I called on the codes that you posted and BCBS said that 21089 because it is unspecified that it falls under surgical codes. They also said that specific code is subject medical review and must be submitted with all medical record, reports and imaging and will go directly for review when the claim is submitted. The person that I talked to also said that the claim must be submitted via paper. Is there a better code to submit? I have looked and there does not seem to be a better code what should I do?

Just wondering if anyone has come up with any new codes to use to replace code S8262. I am looking into code L8048.

BCBS of Illinois only reimburses (allows) $250.00 for 21499 and won't allow us to use D7880. 21089 is a surgical code and I am hesitant to use it.

BCBS use to allow the full amount for our TMD appliances. This stinks!

Would love to hear what everyone is doing?

Thanks
Meaghan in IL

Hi Meaghan in IL.

Yes, I understand why you are hesitant to use the 21089 for a TMJ appliance. It's not the appropriate code. $250 does seem low for the 21499, musculoskeletal procedure, head, with report. They may be paying the lab fee only so that is something I would check into. The service is worth much more and I would definitely consider an appeal.

Hi guest!

Great question. This will depend on what condition the nightguard is being used to treat. For example, if it is simply an occlusal guard to protect the surface of the teeth, 21499 may not be an appropriate code. If the nightguard is being used to treat temporomandibular disorders (TMD), 21499 may be an appropriate code. If the nightguard is being being to treat Obstructive Sleep Apnea, E0486 or E0485 may be the appropriate code.

What we are finding is that the code that is most commonly accepted currently for TMD appliances since the S8262 discontinuation back in June of this year is D7880. However, some insurers are accepting D7899, 21499, or E1399.

D7880 - occlusal orthotic device, by report
D7899 - unspecified TMD therapy, by report
Or, if the medical insurer says they won’t process the “D” codes (most will these days, but you will run into a few that won’t), you can try:
E1399 - Durable medical equipment, miscellaneous
21499 - Unlisted musculoskeletal procedure, head

A narrative report accompanying the claim is recommended since they are all "by report" or "miscellaneous" codes.

If it is for TMD:
You can also check the insurers TMD medical policy on their website, and many of them will list accepted codes right in their policies. For example, here is a link to BCBS of MS's TMD medical policy that lists the currently accepted code as D7880 for TMD appliances in the coding section of the policy:
http://www.bcbsms.com/com/bcbsms/apps/PolicySearch/views/ViewPolicy.php?&noprint=yes&path=/policy/emed/Temporomandibular_Joint.html

Hope this helps, have a great day!

Hi Emily!

No problem :) And great questions -

You would only use the 21499 code, you wouldn't want to bill the "D" code along with it (that would actually indicate there were 2 separate appliances!). Since 21499 is an "unlisted" code, you will want to make sure you include a narrative report accompanying the claim to describe what the code is being used to represent.

CPT stands for "Current Procedural Terminology", and are considered "Level 1" codes. CPT codes include services like office visits, x-rays, surgeries, etc.

HCPCS stands for "Healthcare Common Procedure Coding System", and are considered "Level II" codes. HCPCS codes include durable medical equipment, prosthetics, orthotics & supplies.

Here is a link to a great study group we did that covers the different coding sets in detail, and how they come to be codes!
http://www.screencast.com/t/Kz3Bq24S7sC

Hope this helps, have a great day!

Hi Emily!

Thanks for the kind words! And great question. So there is an ICD-10 diagnosis code for sleep related bruxism (G47.63), however most medical insurers do not offer coverage for treatment of bruxism because they do not consider it a medically necessary treatment. We have seen a few medical insurers start to offer coverage for "painful bruxism", however it is listed in their botox policy generally.

For example, here is a link to Aetna’s medical policy for botox:
http://www.aetna.com/cpb/medical/data/100_199/0113.html

The above policy states:
“OnabotulinumtoxinA (Botox Brand of Botulinum Toxin Type A): Aetna considers onabotulinumtoxinA (Botox) medically necessary for any of the following conditions:
……
V. Painful bruxism”


Hope this helps, have a great day!

Hi guest!

The serial number/mfg # would be provided by the lab/manufacturer that fabricated the device. For example, for oral appliances for OSA, the serial number is usually found built into the material of the appliance. Or, it may be on the invoice you received. If it is not in either place, you may need to contact the lab/manufacturer to obtain the serial number, as it will be unique to the device. (However, the "model number" for some OSA appliances can be found on the PDAC list for E0486 (which is not the same as a serial #, it's a generalized code to stand for all appliances of that type).

Hi guest!

Yes that seems about on par for what many medical insurers allow for a TMD splint. As for the ortho, I don't believe I have come across any medical insurers that will consider orthodontic treatment medically necessary for the treatment of TMD.

However, There is now, under the Affordable Care Act, coverage under medical plans for pediatric orthodontics for some diagnoses. Most policies indicate coverage for ortho for diagnoses/conditions such as severe malocclusions, speech abnormalities, trauma, etc.

Here’s a really good guide from United Healthcare on the Pediatric Dental Essential Health Benefit in the Affordable Care Act (ACA), which includes “medically necessary orthodontia” (among other things, of course)
https://www2.cbia.com/ieb/ag/medical/zpdf/MemberBenefits/Oxford%20Pediatric%20Dental.pdf

And these below are really good reads to wrap your head around it as well – a few sample medical policies on ortho coverage for pediatrics under the medical policy…..they outline the conditions/criteria the patient has to have in order for the ortho to be covered by the medical policy:
BCBS of North Carolina - Orthodontics for Pediatric Patients
https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/orthodontics_for_pediatric_patients.pdf

Aetna - Medically Necessary Orthodontia Related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)
https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins/DCPB039.html#

BCBS of Rhode Island - Pediatric Dental Services -Essential Health Benefit
https://www.bcbsri.com/sites/default/files/polices/Pediatric_%20Dental_%20Services%20_Essential_%20Health_%20Benefit_3.pdf

The one for Aetna even lists out the codes you might use! Here they are below:
Possible orthodontic codes1*
• D8010- Limited orthodontic treatment of the primary dentition
• D8020- Limited orthodontic treatment of the transitional dentition
• D8030- Limited orthodontic treatment of the adolescent dentition
• D8040- Limited orthodontic treatment of the adult dentition
• D8050- Interceptive orthodontic treatment of the primary dentition
• D8060- Interceptive orthodontic treatment of transitional dentition
• D8070- Comprehensive orthodontic treatment of the transitional dentition
• D8080- Comprehensive orthodontic treatment of the adolescent dentition
• D8090- Comprehensive orthodontic treatment of the adult dentition

Hope this helps, have a great day!

D7880 sorry

Need your help, my TMJ dentist submitted procedure code 21110-52 for TMJ orthopedic orthotic appliance but insurance company told the provider to change it to 21089 and then insurance company denied the claim saying "WE NEED MORE INFORMATION ABOUT THIS CLAIM TO DETERMINE IF THE SERVICES RECEIVED WERE MEDICALLY NECESSARY. THE HEALTH CARE PROFESSIONAL WILL PROVIDE THE INFORMATION WE NEED TO PROCESS THIS CLAIM (FACILITY RECORDS, OFFICE NOTES, HISTORY & PHYSICAL, DIAGNOSTIC REPORTS, OPERATIVE/ANESTHESIA RECORDS, AND/OR PHOTOS FOR POTENTIAL COSMETIC PROCEDURES)."

I am confused as 21089 is a surgery code, why insurance company want the previous code to be changed to something that is for surgery and then later asked additional information that is applicable in case of surgical procedure.

Can anyone guide me if 21110-52 is a valid code for TMJ appliance? or perhaps it is 21110 instead? not sure what to. However in my medical insurance i have surgical and non-surgical tmj treatment including appliances covered.

Thanks for your help!