TMJ Diagnosis: Be specific to succeed

In a particular situation, our provider included two diagnoses in the documentation for a temporomandibular joint injection: TMJ pain and face pain. The Medicare Local Coverage Determination (LCD) does not allow either diagnosis: How and what can we report here?

Well, many conditions can be characterized as temporomandibular disorder; as such don't think your provider can only document general diagnoses such as TMJ pain (524.62) or face pain (784.0).

Key factors: The more specific your physician can be with her diagnosis, the better. Here are some examples for diagnoses you might report for present conditions:

848.1 (Jaw sprain) for strain

830.0 (Closed dislocation of jaw) if the TMU or facial pain is owing to recent TMJ dislocation

524.69 (Temporomandibular joint disorders other specified temporomandibular joint disorders) if arthritis causes TMJ cartilage damage

524.63 (Temporomandibular joint disorders articular disc disorder [reducing or non-reducing]) if TMJ disc erosion or misalignment is the reason for the pain.

Here's how: As found in CMS guidelines, many procedures, services, or appliances used to treat TMJ fall within the Medicare program's statutory exclusion at 1862(a)(12), which prohibits compensation for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth...." Owing to this, a catch-all diagnosis of TMJ is not enough. Your provider must figure out and document the real condition or symptom for claims purposes.