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I am going to a DDS, MD for TMJ and have had to pay out of pocket, as I am being told that there are no billing codes but that the office will submit the claims and reimburse me if insurance comes through (I had a consultation visit, visit to be fitted for pain relief orthotic, and will receive the orthotic and follow-up visits). Is this true? I have talked with my medical insurance and have been told that the codes being given by the DDS, MD office are for a surgical procedure. Also, insurance told me that no claims have been sent in so far which I find concerning. Any help would be greatly appreciated as this is extremely expensive! Thank you!
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Hi Guest!
Great questions. Some medical policies do offer coverage for certain diagnosis & treatment services for diagnosed Temporomandibular Joint Disorders (TMD/TMJD). It depends on whether TMD is covered benefit on your medical policy or not, and if the doctor diagnosed you with TMD or not. (i.e. diagnosis codes M26.601-M26.69 are generally indicated for coverage, while other diagnoses that are related to TMD such as atypical facial pain, etc and generally not indicated for coverage alone).
For example, some medical insurers will exclude TMD diagnosis & treatment services in their HMO policies, but include them for their PPO policies. When TMD is a covered benefit, most medical insurers will cover office visits, x-rays, reversible removable appliances, and trigger point injections for patients who meet criteria.
If you would like to tell me what insurance you have, I'd be happy to see if I can locate the medical policy online to see what diagnostic & treatment services are covered for patients who meet criteria. Additionally, you would want to call to make sure that diagnosis & treatment of temporomandibular disorders is a covered benefit on your policy.
As far as the codes being given to you, it is a code for a TMD appliance by chance? What codes? There is some confusion/discrepancy out there right now on what code is best to use for an appliance being used to treat TMD.
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