CPT 11765Surgery

Excision of nail fold toe

CPT 11765 covers the surgical removal of excess or diseased tissue from the nail fold of a toe, commonly performed to treat ingrown toenails or chronic infections around the toenail. This is a minor surgical procedure typically done in an office or outpatient setting.

Showing rates for

National Average

Base Medicare rate

$159.79

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.22

PE RVU (NF)

3.62

MP RVU

0.1

Total RVU

4.94

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Bill in office/clinic setting when possible rather than facility setting to capture the $68.57 differential between non-facility rate ($159.79) and facility rate ($91.22)
Impact: Increases reimbursement by 75% ($68.57 additional per procedure) when performed in physician office
Document bilateral procedures carefully and append modifier 50 or bill with RT/LT modifiers on separate lines depending on payer preference
Impact: Bilateral procedures can yield up to $319.58 total when properly coded, versus denial of second side if not properly modifier-coded
Ensure medical necessity documentation includes failed conservative treatment attempts (soaking, antibiotics, proper footwear) before excision
Impact: Prevents medical necessity denials that result in zero payment; conservative treatment failure documentation critical for Medicare and most commercial payers
Do not bill 11765 with simple nail trimming (11719) or nail removal (11750) on the same toe; these are considered bundled services
Impact: Prevents unbundling denials and potential audit flags; billing both codes together risks $91-160 recoupment plus potential fraud investigation
When performing multiple nail fold excisions on different toes, bill each toe separately with appropriate toe modifiers (TA, T1-T9) to maximize reimbursement
Impact: Can increase total reimbursement to $479.37 for three toes versus potential single payment if not properly specified
Verify whether 11765 is subject to the multiple procedure payment reduction (MPPR) by your specific payer when billing multiple units
Second and subsequent procedures may be reduced by 50% under MPPR rules; knowing this prevents surprise payment reductions of $45-80 per additional toe

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 11765 in 2025?

The 2025 Medicare national average reimbursement for CPT 11765 is $159.79 in the non-facility (office) setting and $91.22 in the facility setting. These rates are based on the total RVU of 4.94 multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary by geographic locality.

Can CPT 11765 be billed bilaterally for both feet?

Yes, CPT 11765 can be billed for both feet when medically necessary. Use modifier 50 for bilateral procedures or bill separate lines with RT (right) and LT (left) modifiers depending on payer requirements. Most payers reimburse bilateral procedures at 150% of the single procedure rate rather than 200%, so expect approximately $239.69 total for bilateral procedures in office settings.

What is the difference between CPT 11765 and 11750?

CPT 11765 is for excision of the nail fold tissue (skin and soft tissue lateral or medial to the nail), while CPT 11750 is for complete removal of the nail plate itself. Code 11765 addresses the surrounding fold tissue often involved in ingrown nails, whereas 11750 removes the actual nail. These codes should not typically be billed together on the same toe as they may be considered bundled.

How many RVUs is CPT code 11765 worth?

CPT 11765 has a total of 4.94 RVUs in 2025, consisting of 1.22 work RVUs, 3.62 non-facility practice expense RVUs (1.5 facility PE RVUs), and 0.1 malpractice RVUs. The higher non-facility PE RVU reflects the additional practice expense when performed in an office setting versus a hospital or ASC.

What diagnosis codes support medical necessity for CPT 11765?

Common ICD-10 codes supporting CPT 11765 include L60.0 (ingrown nail), L03.03- (cellulitis of toe), L03.04- (acute lymphangitis of toe), L08.9 (local infection of skin), and L92.9 (granulomatous disorder of skin). Documentation should show that conservative treatment failed and the nail fold excision is medically necessary to treat infection, pain, or functional impairment.

Can CPT 11765 be performed on multiple toes during the same session?

Yes, CPT 11765 can be performed on multiple toes in the same session when medically necessary. Each toe should be billed separately using anatomic toe modifiers (TA for great toe, T1-T9 for other toes). Be aware that some payers apply multiple procedure payment reductions (MPPR), reducing payment for the second and subsequent procedures by 50%.

Is CPT 11765 subject to the global surgical package?

Yes, CPT 11765 has a 10-day global period, meaning routine postoperative care for 10 days following the procedure is included in the reimbursement and should not be billed separately. Any significant complications or unrelated E/M services during this period would require modifier 24. Pre-operative evaluation on the same day requires modifier 25 if billed separately.