedure pts and new pts. In any business, you need more $$ per client/visit (good attorney charges $500+/hr while crummy one is $200/hr)... or you need huuuge volume (I personally don't like that in podiatry as it creates ridiculous paperwork, cleanup, traffic, much staffing to deal with, staff job dissatisfaction of dust clouds). You won't get rich clipping $1 coupons (cheaping out on staff, cheaping on marketing, billing 11729), but you will get rich doing your bigger ticket services more often. Basically, your time is worth something too. Figure out how to get more refers for surgery/wound/procedure/dme visits.

The only model I can see that has heavy RFC which is also highly profitable - without fraud - use a HUGE volume (nail care done by many MAs, doc pops in fast to say hi or do calluses for 2mins... and on to the next). Nursing home pods also rely on this (speaking of fraud). And yeah, that'll make the office an audit target if they are hitting all 117xx codes many times more than area peers.

So yeah, if anyone is doing that many RFC visits that it's a huge % of your income and 11719 matters, me thinks you might need to re-eval your marketing, your biz (your life?). 🙂

 

[Adam Smasher]

I guess ~20-30 years ago there was an issue where podiatrists were billing 11721 for every single patient and subsequently the nail debridement LCD came to specifically state that "we will come after you if you don't stipulate which of the 10 toenails are thickened" or something to that effect.

When I was in residency, my director thought he could ingratiate himself with the internists if we answered every. Single. Toenail. Consult. To protest, I was ready to present for journal club an early 2000s JAPMA article on nail debridement where they argued the 11721 code was being abused. The investigators actually took the time to randomly evaluate podiatry RFC pts and found the 11721 was appropriate only about 20% of the time. It's hilarious that they did a well designed epidemiology paper on such a stupid topic. I can't find it now because pubmed is full of articles on debridement of open tibia fractures and im nails, so we'll leave finding it to @Bored Snorlax for homework. As for me, that journal club ended up being canceled due to some scheduling conflict, probably better for me that it happened that way.

Here in lobsterland where I live, G0127 is a consolation prize for me. If a pt comes to me for trimming of nails that are basically normal, I can usually document the pinky toenail is sorta funny looking and get reimbursed $22 instead of $17 for the 11719. Billing a 11720 with G0127 doesn't make sense to me. You debride some of the dystrophic nails but only trimmed other dystrophic nails? It feels like a weird thing to document. Just my opinion. I know it's still legit.

 

[Bored Snorlax]

I guess ~20-30 years ago there was an issue where podiatrists were billing 11721 for every single patient and subsequently the nail debridement LCD came to specifically state that "we will come after you if you don't stipulate which of the 10 toenails are thickened" or something to that effect.

When I was in residency, my director thought he could ingratiate himself with the internists if we answered every. Single. Toenail. Consult. To protest, I was ready to present for journal club an early 2000s JAPMA article on nail debridement where they argued the 11721 code was being abused. The investigators actually took the time to randomly evaluate podiatry RFC pts and found the 11721 was appropriate only about 20% of the time. It's hilarious that they did a well designed epidemiology paper on such a stupid topic. I can't find it now because pubmed is full of articles on debridement of open tibia fractures and im nails, so we'll leave finding it to @Bored Snorlax for homework. As for me, that journal club ended up being canceled due to some scheduling conflict, probably better for me that it happened that way.

Here in lobsterland where I live, G0127 is a consolation prize for me. If a pt comes to me for trimming of nails that are basically normal, I can usually document the pinky toenail is sorta funny looking and get reimbursed $22 instead of $17 for the 11719. Billing a 11720 with G0127 doesn't make sense to me. You debride some of the dystrophic nails but only trimmed other dystrophic nails? It feels like a weird thing to document. Just my opinion. I know it's still legit.

Onychauxic dystrophic toenails requiring debridement in Medicare patients. Prevalence and anatomical distribution - PubMed 🙂

 

[heybrother]

I think most people are going to try to pick up $10 where they can. I just reviewed my clinic billing. I'm not an aggressive G0127 biller ie. technically I could likely add it to every single 11056 + 11720 visit - I essentially never do. I add it to isolated 11720s. Over the last 6 years I've been paid like $3K for that code. I suppose I'd rather have it than not.

The other day I wrote to an insurance company asking for better rates. I was at 110% of Medicare for E&M, CPT, and Rads and 100% for DME.
They sent me back a contract offering 115% for E&M and radiology, 75% for DME, and 125% for CPT.
I wrote back and begged for more.
They "upgraded" the offer to 115% for E&M and radiology, 100% for DME, and 130% for CPT - so essentially I kept my DME stable and added 5% to CPT.

You could say - what's the point of the extra 5%, what will it really accomplish etc, but I'd still like to be paid as much as I could. Anything can be templated. You literally put down a template that says "I debrided X mycotic nails. I trimmed Y dystrophic nails" and you pop it in instead of a mycotic procedure template. Then you forward the template for the rest of the patient's life.

 

[Feli]

Maybe we can think of it this way, guys...

A normal PP doc is generating up to around $1M per year gross... $500k minimum, ya? (for pt care they do themselves, not associates)
So, that's $250-$500+ per hour generated by the DPM.... aka $4-$8 per minute.
In reality, we aren't seeing pts 100% of the time (admin, notes, etc), so the $/min or $/hr seeing pts f2f actually has to be even higher.

There is just nooo way a code worth maybe $8-15 (depending on payer) is worth your time. It's not.
Maybe there's some miracle MCR adv plan that'ed even pay $20 for 11719... but it'll also get rejected sometimes. It'll hit deductible. Insurance might be inactive. It takes time to type it in, add a couple mods, put in the text shortcut for it, etc.

It probably works fine in podiatry school clinic to use 11719 (I think OP goes to NYCPM or Temple or something), but it doesn't pay anything consequential out in the actual practice. It's a complete waste of time. There are other codes that are in the same boat.

You have to make those pts who want nail care without fungal nails (or with a plan that doesn't pay RFC) cash pay - or not take them. Use time effectively. Focus on the stuff that actually pays us well (wound care, injects, dme, procedures, high level E&M, cash/otc svcs). 👍

 

[Hybrocure]

Maybe we can think of it this way, guys...

A normal PP doc is generating up to around $1M per year gross... $500k minimum, ya? (for pt care they do themselves, not associates)
So, that's $250-$500+ per hour generated by the DPM.... aka $4-$8 per minute.
In reality, we aren't seeing pts 100% of the time (admin, notes, etc), so the $/min or $/hr seeing pts f2f actually has to be even higher.

There is just nooo way a code worth maybe $8-15 (depending on payer) is worth your time. It's not.
Maybe there's some miracle MCR adv plan that'ed even pay $20 for 11719... but it'll also get rejected sometimes. It'll hit deductible. Insurance might be inactive. It takes time to type it in, add a couple mods, put in the text shortcut for it, etc.

It probably works fine in podiatry school clinic to use 11719 (I think OP goes to NYCPM or Temple or something), but it doesn't pay anything consequential out in the actual practice. It's a complete waste of time. There are other codes that are in the same boat.

You have to make those pts who want nail care without fungal nails (or with a plan that doesn't pay RFC) cash pay - or not take them. Use time effectively. Focus on the stuff that actually pays us well (wound care, injects, dme, procedures, high level E&M, cash/otc svcs). 👍

I agree however injects might as well be nails in terms of reimbursement unless you can add an E+M

 

[Homo sapien]

I agree however injects might as well be nails in terms of reimbursement unless you can add an E+M

Yes but at least they're quicker than the nail desert

 

[HaimFeldman]

Maybe we can think of it this way, guys...

A normal PP doc is generating up to around $1M per year gross... $500k minimum, ya? (for pt care they do themselves, not associates)
So, that's $250-$500+ per hour generated by the DPM.... aka $4-$8 per minute.
In reality, we aren't seeing pts 100% of the time (admin, notes, etc), so the $/min or $/hr seeing pts f2f actually has to be even higher.

There is just nooo way a code worth maybe $8-15 (depending on payer) is worth your time. It's not.
Maybe there's some miracle MCR adv plan that'ed even pay $20 for 11719... but it'll also get rejected sometimes. It'll hit deductible. Insurance might be inactive. It takes time to type it in, add a couple mods, put in the text shortcut for it, etc.

It probably works fine in podiatry school clinic to use 11719 (I think OP goes to NYCPM or Temple or something), but it doesn't pay anything consequential out in the actual practice. It's a complete waste of time. There are other codes that are in the same boat.

You have to make those pts who want nail care without fungal nails (or with a plan that doesn't pay RFC) cash pay - or not take them. Use time effectively. Focus on the stuff that actually pays us well (wound care, injects, dme, procedures, high level E&M, cash/otc svcs). 👍

11719 is also an excellent code to use when you hate your boss and already have one foot out the door. Associates take note.