04 Feb The Science of TMJ Diagnosis Codes
TMJ benefits are notoriously difficult to “crack” in the medical insurance industry. Today we will explore the different diagnosis code sections available for TMJ disorders. Use these codes to implement questionnaires in your practice so that you don’t miss vital symptoms.
The first few sections cover dentofacial abnormalities. Things like jaw asymmetry, hyperplasia, various malocclusions and deviations in the occlusal relationship are all covered under these codes. Examine your patient carefully for anything out of the ordinary with their bite or occlusal relationship and document. If possible take measurement of deviations using your periodontal probe.
Next is codes for temporomandibular joint disorder. Quiz the patient on if they are experiencing pain or tenderness of the jaw, pain in one or both of the temporomandibular joints, aching pain in and around the ear, difficulty or pain with chewing and locking of the joint.
Notate any adhesions or ankylosis. Adhesions are fibrous bands that form between tissues as a result of injury or trauma. Ankylosis is stiffness and immobility of the joint. Also be sure to notate any jaw pain, headaches, migraines, neck tenderness/stiffness and other pain or discomfort your patient may be in. Make sure the chart references any head or neck traumas regardless of how irrelevant they may seem so that these injuries may be included in the narrative.
Treating TMJ pain requires patience both for the patient as well as for the benefits process. It is imperative that documentation be precise, detailed and include terms that relate to the applicable diagnosis. Keep in mind that your clinical notes are your formal diagnosis of your patient. If it isn’t included in your notes then it can’t be substantiated on your claim and diagnosis cannot be applied.