TMJ Insurance Billing Guidelines
The acronym HCPCS originally stood for HCFA Common Procedure Coding System, and is the medical billing process of the Centers for Medicare and Medicaid (CMS). It was previously (before 2001) known as the Health Care Financing Administration (HCFA).
The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that claims are processed in an orderly and consistent manner.
Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.
Medical and dental insurance plans are developed based on research of current literature and review of common practices in the treatment and diagnosis of disease. The applicable certificate language determines benefits that are in effect at the time of service and coverage varies according to the member’s group or individual contract.
Temporomandibular joint (TMJ) disorders (TMD) refer to a group of disorders characterized
by pain in the TMJ and surrounding tissues. Imaging may be indicated as part of the diagnostic process. Initial conservative therapy is generally recommended. There are also a variety of non-surgical and surgical treatment possibilities for patients whose symptoms persist.
Some dental plans cover appliances for bruxism, periodontal mobility, and/or some for TMD, but few cover all three. The patient's clinical problem should be identified before you submit for benefits. To determine if an appliance is covered by a patient’s dental plan, one must determine the purpose of the appliance. Is it needed to minimize the effects of bruxism? Is periodontal mobility a part of the diagnosis. Is the appliance intended for managing musculoskeletal/TMD signs and symptoms?
If the patient is experiencing headaches and pain in the temporomandibular joint area, a narrative report should accompany the insurance claim, describing the diagnosis and symptoms, e.g., limited or deviated mouth opening, TMJ pain, popping, clicking, crepitus, catching, locking, masticatory muscle pain, and other relevant clinical findings. It is important to emphasize that TMD claims may require accompanying documentation in the form of a TMD evaluation form, radiographs, and chart notes. The SOAP (S=subjective, O=objective, A=assessment, P=plan) format is universally accepted by insurance companies.
Intraoral appliances are used in patients for managing TMJ signs and symptoms (pain and/or dysfunction, with or without radiographic evidence of a intracapsular disease process). D7880 is specifically defined as including the treatment of TMJ conditions.
A separate code, D9440, identifies intraoral appliances used to manage bruxism (described in the dental fee schedule as an "occlusal guard").
There is no specific code to report an adjustment of an occlusal guard (D7880 or D9440). Use code D9999 (Unspecified adjunctive procedure, by report) to submit an adjustment of an occlusal guard. Adjusting an occlusal guard is usually not reimbursed.
Appliances can typically be covered under the patient's medical policy and it is recommended that billing be to the medical plan using the appropriate ICD-9 diagnostic codes (ICD-10-CM Codes become effective 10/1/2015) and CPT treatment codes, submitted on the CMS HCFA-1500 medical claim form (Starting April 1, 2014 only the revised form, CMS HCFA-1500 version will be accepted).
