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Hi ttobiassen!
The first thing you will need in order to submit these services to your medical insurer is for your dentist to select the appropriate diagnostic codes (ICD-10) codes that accurately represent your condition being treated.
There are 16 codes to choose from that represent TMJ disorders, and the dentist will likely choose at least pain/symptom code as well.
Here are the specifc TMJ disorder coding options:
M26.611 - Adhesions and ankylosis of right temporomandibular joint
M26.612 - Adhesions and ankylosis of left temporomandibular joint
M26.613 - Adhesions and ankylosis of bilateral temporomandibular joint
M26.621 - Arthralgia of right temporomandibular joint
M26.622 - Arthralgia of left temporomandibular joint
M26.623 - Arthralgia of bilateral temporomandibular joint
M26.631 - Articular disc disorder of right temporomandibular joint
M26.632 - Articular disc disorder of left temporomandibular joint
M26.633 - Articular disc disorder of bilateral temporomandibular joint
M26.641 Arthritis of right temporomandibular joint
M26.642 Arthritis of left temporomandibular joint
M26.643 Arthritis of bilateral temporomandibular joint
M26.651 Arthropathy of right temporomandibular joint
M26.652 Arthropathy of left temporomandibular joint
M26.653 Arthropathy of bilateral temporomandibular joint
M26.69 - Other specified disorders of temporomandibular joint
A few common pain/symptom codes associated with TMJ disorders are:
R51.9 - Headache
M79.11 - Myalgia of mastication muscle
M79.12 - Myalgia of auxiliary muscles, head and neck
G50.1 - Atypical facial pain
As for the procedures - most medical insurers will offer coverage for office visits/exams, x-rays, removable intra-oral appliances, and trigger point injections (when benefits for diagnosis & treatment of TMJ disorders are available on the policy, that is). It is not common to see coverage for a few of the services you listed - the diagnostic casts & occlusal analysis. D7899 stands for: unspecified TMD therapy, by report - so in order to cross code it to medical you would need a better description of what type of lab work this is.
As for the oral evaluation (D0150), 3DCT TMJ (D0368), and Occlusal appliance (D9944), here are the medical codes commonly used to bill these to medical insurance:
D0150 - comprehensive oral evaluation - new or established patient
can be crosscoded to a new or established patient evaluation & management (E&M) codes - 99202-99205 (new patients), or 99211-99215 (established patient):
New patients:
99202 – 15-29 mins
99203 – 30-44 mins
99204 – 45-59 mins
99205 – 60-74 mins
Established patients:
99212 – 10-19 mins
99213 – 20-29 mins
99214 – 30-39 mins
99215 – 40-54 mins
D0368 - Cone beam CT capture and interpretation for TMJ series including two or more exposures
there is actually not currently a specific CPT code for CBCT……the closest CPT code is: “70486 - Computed tomography, maxillofacial area; without contrast material”. Many offices have been using this for some time for CBCT, however, some medical insurers are auditing that code when used for CBCT because the description does not specify “cone beam”.
So, “76497 - Unlisted computed tomography procedure (eg, diagnostic, interventional)” is an option to use (keep in mind you'll need to provide a narrative description for unlisted codes) We also see practices billing out for "76102 - Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; bilateral"
or, there are some medical insurers that will process the “D” codes for procedures when there is not a specific CPT code available.
D9944 - occlusal guard – hard appliance, full arch
the two codes that are currently most commonly accepted by medical insurers for TMJD appliances are:
D7880 - occlusal orthotic device, by report
21299 - Unlisted craniofacial and maxillofacial procedure
As you mentioned, since these codes indicate "unlisted procedure" and "by report", a narrative description/report is required to explain what service the code is being used to represent. The clinical notes from your dentist should explain what the service is (not a big portfolio, but detailed clinical notes from the evaluation & visits you had with the dentist).
Hope this helps!
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Hi!
Very thankful to have found this site that appears to support the kind of inquiries I need in order to save potentially a few thousand dollars. Can I buy somebody a coffee or something? So cool!
I received services over 2 visits from a TMJ specialist, including:
(visit 1)
D0150 - "COMP ORAL EVALUATION" [likely not covered by medical, in this case not covered by my dental because already had 2 this year]
D0368 - "3DCT TMJ" [hopefully covered by medical since this is a diagnostic for a joint, which feels like a medical condition]
(visit 2)
D0470 - "DIAGNOSTIC CASTS" [hypothetically covered by dental, in this case "once per lifetime" haha wow]
D9950 - "OCCLUSION ANALYSIS - MOUNTED" [This is a "by report" code for dental, would that make it a "by report" code for medical?]
D9944 - "OCCLUSION <unreadable>, HARD" [This is the big ticket item and the medical "device" I'm hoping can be covered]
D7899 - "TMJ Add Tx - Lab Work" [Not sure what this is, really]
I know that the TMJ specific treatments are not covered by my dental, so really the only things that COULD be covered are D0150 and maybe D0470, and those add up to only 15% of the total bill. THAT is why I'm hoping to submit to my medical insurance instead. The doctor I saw is pretty old school so I'm hoping he listed correct/reasonable codes that have a hope of being covered. TMJ services are hard enough to find that I didn't really have much choice of who I saw and needed that service before continuing other dental work that would have suffered from a drifting bite.
Finally: how big is the "report" indicated by a "by report" code? Is this just submitting the screenshots from a 3DCT plus some doctors notes, or is this a big portfolio?
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