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Observe TMJ Coverage Guidelines Ever So Carefully

ICD-9-CM coding for TMJ is straightforward, but payer requirements vary widely.

By G. J. Verhovshek, MA, CPC
The temporomandibular joint (TMJ) is where the jawbone (the mandible) is connected to the skull bone (the temporal bone). These joints on either side of the head, just below the ear, allow the jaw to open and close, and to slide from side to side. Like other joints, the TMJ may suffer injury and degradation due to trauma or stress (such as that caused by teeth grinding, or bruxism), and is susceptible to ankylosis, arthritis, dislocation, and neoplasia, among other conditions.
Temporomandibular joint disorder (TMD or TMJD)—also known as TMJ syndrome and Costen’s syndrome—is a broad term to describe acute or chronic inflammation of the joint. Common symptoms include jaw and/or face pain, swelling, limited jaw movement, difficulty chewing, “popping” or clicking sounds, and locking of the joint. Because the joint is so close to the ear, tinnitus (ringing in the ears), headaches and dizziness also may occur.
If a diagnosis of TMD is not confirmed, report the applicable signs and symptoms codes (e.g., 719.48 Pain in joint involving other specified sites). A definitive diagnosis of TMD is classified to ICD-9-CM category 524.6 (fifth digit required):
524.60                   Temporomandibular joint disorders, unspecified (includes temporomandibular joint-pain-dysfunction syndrome)
524.61                  Adhesions and ankylosis (bony or fibrous) of temporomandibular joint
524.62                   Arthralgia of temporomandibular joint
524.63                  Articular disc disorder (reducing or non-reducing)
524.64                   Temporomandibular joint sounds on opening and/or closing the jaw
524.69                  Other specified temporomandibular joint disorders
A definitive diagnosis of TMD may be made through history and an evaluation of jaw movement, listening for jaw sounds, etc., and may include diagnostic studies such as computed tomography (CT) or magnetic resonance imaging (MRI). Note that TMD also may occur secondary to other injury, such as dislocation (830.0 Closed dislocation of jaw).

Check Payer Guidelines Before Billing

Treatment for TMD ranges from doing nothing (symptoms may resolve on their own) to full-blown surgery—including everything in between, from over-the-counter medications to bite guards, stress management, Botox® injections, physical therapy, and more. Coding for TMD treatment is complicated further by coverage and billing requirements that vary widely from payer to payer.
Medicare statute, per 1862(a)(12) of the Social Security Act, excludes payment “for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” As a result, Medicare generally does not cover TMD treatment—and neither do many other payers (TMJ disorders occupy a hazy middle ground between dental and medical benefits). In those cases when the insurer does cover TMD, they typically require pre-authorization of services and for the provider to follow a strict treatment protocol (beginning with the most conservative treatments).

Illustrations copyright Ingenix. All rights reserved.


Policy Examples Show the Need for Vigilance

As an example of possible coding scenarios, UnitedHealthcare provides coverage determination guidelines that list TMD-related services, to include:

  • Evaluations (consultations, office visits, examinations)
  • Diagnostic testing (e.g., panoramic X-ray) (subject to company medical policy criteria)
  • Dental casts
  • Arthrocentesis (e.g., 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa))
  • Arthroplasty (e.g., 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft), 21242 Arthroplasty, temporomandibular joint, with allograft, and 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement)
  • Arthroscopy (e.g., 29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) or 29804 Arthroscopy, temporomandibular joint, surgical)
  • Arthrotomy (e.g., 21010 Arthrotomy, temporomandibular joint)
  • TMJ splints/biteplates
  • Trigger point injections (e.g., 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s))
  • Corticosteroid injections
  • Physical therapy

Coverage does not apply to all patients/plans, and UnitedHealthcare specifically excludes other treatment options—such as biofeedback, acupuncture, and TMJ implants—in all cases.
A clinical policy bulletin for Aetna likewise explains, “Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD). … For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna’s Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history … and physical examination, TMJ radiographs/diagnostic imaging reports, patient records reflecting a complete history of 3 to 6 months of non-surgical management (describing the nature of the non-surgical treatment, the results, and the specific findings associated with that treatment), and the proposed treatment plan.”
Aetna also lists potentially covered and always excluded services for TMD, but its list differs from UnitedHealthcare’s. For instance, “Aetna considers relaxation therapy, electromyographic biofeedback, and cognitive behavioral therapy medically necessary for treatment of TMJ/TMD.”
Blue Cross/Blue Shield of North Carolina’s (BCBSNC) Corporate Medical Policy observes different criteria from either UnitedHealthcare or Aetna. BCBSNC “determine[s] medical necessity for evaluation and treatment of Temporomandibular Joint Dysfunction on an individual consideration basis.” Coverage may include bite splints or oral orthotic appliances, physical therapy, and/or TMJ surgery, while braces and orthodontic treatment are considered dental therapy and are not eligible under medical benefits.

Know Payer Requirements

Check with the payer to determine if coverage is available and, if so, what is covered and in what order. Coding must reflect the service provided, as supported by documentation, but insurer reimbursement requires that the provider carefully observe applicable guidelines. For Medicare beneficiaries and others who may not be covered, carefully explain treatment options, their costs, and the patient’s financial responsibility.

Medical coding books

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.


Medical coding books

No Responses to “Observe TMJ Coverage Guidelines Ever So Carefully”

  1. Jean A Williams, CPC says:

    We are in discussion on the correct icd-9 code for chronic dislocation of the jaw. Should we code in the 830.0-830.1 or would 524.69 be the correct code. This happens to pt when brushing teeth or yawning.
    Pt comes in frequently for reduction of jaw dislocation under anesthesia. We are divided on the correct code. Do you have any documentation to help us select the correct code in this situation. We would appreciate your help.
    Jean A Williams, CPC