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Hello. We have a patient that has severe headaches daily and progress at night time. She also had a car accident 16 years ago. She clenches and grinds, she also gets jaw and ear pain. To treat her symptoms, my doctor is recommending orthodontic treatment that can be classified as 21499 to correct her bite and possibly do a Nightguard after braces are done. What would be the diagnosis code and modifier for this kind of treatment? Please advise.
Hi Guest! Below are some diagnosis coding options based on what you described: R51 – Headache G47.63 – Sleep related bruxism F45.8 – Other somatoform disorders R68.84 – Jaw pain H92.01 – Otalgia, right ear H92.02 – Otalgia, left ear H92.03 – Otalgia, bilateral H92.09 – Otalgia, unspecified ear Modifiers do not get used on diagnosis codes, only procedure (CPT) and supply/equipment (HCPCS) codes 🙂 Hope this helps, have a great day!
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