|Billing for TMD appliances|
|Monday, 02 January 2012 09:42|
By Elmer A. Villalon, DMD
Medical insurance billing for temporomandibular Disorder treatment, which often times includes TMD appliances, can be very difficult and problematic for many dental offices. However, having a grasp of how medical insurances work and knowing what each individual insurance company is looking for, including billing codes, nomenclature and documentation, can simplify the process and lessen the reimbursement turnaround time.
Several nonsurgical treatments, which can be considered medically necessary for treating temporomandibular disorders, but are insurance policy dependant, include: appliances or orthotics and their management, pharmacologic management, physical therapy (e.g. electrogalvanic stimulation, Ionotophoresis, ultrasound, spray and stretch, manual stretching), biofeedback therapy, and therapeutic injections. Medical billing for each of these nonsurgical TMD treatments can be discussed at length, however, this article will limit its discussion on how to appropriately bill medical insurance for a TMD appliance.
Oral appliances to treat temporomandibular disorders are known by numerous names including: occlusal orthopedic appliances, occlusal appliances, orthotics, occlusal splints, bite appliances, bite splints, bite plates, mouth guards, occlusal guards, stabilization splint, and mandibular repositioning appliances (MORAs). For the purpose of continuity, this article will use the vernacular of occlusal appliance.
If an insurance company allows for nonsurgical management of a temporomandibular disorder, including an oral appliance, proof of medical necessity will be required. Many medical insurance carriers will require evidence that the patient has clinically significant masticatory impairment with documented pain and/ or loss of function. Radiologic imaging may or may not be a requirement but generally it is recommended, at least by some insurance companies, for patients with severe and chronic symptoms. The information gathered in the patient's interview and TMD evaluation needs to be summarized in a narrative and submitted to the insurance company. Once the TMD impairment has been defined and a diagnosis established, then appropriate medical coding for an appliance must be made. This is where the frustration can begin. However, before elaborating on medical billing for a TMD occlusal appliance, this article will address billing to dental insurance companies which cover occlusal appliances.
Dental Insurance billing for a TMD Appliance
Most medical insurance plans do not cover tooth wear from known bruxism. However, should a patient have dental benefits this behavior may be covered - even If there is no pain or TMD dysfunction. If there are signs of bruxism tooth wear, including wear facets and/or abfractions and there is confirmation by the patient of night-time "grinding", or there is confirmation by a significant other of the patient's nocturnal behavior, an occlusal appliance is likely to be covered under the patient's dental benefit plan.
Some medical insurance plans will reimburse for a TMD appliance when there is temporomandibular joint dysfunction and/ or TMD related face pain, and possibly headache. Very rarely will medical insurance reimburse for tooth wear as a consequence of buxism. In summary, many dental insurance plans will reimburse for an occlusal appliance if there is solely tooth wear and/or if there is tooth wear and a TMD condition. If there is only tooth wear from bruxism, medical insurance will very rarely reimburse.
It should be noted that most dental insurance reimbursements for occlusal appliances are often much less than medical insurance reimbursement. Also, if the dentist is an in-network dentist for a dental insurance company then the reimbursement rate will be less than if he/she is an out-of-network dentist.
When doing an estimate for a TMD appliance, it is important that the receptionist include in the dental insurance inquiry the following information: the maximum amount of dental benefit coverage, how much of the benefit has been used to date, the appliance reimbursement amount, the percentage of coverage for the appliance, and if other TMD appliance procedures are covered.
Dental codes for a TMD appliance include:
D9940 occlusal guard by report,
Dental codes for other TMD treatment:
D0320 temporomandibular joint arthrogram, including injection
Billing Medical Insurance for a TMD Appliance
Before billing a medical insurer for a TMD appliance, it is best to understand some of the medical coding history and medical taxonomy.
Coding classification standards: The Health Insurance Portability and Accountability Act of 1996 (HIPPA) named certain types of organizations as covered entities. These 'covered' entities include health plans, healthcare clearinghouses and various healthcare providers. HIPPA also set the classification system standards that these covered entities must use in the processing of claims. The covered entities must use explicit coding to identify the diagnosis and clinical procedures on claims and encounter forms. Some of the HIPPA coding set standards created are as follows:
Health Care Common Procedure Coding System (HCPCS) - This code set was created by the Center for Medicare and Medicaid Services (CMS) and represents items and supplies and non-physician services not covered by the American Medical Association CPT-4 codes. This would include "Instructions for Billing Maxillofacial Services". There will be more discussion on this topic later in the article.
Current Procedure Terminology (CPT) – This coding system is used for outpatient procedures and is maintained by the American Medical Association. These codes are used for documenting services provided to patients. A revised edition of the CPT edition is published annually and is made available each January; revisions include additions and deletions. All CPT codes have five digits.
International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) Volumes 1 and 2 (diagnosis codes) – This coding system is maintained by the National Center for Health Statistics (NCHS) and Centers for Disease Control within the Department of Health and Human Services (HHS). The International Classification of Diseases, 9th revision, Clinical Modification Volume 3 (procedure codes) is maintained by CMS and is used for inpatient (hospital) procedures.
The International Classification of diseases, 10th revision, Clinical Modification (ICD-10-CM) will be the new diagnosis coding system developed to replace ICD-9-CM volume 1 and 2. Also, the ICD, 10th revision, Procedure Coding System (ICD-10-PCS) is the new procedure coding system for inpatient (hospital) procedures replacing ICD-9-CM Volume 3. The new ICD-10-CM and PCS compliance and implementation date is scheduled for October 1, 2013.
Having a good understanding of how medical insurance works is very important for front office dental staff. When front office personnel are competent with such billing procedures then they are capable of asking the correct billing questions and can complete the patient's medical insurance questionnaire correctly.
It should be appreciated that some states require that medical insurance carry TMD benefits. However, many insurance companies in states that do not have this requirement have independently decided to carry such benefits. The dental office should not complete insurance paper work for TMD treatment until an inquiry with the patient's medical insurance is made. If the patient's medical plan does allow for TMD benefits then the appropriate inquiry questions should be asked.
The receptionist should have a medical insurance questionnaire to ask the insurance company appropriate and needed questions about the patient's medical plan and benefits. Because some insurance companies identify TMDs as TMJ disorders, it may be prudent to use the acronym of TMJ when speaking to medical plan personnel, as benefits may not be listed with the acronym of TMD or the insurance personnel may not be familiar with the acronym. Dentists should make this point very clear when training their front office staff.
Questions the medical benefits summary sheet should include are as follows:
Once the patient's benefits have been confirmed, a diagnosis established and a narrative created then the dentist can either submit a pre-authorization request for treatment or begin billing for treatment rendered. If no pre-authorization is needed then the dentist would, of course, submit for treatment as it is rendered. It should be noted that TMD treatment for headaches, particularly migraine headaches, as a sole symptom is typically not covered by medical plans. Headaches should be reported as a symptom that presents with other TMD signs and symptoms: TMJ capsulitis, TMJ synovitis, TMJ sounds, TMJ dysfunction, face pain, pain with chewing, TMJ pain, facial muscle soreness, ear pain, tinnitus and pain behind the eye, etc.
Coding for TMD appliances can at times be a bit complicated and that is why it is important for the receptionist to be thorough when questioning about TMD appliance codes. Sometimes medical plans will not share coding information during the benefit interview call, so a trial coding with the 1500 CMS may be needed. However before doing this, try accessing the insurance website and do a search for the insurance policy on TMD benefits. Many insurance companies describe their policy guidelines for TMD benefits on their website and also have a code reference. Insurance website references can be extremely helpful and help decrease the reimbursement waiting period.
Diagnosis codes for a TMD condition is needed before any treatment is covered. As with other medical coding, ICD codes change and some older codes can become obsolete, so is important to stay current of any changes.
Some of the more common ICD Diagnosis Codes for TMDs are as follows:
Other ICD Diagnosis Coding which can be used includes:
As discussed earlier, when calling to inquire about medical TMD benefits it is important to ask about coding, particularly the occlusal appliance code. There are multiple codes for this procedure and each insurance company can require a different code. Medical codes that are generally used to bill medical insurances for occlusal appliances are listed below:
Preparation; Oral Surgical Splint
When a medical insurance company requests an occlusal appliance code using an HCPCS code, use the dental code D7880, or the durable medical equipment code, S8262 (mandibular orthopedic repositioning device). While the code S8262 can be used for a TMD appliance, it more frequently used for non-TMD purposes. If a medical insurance should happen to cover bruxism, which is rare, then the HCPCS code to use is the dental code D9940 (occlusal guard) or the CPT code 21299 (unlisted craniofacial and maxillofacial procedure).
Some medical carriers may consider CPT codes 99002 and 99070 for occlusal appliances; however, most insurance companies have stopped using these codes because of a change in the 2005 Medicare billing guidelines. The code 99070 remains valid, but requires a modifier to describe the type of material used. This code is used to report supplies and materials used by the provider which are considered superior to those characteristically used with the conventional office visit or services rendered. The CPT code 99002 requires that the completing of the occlusal appliance order application has been handled, designed, and delivered by an outside laboratory but it is fitted and inserted by the provider (dentist or physician).
A common CPT code which is used for the oral appliances is 21089, Unlisted Maxilla Prosthetic Procedure. This code should be billed only when the occlusal appliance is constructed in the dental office. Use CPT code 21299 if a laboratory outside the dental office constructs the occlusal appliance. Code 21299 is a very appropriate code since most dentists have their appliances constructed by outside dental laboratories.
Another occlusal appliance CPT code which some insurance companies accept is 21085. You can try this code should other codes be declined. Also, CPT codes ending in "89 "or "99" necessitate an oral appliance narrative. In the shaded area above field 24 D, which is identified as procedures services in the CMS – 1500 Claim Form, you can place a narrative comment and it should be preceded with the letters ZZ, which is a needed qualifier. The narrative should read ZZ and then the name of the procedure (e.g. ZZ oral appliance).
You can also use field # 19 (Reserved for local use) to inform the insurance company that a more detailed narrative is attached to the claim. Make a comment in this field such as; see attached narrative for further information. It is recommended that this field be completed and a thorough narrative be submitted. The narrative should be written as any other detailed report. It is also recommended that the narrative contain supplemental information regarding an occlusal appliance: what is an occlusal appliance, how it works, and why it is medically necessary. Should the oral appliance be made in house, you may want to include some brief comments regarding the in house construction of the oral appliance. Field # 23 asks for a treatment authorization number for your patient; if one has been provided, do not forget to place that number in this field.
Billing for Oral Appliance Adjustments
Billing for adjustments of the occlusal appliance, after it has been inserted, can sometimes be challenging. When doing the insurance inquiry, ask what the insurance policy is regarding occlusal adjustments or check outs after an appliance has been inserted. Some insurances may have a limited number of adjustments allowed for, or billing for adjustments cannot be made until after a defined period of time; e.g. six months. The recommended code to use for an adjustment is the CPT code 97762.
This code is used for a checkout of an orthotic/prosthetic of an established patient. The checkout is for an oral appliance adjustment and the documentation of how the patient is responding to the oral appliance. This procedure has a time unit of 15 minutes, but if it takes an extra 15 minutes then place the number 2 in the units field (24G) of the CMS-1500 Claim Form. Sometimes a medical plan will require the code 21299 be used for an oral appliance adjustment. If this is the case, a narrative should be included with this code indicating that if is an orthotic adjustment. It is important to ask during the insurance inquiry which field they want the narrative noted; field 19 or 24 D.
In conclusion, it is important for both dentists and front end dental staff to understand that submitting medical insurance is much different than submitting dental insurance. Delays in reimbursement can occur when incorrect coding is submitted; therefore, using correct coding for the ICD, CPT or the HCPCS is mandatory if you desire prompt reimbursement. Remember, to help overcome reimbursement delays, the dentist and front end staff should be knowledgeable with medical insurance coding and protocol, including; how to properly complete a 1500 CMS form, how to do an insurance inquiry and how to submit for treatment rendered. Once the dentist and staff are adequately trained in such basics then many reimbursement delays can be prevented. Reimbursement delays will occur if the 1500CMS form is not properly completed or is lacking the required information, and each insurance company may require something specific and/or random, and knowing how to proper probe for needed information will take time and experience.
I would also recommend that the front end office create a log book to document techniques, strategies and other pertinent information which may be insurance specific. Often times, there is an insurance game that is insurance company and plan specific, so learn how to play their game and then document it and retain it in a log. You and your staff will find that there will be less frustration and improved reimbursement time when you have a log to refer to that is insurance company and plan specific.
Often, a patient narrative report is required, so doctor prepare your narrative promptly and well. Also, sending supplemental forms including; a medical necessity form, in-house appliance fabrication form or any other needed document, may be required by the insurance company, so know which field on the 1500 CMS form to complete and then remember to include the information with your claim.
This article includes supplemental forms; medical necessity form, an insurance questionnaire form and an in-house appliance form that your office may desire to use or modify when submitting your billing to a medical insurance company. Hopefully, you will find them useful.
Description of Medical Necessity for TMJ Appliance usage when treating a Temporomandibular Disorder
This supplement is intended for medical insurance company use. It identifies the different codes used for an occlusal orthotic, also known as an occlusal appliance or bruxism appliance (and other titles as well), to treat a temporomandibular Joint Disorder. It further discusses why an occlusal appliance is medically necessary to manage a temporomandibular disorder and its associated symptoms (face pain, temporomandibular joint pain, headaches, ear pain, etc).
Also included in this supplement is an explanation of how an occlusal appliance is fabricated in the dental office. Your company may or may not require this information.
Medical Coding for a Temporomandibular Disorder Occlusal Appliance or Bruxism Appliance
The CPT or HCPCS code used for billing an occlusal appliance is varied and insurance company specific. In most cases, the code we are using to bill for the appliance is the code selected after a member of our staff consulted with a representative of your company. The code your company has suggested our dental office use is the one circled below.
Why an Occlusal or Bruxism Appliance is needed to treat a Temporomandibular Disorder:
The occlusal appliance is used as a "mouth or jaw crutch" to aid in relieving a Temporomandibular Joint Disorder and orofacial pain by addressing one or more of the following:
Please Note: While it is not entirely known how an occlusal appliance works the above mentioned are a few of the believed mechanisms of action.
How the Occlusal Appliance is fabricated in the Dental Office
The Occlusal Appliance is a custom fabrication made from hard acrylic (plastic) and has been made in our dental office. The appliance can be made for either the upper or lower dentition (teeth). It is fabricated after upper and lower dental impressions are taken, poured up in stone and allowed to harden. Once the models have hardened they are mounted on a dental articulator (a simulator of the jaws) with a wax bite which was taken at the dental impression appointment.
The appliance is then fabricated out of acrylic (plastic) in this mounted position. The appliance is removed from either the upper or lower model, finished and then polished. At the patient appliance insertion appointment, which is about one half hour to an hour, the appliance is fitted over the teeth and then the acrylic is adjusted to a balanced occlusion (bite). The patient is then instructed on how to use and care for the appliance. The patient is then seen for follow up appointments for bite adjustments and other, as needed, follow up care.
Name of Policy Holder: _____________________________DOB: _______________
Name and Address of Insurance CO for billing: _________________________________
Is there TMD Coverage (Surgical or other): ____________________________________
First Name of Insurance agent (if allowed for) and extension number (if allowed for):