Missing documentation
Plan Type
Commercial (ASH CPG 209)
Pillar 1 - Diagnosis
L60.0 (Ingrowing nail)
Pillar 2 - Symptoms
Pain + Objective findings (erythema/edema)
Pillar 3 - Functional Impairment
Cannot wear closed-toe shoes
Spicule Rule
No 'spicule' in note
Anesthesia
3cc 1% Lidocaine digital block
Surgical Terminology
Surgical terminology used (avulsion/elevator/hemostat)
Nail Border
Medial border documented
Conservative Modalities
2 modalities: warm_soaks, shoe_modification
Conservative Duration
7 days documented
Conservative Failure
Failure documented
EOC Check
Check member's EOC for carve-back: 'This exclusion does not apply to treatment of toenails when Medically Necessary'
Digit Modifier
TA modifier appended
CPG 228 Bundling
No prohibited same-day codes
NCCI Bundling
No same-digit bundling conflicts
Documentation Quality
3/9 operative note elements - Incomplete. Higher denial/audit risk.
Revenue at Risk
$450
Annual Impact (est.)
$67,500
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Full Intelligence Report: CPT 11730
