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courtneydsnow
#1 Posted : Friday, June 19, 2015 5:16:45 PM(UTC)
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courtneydsnow

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Code for Mandibular Orthopedic Repositioning Device used for TMD appliance (S8262) discontinued as of June 30, 2015


Code S8262, Mandibular Orthopedic Repositioning Device commonly used for TMD appliances will be retired as of June 30, 2015. This code has been in the “temporary” code set of the HCPCS coding manual. The Center for Medicaid and Medicare Services (CMS) reserves the right to revise codes without notice and has decided to retire the temporary code with short notice.
The quarterly HCPCS coding update file has been released on CMS’s website. One of the “discontinued” codes included in the update is S8262, standing for “Mandibular Orthopedic Repositioning Device, Each”. The discontinue date is at the end of the this month on June 30th, 2015.
You can download a copy of the coding update file on CMS’s website using the link below:

Download coding update files here


The discontinuation of S8262 is found on the “Other codes effective July 1, 2015” file.



So what code do insurers want dental practices to use for a TMD appliance instead after June 30?

Various current medical policies for treatment of TMD and found the following codes related to TMD:

D7880 - Occlusal orthotic device, by report
D7889 - Unspecified TMD therapy, by report
21499 - Unlisted musculoskeletal procedure, head, by report


The example below shows BCBS of MA's medical policy for Temporomandibular Joint Dysfunction and specifies that D7880 can be used on a medical claim (CMS 1500) with the appropriate TMJ Disorder diagnosis code.


You can view the full policy here


TIP: Pre-authorizations may need to be resent for treatment planned July 1 or later.

Edited by user Wednesday, September 16, 2015 10:35:27 AM(UTC)  | Reason: Not specified

Kat- Dr. Lisa Rubis Office 815-207-7463
#2 Posted : Thursday, July 23, 2015 5:24:25 PM(UTC)
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I called on the codes that you posted and BCBS said that 21089 because it is unspecified that it falls under surgical codes. They also said that specific code is subject medical review and must be submitted with all medical record, reports and imaging and will go directly for review when the claim is submitted. The person that I talked to also said that the claim must be submitted via paper. Is there a better code to submit? I have looked and there does not seem to be a better code what should I do?
courtneydsnow
#3 Posted : Thursday, July 23, 2015 6:20:19 PM(UTC)
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Hi Kat!

Yes all of the codes that we see offices using for TMD orthotics since the discontinuation of S8262 are considered "non-specific" or "misceallaneous" codes, because there is not a CPT or HCPCS code that currently described an orthotic for treating TMD.....so most likely, they will all require the documentation (narrative report) when submitted for pre-auth or with the claim itself. You will usually know you need to do that if the codes description says anything like "by report", "unspecified" or "misceallaneous", as shown below:

D7880 - Occlusal orthotic device, by report
D7889 - Unspecified TMD therapy, by report
21499 - Unlisted musculoskeletal procedure, head, by report


Some insurers may also accept E1399 for Durable Medical Equipment, Miscellaneous
if they consider the TMD appliance DME.

The descriptions of D7880 and D7889 seems to sit a TMD appliance very well.....but of course, send your DentalWriter narrative report with the claim or pre-auth!!

Hope this helps, please let me know if you have any further questions

Edited by user Wednesday, September 16, 2015 12:23:56 PM(UTC)  | Reason: Not specified

Guest
#4 Posted : Tuesday, September 1, 2015 8:36:13 PM(UTC)
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Just wondering if anyone has come up with any new codes to use to replace code S8262. I am looking into code L8048.

BCBS of Illinois only reimburses (allows) $250.00 for 21499 and won't allow us to use D7880. 21089 is a surgical code and I am hesitant to use it.

BCBS use to allow the full amount for our TMD appliances. This stinks!

Would love to hear what everyone is doing?

Thanks
Meaghan in IL
Rose
#5 Posted : Wednesday, September 16, 2015 12:20:52 PM(UTC)
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Originally Posted by: Guest Go to Quoted Post
I called on the codes that you posted and BCBS said that 21089 because it is unspecified that it falls under surgical codes. They also said that specific code is subject medical review and must be submitted with all medical record, reports and imaging and will go directly for review when the claim is submitted. The person that I talked to also said that the claim must be submitted via paper. Is there a better code to submit? I have looked and there does not seem to be a better code what should I do?


Lisa, it's true that even though some TMJ medical policies list 21089, which is an unspecified prosthetic device, this is not the appropriate code for a TMJ orthotic. The 21089 is in the surgical prosthesis section of CPT and is a for a replacement of a body part such as a new nose, ear, an obturator for a cleft palate, etc. Also, the CPT codes listed in this section do require that the provider makes the custom device.

I hope this helps!

Rose Nierman, CEO Nierman Practice Management
www.DentalWriter.com
Rose
#6 Posted : Wednesday, September 16, 2015 12:29:41 PM(UTC)
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Originally Posted by: Guest Go to Quoted Post
Just wondering if anyone has come up with any new codes to use to replace code S8262. I am looking into code L8048.

BCBS of Illinois only reimburses (allows) $250.00 for 21499 and won't allow us to use D7880. 21089 is a surgical code and I am hesitant to use it.

BCBS use to allow the full amount for our TMD appliances. This stinks!

Would love to hear what everyone is doing?

Thanks
Meaghan in IL



Hi Meaghan in IL.

Yes, I understand why you are hesitant to use the 21089 for a TMJ appliance. It's not the appropriate code. $250 does seem low for the 21499, musculoskeletal procedure, head, with report. They may be paying the lab fee only so that is something I would check into. The service is worth much more and I would definitely consider an appeal.
Guest
#7 Posted : Friday, December 4, 2015 11:23:51 AM(UTC)
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BCBSIL is no longer accepting D7880. Is it okay to only submit 21499 to medical insurance for a nightguard??? How should we be submitting nightguards to medical insurance?
courtneydsnow
#8 Posted : Friday, December 4, 2015 11:31:49 AM(UTC)
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Hi guest!

Great question. This will depend on what condition the nightguard is being used to treat. For example, if it is simply an occlusal guard to protect the surface of the teeth, 21499 may not be an appropriate code. If the nightguard is being used to treat temporomandibular disorders (TMD), 21499 may be an appropriate code. If the nightguard is being being to treat Obstructive Sleep Apnea, E0486 or E0485 may be the appropriate code.

What we are finding is that the code that is most commonly accepted currently for TMD appliances since the S8262 discontinuation back in June of this year is D7880. However, some insurers are accepting D7899, 21499, or E1399.

D7880 - occlusal orthotic device, by report
D7899 - unspecified TMD therapy, by report
Or, if the medical insurer says they won’t process the “D” codes (most will these days, but you will run into a few that won’t), you can try:
E1399 - Durable medical equipment, miscellaneous
21499 - Unlisted musculoskeletal procedure, head

A narrative report accompanying the claim is recommended since they are all "by report" or "miscellaneous" codes.

If it is for TMD:
You can also check the insurers TMD medical policy on their website, and many of them will list accepted codes right in their policies. For example, here is a link to BCBS of MS's TMD medical policy that lists the currently accepted code as D7880 for TMD appliances in the coding section of the policy:
http://www.bcbsms.com/com/bcbsms/apps/PolicySearch/views/ViewPolicy.php?&noprint=yes&path=/policy/emed/Temporomandibular_Joint.html

Hope this helps, have a great day!
Guest
#9 Posted : Friday, December 4, 2015 12:19:28 PM(UTC)
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Wow, thanks so much for the prompt response!!! Yes, most of our claims are being sent due to treating temporomandibular disorder. So I guess my question is, is it okay to ONLY submit the 21499 by itself or does it need the accompanying D code? What is the difference between a CPT Code and a HCPCS Code?

~Emily
courtneydsnow
#10 Posted : Friday, December 4, 2015 12:31:48 PM(UTC)
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Hi Emily!

No problem :) And great questions -

You would only use the 21499 code, you wouldn't want to bill the "D" code along with it (that would actually indicate there were 2 separate appliances!). Since 21499 is an "unlisted" code, you will want to make sure you include a narrative report accompanying the claim to describe what the code is being used to represent.

CPT stands for "Current Procedural Terminology", and are considered "Level 1" codes. CPT codes include services like office visits, x-rays, surgeries, etc.

HCPCS stands for "Healthcare Common Procedure Coding System", and are considered "Level II" codes. HCPCS codes include durable medical equipment, prosthetics, orthotics & supplies.

Here is a link to a great study group we did that covers the different coding sets in detail, and how they come to be codes!
http://www.screencast.com/t/Kz3Bq24S7sC

Hope this helps, have a great day!
Guest
#11 Posted : Friday, December 4, 2015 2:10:31 PM(UTC)
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Thanks so much, Courtney!!! You guys are awesome. It definitely helped. Sorry, one more question! ;)

What if we are submitting the nightguard strictly to treat nocturnal bruxism? What code would it be then? And what if the insurance company doesn't accept the D code...?
courtneydsnow
#12 Posted : Friday, December 4, 2015 2:18:11 PM(UTC)
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Hi Emily!

Thanks for the kind words! And great question. So there is an ICD-10 diagnosis code for sleep related bruxism (G47.63), however most medical insurers do not offer coverage for treatment of bruxism because they do not consider it a medically necessary treatment. We have seen a few medical insurers start to offer coverage for "painful bruxism", however it is listed in their botox policy generally.

For example, here is a link to Aetna’s medical policy for botox:
http://www.aetna.com/cpb/medical/data/100_199/0113.html

The above policy states:
“OnabotulinumtoxinA (Botox Brand of Botulinum Toxin Type A): Aetna considers onabotulinumtoxinA (Botox) medically necessary for any of the following conditions:
……
V. Painful bruxism”


Hope this helps, have a great day!
Guest
#13 Posted : Monday, March 28, 2016 2:33:09 PM(UTC)
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Is there a serial no. or mfg. no or anything for the mandibular orthopedic. Medicare is being ultra stubborn
courtneydsnow
#14 Posted : Tuesday, March 29, 2016 6:51:07 AM(UTC)
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Hi guest!

The serial number/mfg # would be provided by the lab/manufacturer that fabricated the device. For example, for oral appliances for OSA, the serial number is usually found built into the material of the appliance. Or, it may be on the invoice you received. If it is not in either place, you may need to contact the lab/manufacturer to obtain the serial number, as it will be unique to the device. (However, the "model number" for some OSA appliances can be found on the PDAC list for E0486 (which is not the same as a serial #, it's a generalized code to stand for all appliances of that type).
Guest
#15 Posted : Tuesday, September 27, 2016 11:51:43 AM(UTC)
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We need to submit orthodontic to medical insurance to fix the TMJ Dental code D8090 and TMJ splint d7880. BCBSMN only allows 700.00 on splint and will not accept the dental ortho code needs a medical code for that. If us for full upper and lower braces. Char
courtneydsnow
#16 Posted : Wednesday, September 28, 2016 8:16:10 AM(UTC)
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Hi guest!

Yes that seems about on par for what many medical insurers allow for a TMD splint. As for the ortho, I don't believe I have come across any medical insurers that will consider orthodontic treatment medically necessary for the treatment of TMD.

However, There is now, under the Affordable Care Act, coverage under medical plans for pediatric orthodontics for some diagnoses. Most policies indicate coverage for ortho for diagnoses/conditions such as severe malocclusions, speech abnormalities, trauma, etc.

Here’s a really good guide from United Healthcare on the Pediatric Dental Essential Health Benefit in the Affordable Care Act (ACA), which includes “medically necessary orthodontia” (among other things, of course)
https://www2.cbia.com/ieb/ag/medical/zpdf/MemberBenefits/Oxford%20Pediatric%20Dental.pdf

And these below are really good reads to wrap your head around it as well – a few sample medical policies on ortho coverage for pediatrics under the medical policy…..they outline the conditions/criteria the patient has to have in order for the ortho to be covered by the medical policy:
BCBS of North Carolina - Orthodontics for Pediatric Patients
https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/orthodontics_for_pediatric_patients.pdf

Aetna - Medically Necessary Orthodontia Related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)
https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins/DCPB039.html#

BCBS of Rhode Island - Pediatric Dental Services -Essential Health Benefit
https://www.bcbsri.com/sites/default/files/polices/Pediatric_%20Dental_%20Services%20_Essential_%20Health_%20Benefit_3.pdf

The one for Aetna even lists out the codes you might use! Here they are below:
Possible orthodontic codes1*
• D8010- Limited orthodontic treatment of the primary dentition
• D8020- Limited orthodontic treatment of the transitional dentition
• D8030- Limited orthodontic treatment of the adolescent dentition
• D8040- Limited orthodontic treatment of the adult dentition
• D8050- Interceptive orthodontic treatment of the primary dentition
• D8060- Interceptive orthodontic treatment of transitional dentition
• D8070- Comprehensive orthodontic treatment of the transitional dentition
• D8080- Comprehensive orthodontic treatment of the adolescent dentition
• D8090- Comprehensive orthodontic treatment of the adult dentition

Hope this helps, have a great day!
Guest
#17 Posted : Wednesday, January 25, 2017 6:41:32 PM(UTC)
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I'm working with BCBS of ND. What codes would you use to differentiate a day gaurd/ Clench Gaurd / and a night guard for TMD. In ND we have differentiate them or they lump them together an we only get paid for one. We used the D99880 zero I believe for the day gaurd and the same for night and they didn't pay for the night occlusal guard. How could we code this differently. They are both for TMD, but used for different reasons.
Guest
#18 Posted : Wednesday, January 25, 2017 6:43:26 PM(UTC)
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D7880 sorry
courtneydsnow
#19 Posted : Thursday, January 26, 2017 8:28:55 AM(UTC)
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Hi Guest!

Great question. Unfortunately there are not separate codes that we are aware of to signify different types of appliances used to treat TMD for different reasons (basically, for most medical insurers, in their eyes they are all used to treat TMD.....or if being used for something else - i.e. bruxism, is not considered medically necessary so not covered). I have seen a few offices attempt to bill one splint under D7880, and then another under either 41899 or 21499, however I have not seen offices be successful with it.

I have seen a few medical insurers start to work language into their medical policies for treatment of TMD that only 1 splint is considered medically necessary. I looked up BCBS of ND's medical policy to TMD for you - they do not specifically state that language as some others do, however that may be the case here as well (that they only consider 1 splint medically necessary for coverage). Here is a link to their medical policy for TMD in case you need/want it:
https://bb.thor.org/BulletinBoard/ViewFile.aspx?param=Bulletins%5cBlue_Cross_Blue_Shield_ND_Medical_Policy%5cTemporomandibular_Joint_(TMJ)_Dysfunction_.htm

Hope this helps!
Guest
#20 Posted : Thursday, March 9, 2017 11:51:17 PM(UTC)
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Need your help, my TMJ dentist submitted procedure code 21110-52 for TMJ orthopedic orthotic appliance but insurance company told the provider to change it to 21089 and then insurance company denied the claim saying "WE NEED MORE INFORMATION ABOUT THIS CLAIM TO DETERMINE IF THE SERVICES RECEIVED WERE MEDICALLY NECESSARY. THE HEALTH CARE PROFESSIONAL WILL PROVIDE THE INFORMATION WE NEED TO PROCESS THIS CLAIM (FACILITY RECORDS, OFFICE NOTES, HISTORY & PHYSICAL, DIAGNOSTIC REPORTS, OPERATIVE/ANESTHESIA RECORDS, AND/OR PHOTOS FOR POTENTIAL COSMETIC PROCEDURES)."

I am confused as 21089 is a surgery code, why insurance company want the previous code to be changed to something that is for surgery and then later asked additional information that is applicable in case of surgical procedure.

Can anyone guide me if 21110-52 is a valid code for TMJ appliance? or perhaps it is 21110 instead? not sure what to. However in my medical insurance i have surgical and non-surgical tmj treatment including appliances covered.

Thanks for your help!
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