Neurology & Pain Management Coding Alert

Question: Our provider included two diagnoses in the documentation for a temporomandibular joint injection: TMJ pain and face pain. The Medicare LCD (local coverage determination) does not allow either diagnosis. What can we report?

Missouri Subscriber 

Answer: Many conditions can be characterized as temporomandibular disorder, so don’t think your provider can only document general diagnoses such as TMJ pain (524.62) or face pain (784.0). 

Important: The more specific your physician can be with her diagnosis, the better. Consider these examples for diagnoses you might report for current conditions:

• 848.1 (Jaw sprain) for recent TMJ strain
• 830.0 (Closed dislocation of jaw) if the TMJ or facial pain is due to recent TMJ dislocation
• 524.61 (Temporomandibular joint disorders , adhesions and ankylosis [bony or fibrous]) if there is a stiffening of the TMJ due to a bony or fibrous union across the joint
• 524.69 (Temporomandibular joint disorders other specified temporomandibular joint disorders) if the patient has recurrent TMJ dislocation or if arthritis has caused TMJ cartilage damage
• 524.63 (Temporomandibular joint disorders articular disc disorder [reducing or non-reducing]) if TMJ disc erosion causes the pain.

Explanation: As noted in CMS guidelines, many procedures, services, or appliances used to treat TMJ fall within the Medicare program’s statutory exclusion at 1862(a)(12), which prohibits payment “for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth....” Because of this, a catchall diagnosis of TMJ is insufficient. Your provider must determine and document the patient’s actual condition or symptom for claims purposes.