Author: Rose Nierman, RDH, Nierman Practice Management

When your patient presents with an injury, specific ICD-10 codes are available for trauma to the temporomandibular joint (TMJ) or teeth. In addition to the diagnosis, it’s important to document the accident as soon as possible and to contact the insurer to start a case file.  Time is of essence since some accident policies stipulate that the patient must be seen within 1-2 days following an accident or incident.  Insurers may also stipulate that the treatment be completed within 1 year (time limits vary from 6 months to 2 years or more).  Contact the insurer as soon as possible with a written treatment plan and a narrative report outlining the accident in the patient’s words.  Also, imaging may be required as documentation for accident cases.

Accident codes are VERY specific, there are thousands available! Below are two examples:

  • 11XA – Struck by baseball bat, initial encounter
  • 8XXA – Fall on or from other playground equipment, initial encounter

To communicate the diagnostic story and events, list the code to describe the condition first, then the specific incident & lastly, supporting codes for place of occurrence (when applicable)

Example:  Fracture of tooth – Fall 

Injury to Teeth for Medical Insurance
Fracture of tooth (traumatic), initial encounter S02.5XXB
Fall, Same Level, Initial encounter W18.30XA

 

Sample Letter for Accident – TMJ Treatment and Implants Required

Patient is undergoing treatment for traumatically induced loss of teeth and TMJ pain. State law requires that the insurance carrier is responsible for treatment of injuries resulting from an accident.  The patient did not have signs or symptoms of temporomandibular joint disorder prior to the accident.

HISTORY OF PRESENT ILLNESS AND ACCIDENT

The patient states the pain or condition first occurred on October 12, 2018.  She believes the cause of the pain or condition to be an athletic endeavor.  Her head and jaw forcibly struck the basketball court floor.

Ms. Patient stated that that her teeth were broken during the fall in the sports arena. She also reported that her neck and jaw were painful shortly after the accident and continued to worsen the next day.

I understand that the insurer is obligated to restore the patient as close as possible to pre-accident status. This patient did not have removable teeth prior to the accident and oral implants will be required along with temporomandibular joint treatment. The recommended plan is initial TMJ orthotic therapy with follow up visits, oral implant surgical procedures and prosthetic restoration.

The above letter was sent to the insurance company in a preauthorization FAX request.  For accident cases, it’s essential to start the case file as soon as possible with the entire plant written out.  When there is a possibility of permanent impairment, the provider may indicate that the patient will be reevaluated in three to six months for reevaluation.

Contact Us

If you have any questions about accident cases, medical billing claim solutions, or narrative reports, please feel free to contact Rose Nierman and our team through our site or at 1-800-879-6468.

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