Otolaryngology Coding Alert

Question: What diagnosis should I use for jaw pain due to temporomandibular joint (TMJ) disorder? I’d like to be more specific than “generalized pain.”

Georgia Subscriber

Answer: You’re correct to try to steer clear of “catchall” diagnoses such as 780.96 (Generalized pain) whenever possible. The best diagnoses depend on your carrier guidelines and exactly what kind of pain the patient has.

Some coders recommend 524.60 (Temporomandibular joint disorders, unspecified) or 524.62 (Arthralgia of temporomandibular joint). Some insurance carriers, however, deny claims with TMJ as the primary diagnosis -- although they accept TMJ as a secondary diagnosis. Check the note because there is often also mention of a headache along with TMJ complaints. A headache (784.0) could be your primary diagnosis code with TMJ as a secondary diagnosis if it is documented in the chart.

Because of this, check which other diagnoses apply to the situation. You might be able to submit 526.9 (Unspecified disease of the jaws) or another pain-related symptom as the primary diagnosis and include the TMJ diagnosis as primary.

Collections note: Although you might be tempted to report one of these other diagnoses as the primary code because it increases your chances of reimbursement, remember to always code 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.