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Q/A: What Diagnosis Codes Should I Use for TMJ Headache Massage for Coverage?

October 16th, 2018 - Wyn Staheli, Director of Research
Categories:   Diagnosis Coding   Physical Medicine|Physical Therapy   Documentation Guidelines   Insurance   Reimbursement  
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Question:

We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as TMJ related so they can be more widely covered?

Answer

TMJ has a history of being denied for treatment - any type of treatment and that includes massage. Documentation must always be correct and clear. If the patient is getting massage FOR the TMJ then the notes must reflect this. Documenting a headache that is associated or caused by TMJ is fine, but the notes need to reflect that as well.

You really need to be careful about how you bill insurance based on what was treated. Having a different diagnosis than what is on the referral could potentially be a red flag for an auditor unless your findings are properly documented.

It can also depend on what where the massage is being done. If, for example, you are massaging the muscle because of spasms or myofascial pain, then you could report M79.10-M79.18 (depending on the location) as long as the documentation supports that diagnosis.

Bottom line is that it's pretty unlikely that using a different diagnosis code will help much with insurance payment issues. They just really don't cover much for TMJ.

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