03/26/2024

Timeframe for Billing 11730

11730 Healthfirst frequency In reply to the previous member inquiry, I thought that Medicare Advantage plans must follow the Medicare guideline which is 3 months. How can they get away with a 224 day limit?

The rule as per the Medicare LCD Policy and Billing and Coding Article is 32 weeks (8 months). This applies to all third-party carriers including Medicare Advantage plans.

Please see excerpt from Billing and Coding Article- Surgical Treatment of Nails (A52998)

“CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same (finger) less than 4 months (16 weeks) or the same (toe) less than 8 months (32 weeks) following a previous avulsion. “

“A medically reasonable and necessary repeat avulsion of the same nail within 16 weeks (finger) or 32 weeks (toe) of a previous avulsion of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.”