It’s estimated that over 10 million Americans suffer from Temporomandibular (TMJ) pain. In chronic cases (over 3 months duration), dental practices treating TMJ disorder can help their patients break the cycle of pain and lead the way for successful appliance therapy by recommending trigger point therapy.  Many medical plans cover trigger point therapy along with splint therapy when treatment is medically necessary. Whether the trigger point therapy consists of physical medicine modalities or injections, medical insurers are known to step up to the plate with reimbursement in many cases.

To bill medical insurance, it’s essential to document jaw discomfort, painful mastication, myalgia in the muscles of mastication and other chief complaints that validate medical necessity.

A leading insurer’s medical policy maintains that that “Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS). The large upper back muscles are prone to developing myofascial pain, as well as the neck and temporomandibular joint (TMJ) joint. Injections with local anesthetics and steroids are considered medically necessary in this plan”.

Q. How does a dental office bill medical for medically necessary procedures?

A. It’s essential to submit a narrative report showing the need for treatment and that the services are medically necessity. The ideal format for narratives and letters of medical necessity is a SOAP format (subjective, objective, assessment and plan).

SOAP notes should Include:

  1. Subjective symptoms such as headaches and facial pain
  2. Objective exam findings such as pain on palpation of the muscles of mastication and restricted TMJ range of motion
  3. Assessment including a specific diagnosis with medical diagnosis codes listed (myalgia or a TMJ disc disorder)
  4. Plan including a notation that other conservative management therapies failed to control pain and other modalities are recommended

Q. Other than a narrative, what else do I need to bill TMJ appliances or trigger point therapy?

A. To bill TMJ appliances or trigger point therapy, submit the appropriate International Classification of Diseases (ICD) diagnostic code and Current Procedural Terminology (CPT) procedure codes on a medical claim form (CMS 1500).  Software programs, such as DentalWriter™ Software help to generate your narratives of medical necessity and medical claims.

Q. Does Medical insurance reimburse for more than one appointment for TMJ appliances and trigger point therapy?

A. Medical plans commonly reimburse sessions consisting of two to four appointments for trigger point therapy prior to or during oral appliance therapy. In addition, the head, neck and facial screening and exam is reimbursable, as well as necessary imaging such as panorex or cephalometric imaging.

After placement of TMJ appliances, insurers typically reimburse for several follow up visits for management of the appliance and pain management

Q. What other services does medical insurance typically reimburse?

A. Cross-coding from dental to medical codes allows dental offices to report specific procedures to medical plans treatment for TMJ disorders, obstructive sleep apnea and oral surgeries. Whether you’re providing TMJ orthotics, trigger point injections, frenectomies, dental bone grafts or dental implants it’s well-worthwhile to verify if these services are covered under medical insurance.

TMJ dysfunction can be chronic and debilitating, and if left untreated can lead to other symptoms like migraines and tinnitus. Fortunately, there are now ways to resolve imbalances in the jaw and break the cycle of pain with dental office therapy.  And as icing on the cake, there’s a chance medical insurance has your patient covered.

Author: Rose Nierman, Founder & CEO of Nierman Practice Management

Connect With Us

Rose Nierman, is the Founder and CEO of Nierman Practice Management, and DentalWriter™ narrative report (for SOAP reports) and medical billing software.  NPM also hosts CE courses on Medical Billing for Dentists and clinical treatment of TMJ disorders and Dental Sleep Medicine. For more information, contact Nierman Practice Management at 1-800-879-6468.