Primary Care 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?

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 strain
• 830.0 (Closed dislocation of jaw) if the TMU or facial pain is due to recent TMJ dislocation
• 524.69 (Temporomandibular joint disorders other specified temporomandibular joint disorders) if arthritis causes TMJ cartilage damage
• 524.63 (Temporomandibular joint disorders articular disc disorder [reducing or non-reducing]) if TMJ disc erosion or misalignment 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 catch-all diagnosis of TMJ is insufficient. Your provider must determine and document the actual condition or symptom for claims purposes.