12/07/2023

Correct Billing for Nail Avulsion Without Anesthesia

I saw a patient; she was 100 years young. She had a loose lytic nail left hallux. She/daughter refused anesthetic and so I removed the whole nail without anesthesia.How is this billed?

Based on the information provided, CPT 11730 should be billed for this service. Local anesthesia is included in the allowance of this claim. Because the patient and their healthcare proxy both refused anesthetic for the minor procedure, it should be clearly documented since it is an unusual circumstance. The claim should be billed with the T modifier that correlates with the avulsion.