Significant revenue is lost annually by emergency physicians due to lack of appropriate documentation of skin and/or mucous membrane repairs or debridement/removal of nails (whether toenails or fingernails).  The following codes and Texas Medicare reimbursements (applicable to the ‘Rest of Texas’ GPCI—which includes Bexar County) may be helpful in encouraging proper documentation of work done in treatment of emergency department patients with skin, mucous membrane or nail/nailbed injuries.

Note:  If you provide packing, in addition to incision and drainage, the work is greater and the Medicare reimbursement is commensurately larger. 

Note:  The simple debridement, or trimming of a nail, whether toenail or fingernail, is described by codes 11720 and 11721.  The complete or partial removal of a nail(s)(codes 11730 and 11732) entails greater skill and work, and is therefore reimbursed at a higher level than debridement of a nail.  If the nail is both removed and a nailbed laceration is also repaired, then codes 11730 and 11760 are reported on the claim. 

The following examples illustrate how complete and accurate documentation impact reimbursement:  (examples involve Medicare patient in Bexar County) 

Example #1: A 66 year old male presents to the ED with a history of a heavy tile falling on his right foot.  He has sustained avulsions of the bases of the nails of the great and second toes, which involve both the skin and nailbeds of each toe.  The physician provides local anesthesia and removes the entirety of each nail, sutures a 1 cm laceration of the skin of each toe and also sutures 1.5 cm lacerations of the nailbeds of each toe.  The physician simply documents nailbed repair of great toe with 4 sutures of 6.0 Vicryl and repair of nailbed of 2^nd toe with 3 sutures of 6.0 Vicryl”.  The physician fails to mention that he completely removed (or avulsed) the damaged nails from these two toes and also fails to mention that he repaired 1 cm lacerations of the skin adjacent to each nail with 2 sutures of 4.0 nylon.  Since the physician documentation is inadequate, the coder submits codes as follows:

Note:  Since there were two nailbeds repaired, the code of 11760 is reported at “2 units”for a total Medicare reimbursement of $255.20 

If the same patient with identical injuries has proper documentation of services rendered by the physician, then codes assigned by the coder are as follows:

Note:  This code of 12001 is reported as “2 units” so the pay for a single unit is doubled

Note:  This code is reported as “2 units” since two nailbeds were repaired, and the payment for a single unit will be doubled.  When a nailbed is repaired, the removal of the nail is “bundled” into the payment for the “repair of nailbed”.

Total Medicare reimbursement for repair of injuries to these two toes (with adequate and complete documentation in ED Record): $ 447.48

Total Medicare reimbursement for repair of injuries when inadequate documentation is provided by the ED physician:  $ 255.20 

Total reimbursement lost when physician fails to document properly:  $ 192.28 

Example # 2: A 68 year old female trips over her cat and falls, sustaining a thru and thru laceration of the lower lip of  1.2 cms, which involves only the mucosa of the lower lip, but extends all the way down to the vermilion border.  The emergency physician documents only “lower lip laceration of 1.2 cms closed with 6 sutures”.  The physician does not specify that the laceration involves the mucosa of the lower lip and therefore, the coder assumes that only skin was repaired.  Coding is as follows:

If the physician had provided proper documentation of his work and indicated that he repaired the full thickness of the mucosa of the lower lip and that the repair entailed over one half of the vertical height of the lip (repaired with 6 sutures of 6.0 chromic), then coding and reimbursement would be as follows:

Difference in reimbursement for same repair                      $ 289.50

            Inadequate documentation                                        $   99.17
            Proper documentation                                                $  388.67 

An extra minute of documentation can make a difference of hundreds of dollars!