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#1 Posted : Thursday, January 18, 2018 2:46:03 PM(UTC)

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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.
#2 Posted : Thursday, January 18, 2018 6:09:39 PM(UTC)

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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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