The ingrown toenail, medically termed onychocryptosis, is a common and often painful condition where the edge of the nail plate grows into the surrounding soft tissue of the nail fold. When conservative treatments like soaking and lifting the nail fail, a surgical procedure is often necessary to resolve the issue and prevent recurrence. For healthcare providers, translating this procedure into a standardized language for billing purposes requires the use of Current Procedural Terminology (CPT) codes. Selecting the correct code depends entirely on the surgical technique used, particularly whether the procedure is temporary or permanent.
The Wedge Excision Technique
The anatomy of an ingrown toenail includes the nail plate and the nail matrix, the tissue responsible for growth. Wedge excision often begins with a partial nail avulsion, which is the removal of the segment of the nail plate cutting into the adjacent tissue. This partial removal is accomplished after administering a local anesthetic to the toe.
Once the offending nail piece is removed, the surgeon addresses the hypertrophied, or overgrown, soft tissue of the nail fold, which has become inflamed. In a true wedge excision, this excess soft tissue is surgically removed to create space and alleviate pressure on the remaining nail. This step is designed to immediately relieve symptoms and is distinct from the more complex procedure of permanently stopping nail growth.
Identifying the Correct CPT Code for Excision Without Matrix Destruction
When a surgeon performs a partial nail avulsion and/or a wedge excision of the nail fold tissue without destroying the nail’s growth center, the procedure is considered temporary. The CPT code for this simple removal of a portion of the nail plate is 11730, described as “Avulsion of nail plate, partial or complete, simple; single.” This code is appropriate when the goal is to remove the problem section of the nail.
A separate, less common code, 11765, exists specifically for “Wedge excision of skin of nail fold.” This code is used when the surgeon only excises the inflamed skin (hypertrophic granulation tissue) without removing the nail plate or matrix. Because most definitive surgical treatments for an ingrown nail include removing the nail segment, CPT 11730 is typically the code used for temporary relief. When billing, it is necessary to apply the correct anatomical modifier, such as T-modifiers (T1-T9) or the standard -RT or -LT, to specify the exact toe and side treated.
Coding for Permanent Removal (Matrixectomy) and Chemical Ablation
The definitive treatment for a recurrent or severe ingrown toenail involves preventing the problem-causing section of the nail from ever growing back, which requires destroying the nail matrix. This permanent procedure, known as a matrixectomy, is typically performed after the partial nail avulsion and soft tissue excision are complete. The correct CPT code for this combined, permanent procedure is 11750, which is defined as “Excision of nail and nail matrix, partial or complete, for permanent removal.”
The destruction of the matrix is often achieved through chemical ablation, most commonly using a substance like phenol or trichloroacetic acid, applied to the exposed nail matrix tissue. CPT code 11750 is comprehensive, meaning it includes the initial partial nail avulsion, the wedge excision of the nail fold, and the subsequent chemical or surgical destruction of the matrix. Therefore, a provider cannot bill for both CPT 11730 (avulsion) and 11750 (permanent excision) on the same toe during the same visit.
Essential Documentation and Reimbursement Guidelines
Accurate documentation is essential for successful reimbursement for any nail procedure. The operative note must clearly establish the medical necessity for the surgery, referencing the ingrown toenail using the appropriate ICD-10 code, such as L60.0 (Ingrowing nail). Documentation of local anesthesia is also necessary, as it is a standard component of both CPT 11730 and 11750.
For procedures billed under CPT 11750, the documentation must explicitly state that the nail matrix was destroyed and specify the method used, such as “chemical matrixectomy with phenol.” If a permanent removal is performed on a recently treated toe, the provider may need to append a specific modifier, like the KX modifier, to indicate that the procedure was medically necessary despite the prior treatment.