Oral Surgery Coding & Reimbursement Alert

Question: If my clinician’s diagnosis is jaw pain due to a TMJ problem, should I list the diagnosis as facial pain, generalized pain or a more specific TMJ related diagnosis? I am having this confusion as I am noticing that Medicare and many insurance carriers don’t provide coverage for TMJ related problems.

Maryland Subscriber

Answer: 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 disorder is insufficient. Your provider must determine and document the patient’s actual condition or symptom for claims purposes.

However, you cannot report a generalized diagnosis or just using the symptoms present to report the diagnosis when a more specific diagnosis code is present. For this reason, you should not list the diagnosis as facial pain (784.0) or generalized pain (780.96).

Many insurance carriers including Medicare will not allow you to report a TMJ related diagnosis with an expansion to the ICD-9 code, 524.6x such as 524.60 (Temporomandibular joint disorders, unspecified) or 524.62 (Temporomandibular joint disorders arthralgia of temporomandibular joint) to be the primary diagnosis. However, some carriers might allow you coverage for these diagnosis options but you might need preauthorization prior to any procedure being performed. So, it is best to check with individual carriers prior to reporting a TMJ related diagnosis code.

You might otherwise have to list some other ICD-9 code (for instance, 526.9 (Unspecified disease of the jaws) or another pain-related symptom) as the primary diagnosis code and the specific TMJ related code as the secondary diagnosis.

Caveat: Although you might be tempted to report another diagnosis as the primary code because it increases your chances of reimbursement, remember to always report according to your surgeon’s notes and the patient’s condition. Dealing with a rejected claim because of a TMJ diagnosis is better than being accused of fraudulent coding.

ICD-10: When you begin using ICD-10 codes after Oct.1, 2015, you will have to switch to using these codes instead of ICD-9 codes:

• 524.60 will become either M26.60 (Temporomandibular joint disorder, unspecified) or M26.69 (Other specified disorders of temporomandibular joint)
• 524.62 will become M26.62 (Arthralgia of temporomandibular joint)
• 526.9 will become either M27.9 (Disease of jaws, unspecified) or M27.0 (Developmental disorders of jaws)
• 780.96 will become R52 (Pain, unspecified)
• 784.0 will become either G44.1 (Vascular headache, not elsewhere classified) or R51 (Headache) although R51 is a better choice for facial pain.