Revenue Cycle Insider

Question: Encounter notes indicate that the pain management (PM) provider treated a patient with “TMJ disorder.” That’s about all I have in the notes. Is it enough to choose an ICD-10-CM code?

Tennessee Subscriber

Answer: There is a code set for unspecified temporomandibular joint (TMJ) disorder, but even those are more specific than the information you have in front of you.

Query the physician if you can, as there are multiple TMJ disorder types. If you have to work with what you have, follow these steps to decide on a diagnosis code:

• Check the notes to see if there is any indication of laterality in the TMJ disorder.
• Go to the M26.60- (Temporomandibular joint disorder, unspecified) entry in ICD-10-CM.
• Choose one of the following codes if you can deduce laterality from the notes: M26.601 (Right temporomandibular joint disorder, unspecified), M26.602 (Left temporomandibular joint disorder, unspecified), or M26.603 (Bilateral temporomandibular joint disorder, unspecified).
• If you cannot deduce laterality from the notes, assign M26.609 (Unspecified temporomandibular joint disorder, unspecified side) instead.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC