by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Aug 7th, 2015 - Reviewed/Updated Aug 7th
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history (i.e., Aetna Temporomandibular Disorder Questionnaire) and physical examination, TMJ radiographs/diagnostic imaging reports, patient records reflecting a complete history of 3 to 6 months of non-surgical management (describing the nature of the non-surgical treatment, the results, and the specific findings associated with that treatment), and the proposed treatment plan. The provider will be notified of the coverage decision after review of all pertinent data.
Read the entire policy Aetna Policy Number 0028 last review 3/06/2015 Number 0028
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CPT Codes / HCPCS Codes / ICD-9 Codes |
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CPT codes covered if selection criteria are met: |
|
|
Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) |
|
|
single or multiple trigger point(s), 3 or more muscles |
|
|
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance [not covered for viscosupplementation injection] |
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Cartilage graft; costochondral [autologous] |
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Arthrotomy, tempomandibular joint |
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|
Condylectomy, tempomandibular joint (separate procedure) |
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Meniscectomy, partial or complete, tempomandibular joint (separate procedure) |
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Coronoidectomy (separate procedure) |
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Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) |
|
|
Impression and custom preparation; surgical obturator prosthesis |
|
|
interim obturator prosthesis |
|
|
definitive obturator prosthesis |
|
|
mandibular resection prosthesis |
|
|
oral surgical splint |
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal |
|
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Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft |
|
|
Osteotomy, mandible, segmental; |
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Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) |
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Arthroplasty, temporomandibular joint, with allograft |
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Arthroplasty, temporomandibular joint, with prosthetic joint replacement |
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Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
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Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
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Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
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Closed treatment of mandibular fracture; without manipulation |
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with manipulation |
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Percutaneous treatment of mandibular fracture; with external fixation |
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Closed treatment of mandibular fracture with interdental fixation |
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Open treatment of mandibular fracture with external fixation |
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Open treatment of mandibular fracture; without interdental fixation |
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with interdental fixation |
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Open treatment of mandibular condylar fracture |
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Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints |
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Closed treatment of temporomandibular dislocation; initial or subsequent |
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complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent |
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Open treatment of temporomandibular dislocation |
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Interdental wiring, for condition other than fracture |
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Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) |
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Arthroscopy, temporomandibular joint, surgical |
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Psychotherapy |
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Biofeedback training by any modality |
|
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Application of a modality to 1 or more areas; hot or cold packs |
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Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
|
|
massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
|
|
Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes |
|
|
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
|
|
Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
|
|
+ 97811 |
without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure) |
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with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
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+ 97814 |
with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure) |
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CPT codes not covered for indications listed in the CPB: |
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Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed |
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Genioplasty |
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Augmentation mandibular body or angle |
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Reconstruction midface, Lefort I |
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Reconstruction midface, Lefort II |
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Reconstruction midface, Lefort III (extracranial), any type, requiring bone grafts (includes obtaining autografts) |
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Reconstruction midface, Lefort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts) |
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Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) |
|
|
Reconstruction of mandibular rami and/or body, sagittal split |
|
|
Osteotomy, mandible, segmental; with genioglossus advancement |
|
|
Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) |
|
|
Osteoplasty, facial bones |
|
|
Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia) |
|
|
Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder) |
|
|
Radiologic examination, teeth; single view |
|
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partial examination, less than full mouth |
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complete, full mouth |
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Computerized tomography, maxillofacial area; with contrast material(s) |
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without contrast material, followed by contrast material(s) and further sections |
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Joint survey, single view, 2 or more joints (specify) [joint vibration analysis for TMJ] |
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Needle electromyography; cranial nerve supplied muscle(s), unilateral |
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cranial nerve supplied muscles, bilateral |
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Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) |
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Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method |
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|
Application of a modality to 1 or more areas; electrical stimulation (unattended) |
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|
diathermy (e.g., microwave) |
|
|
infrared |
|
|
ultraviolet |
|
|
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes |
|
|
iontophoresis, each 15 minutes |
|
|
ultrasound, each 15 minutes |
|
|
Hubbard tank, each 15 minutes |
|
|
Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes |
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|
Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes |
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Other CPT codes related to the CPB: |
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Radiologic examination, temporomandibular joint, open and closed mouth; unilateral |
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bilateral |
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Temporomandibular joint arthrography, radiological supervision and interpretation |
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Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) |
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Computerized tomography, maxillofacial area; without contrast material |
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Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) |
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with contrast material(s) |
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without contrast material(s), followed by contrast material(s) and further sequences |
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HCPCS codes covered if selection criteria are met: |
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Temporomandibular joint arthrogram, including injection |
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Other temporomandibular joint films, by report |
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Tomographic survey |
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Cephalometric film |
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Obturator prostheses |
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Mandibular resection prosthesis with guide flange |
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Surgical stent |
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Surgical splint |
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Mandible, open reduction (teeth immobilized, if present) |
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Mandible, closed reduction (teeth immobilized, if present) |
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Mandible, open reduction |
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Mandible, closed reduction |
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Reduction of dislocation and management of other temporomandibular joint dysfunctions |
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Electromyography (EMG), biofeedback device |
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Mandibular orthopedic repositioning device, each |
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HCPCS codes not covered for indications listed in the CPB: |
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Electrodes (e.g., apnea monitor), per pair |
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Lead wires (e.g., apnea monitor), per pair |
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Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz. |
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Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) |
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Oral/facial photographic images |
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Prosthodontics (removable) |
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Prosthodontics (fixed) |
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Unspecified TMD therapy, by report |
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Osteoplasty, for orthognathic deformities |
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Osteotomy - mandibular rami |
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Osteotomy - mandibular rami with bone graft; includes obtaining the graft |
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Osteotomy - segmented or subapical |
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Osteotomy, body of mandible |
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Lefort I (maxilla, total) |
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Lefort I (maxilla, segmented) |
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Lefort II or Lefort III (osteoplasty of facial bones for midfce hypoplasia or retrusion), without bone graft |
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Lefort II or Lefort III, with bone graft |
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Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, autogenous or nonautogenous, by report |
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Sinus augmentation with bone or bone substitutes |
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Bone replacement graft for ridge preservation - per site |
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Repair of maxillofacial soft and/or hard tissue defect |
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Occlusal guards, by report |
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Occlusal adjustment, limited |
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Occlusal adjustment, complete |
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Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation |
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Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation |
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Neuromuscular stimulator, electronic shock unit |
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Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose [knee only - see selection criteria] |
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Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose [knee only - see selection criteria] |
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Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose [knee only - see selection criteria] |
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Hyaluronan or derivative, Synvisc, or Synvisc-One for intra-articular injection, per dose [knee only - see selection criteria] |
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ICD-9 codes covered if selection criteria are met: |
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Temporomandibular joint disorders |
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Fracture of mandible, closed or open, or malar and maxillary bones closed or open |
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Dislocation of jaw, closed or open |
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Other ICD-9 codes related to the CPB: |
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Other specified psychophysiological malfunction |
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Organic sleep disorders |
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Migraine |
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Glossopharyngeal neuralgia |
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715.1 |
Osteoarthrosis, localized, primary [temporomandibular joint] |
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Osteoarthrosis, localized, secondary [temporomandibular joint] |
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Osteoarthrosis, localized, not specified whether primary or secondary [temporomandibular joint] |
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Loose body in joint, other specified sites [temporomandibular joint] |
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Pathological dislocation, other specified sites [temporomandibular joint] |
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Recurrent dislocation of joint, other specified sites [temporomandibular joint] |
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Hemarthrosis, other specified sites [temporomandibular joint] |
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Myalgia and myositis, unspecified |
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Aseptic necrosis of bone, site unspecified |
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Aseptic necrosis of bone, other |
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Sleep disturbances |
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Chronic fatigue syndrome |
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Headache |
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Late effect of certain complications of trauma [scarring of temporomandibular joint that is severe and the result of old injury or prior procedure] |
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Late effect of complications of surgical and medical care [scarring of temporomandibular joint that is severe and the result of old injury or prior procedure] |
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Injury of face and neck [temporomandibular joint] |
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Other complications due to internal joint prosthesis and other internal orthopedic device, implant, and graft |
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Other postprocedural states [head and neck tumor resection] |
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CPT Codes / HCPCS Codes / ICD-10 Codes |
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Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": |
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ICD-10 codes will become effective as of October 1, 2015 : |
|
|
CPT codes covered if selection criteria are met: |
|
|
Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) |
|
|
single or multiple trigger point(s), 3 or more muscles |
|
|
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance [not covered for viscosupplementation injection] |
|
|
Cartilage graft; costochondral [autologous] |
|
|
Arthrotomy, tempomandibular joint |
|
|
Condylectomy, tempomandibular joint (separate procedure) |
|
|
Meniscectomy, partial or complete, tempomandibular joint (separate procedure) |
|
|
Coronoidectomy (separate procedure) |
|
|
Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) |
|
|
Impression and custom preparation; surgical obturator prosthesis |
|
|
interim obturator prosthesis |
|
|
definitive obturator prosthesis |
|
|
mandibular resection prosthesis |
|
|
oral surgical splint |
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal |
|
|
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft |
|
|
Osteotomy, mandible, segmental; |
|
|
Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) |
|
|
Arthroplasty, temporomandibular joint, with allograft |
|
|
Arthroplasty, temporomandibular joint, with prosthetic joint replacement |
|
|
Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
|
|
Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
|
|
Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) |
|
|
Closed treatment of mandibular fracture; without manipulation |
|
|
with manipulation |
|
|
Percutaneous treatment of mandibular fracture; with external fixation |
|
|
Closed treatment of mandibular fracture with interdental fixation |
|
|
Open treatment of mandibular fracture with external fixation |
|
|
Open treatment of mandibular fracture; without interdental fixation |
|
|
with interdental fixation |
|
|
Open treatment of mandibular condylar fracture |
|
|
Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints |
|
|
Closed treatment of temporomandibular dislocation; initial or subsequent |
|
|
complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent |
|
|
Open treatment of temporomandibular dislocation |
|
|
Interdental wiring, for condition other than fracture |
|
|
Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) |
|
|
Arthroscopy, temporomandibular joint, surgical |
|
|
Psychotherapy |
|
|
Biofeedback training by any modality |
|
|
Application of a modality to 1 or more areas; hot or cold packs |
|
|
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
|
|
massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
|
|
Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes |
|
|
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes |
|
|
Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
|
|
+ 97811 |
without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure) |
|
with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient |
|
|
+ 97814 |
with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to primary procedure) |
|
CPT codes not covered for indications listed in the CPB: |
|
|
Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed |
|
|
Genioplasty |
|
|
Augmentation mandibular body or angle |
|
|
Reconstruction midface, Lefort I |
|
|
Reconstruction midface, Lefort II |
|
|
Reconstruction midface, Lefort III (extracranial), any type, requiring bone grafts (includes obtaining autografts) |
|
|
Reconstruction midface, Lefort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts) |
|
|
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) |
|
|
Reconstruction of mandibular rami and/or body, sagittal split |
|
|
Osteotomy, mandible, segmental; with genioglossus advancement |
|
|
Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) |
|
|
Osteoplasty, facial bones |
|
|
Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia) |
|
|
Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder) |
|
|
Radiologic examination, teeth; single view |
|
|
partial examination, less than full mouth |
|
|
complete, full mouth |
|
|
Computerized tomography, maxillofacial area; with contrast material(s) |
|
|
without contrast material, followed by contrast material(s) and further sections |
|
|
Joint survey, single view, 2 or more joints (specify) [joint vibration analysis for TMJ] |
|
|
Needle electromyography; cranial nerve supplied muscle(s), unilateral |
|
|
cranial nerve supplied muscles, bilateral |
|
|
Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) |
|
|
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method |
|
|
Application of a modality to 1 or more areas; electrical stimulation (unattended) |
|
|
diathermy (e.g., microwave) |
|
|
infrared |
|
|
ultraviolet |
|
|
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes |
|
|
iontophoresis, each 15 minutes |
|
|
ultrasound, each 15 minutes |
|
|
Hubbard tank, each 15 minutes |
|
|
Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes |
|
|
Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes |
|
|
Other CPT codes related to the CPB: |
|
|
Radiologic examination, temporomandibular joint, open and closed mouth; unilateral |
|
|
bilateral |
|
|
Temporomandibular joint arthrography, radiological supervision and interpretation |
|
|
Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) |
|
|
Computerized tomography, maxillofacial area; without contrast material |
|
|
Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) |
|
|
with contrast material(s) |
|
|
without contrast material(s), followed by contrast material(s) and further sequences |
|
|
HCPCS codes covered if selection criteria are met: |
|
|
Temporomandibular joint arthrogram, including injection |
|
|
Other temporomandibular joint films, by report |
|
|
Tomographic survey |
|
|
Cephalometric film |
|
|
Obturator prostheses |
|
|
Mandibular resection prosthesis with guide flange |
|
|
Surgical stent |
|
|
Surgical splint |
|
|
Mandible, open reduction (teeth immobilized, if present) |
|
|
Mandible, closed reduction (teeth immobilized, if present) |
|
|
Mandible, open reduction |
|
|
Mandible, closed reduction |
|
|
Reduction of dislocation and management of other temporomandibular joint dysfunctions |
|
|
Electromyography (EMG), biofeedback device |
|
|
Mandibular orthopedic repositioning device, each |
|
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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