PATIENT ENCOUNTER FORM FOR TMJ-RELATED PROCEDURE

Patient Name: ____________________________________________ Sex: M F Age:________ Date: _________________ Time In:_________ Time Out:_________
Insurance: Dental □ Medical □ Company Name:________________________________________ Secondary Ins: □ Yes □ No Company Name:_________________________________

DIAGNOSTIC CODES:
 Dentofacial functional abnormalities, e.g., abnormal jaw closure & malocclusion  Unspecified diseases of jaw  Aseptic necrosis of bone
 TMJ Disorders, unspecified  Rheumatoid arthritis  Abnormal involuntary movements
 Adhesions & ankylosis, bony or fibrous  Osteoarthritis, localized, TMJ  Headache
 TMJ Arthralgia  Traumatic Arthropathy of TMJ  Swelling, mass, or lump in the head & neck
 Articular disc disorder  Neck Pain  Closed dislocation of jaw / TMJ joint
 Other specified TMJ disorder  TMJ synovitis & tenosynovitis  Open dislocation of jaw / TMJ joint
 Exostosis of jaw  Infective myositis  TMJ ligament sprain
 Other specified TMJ disorders  Myositis / myalgia, unspecified
CPT CODES
PATIENT EVALUATION AND MANAGEMENT - (Check all that apply):
Code New Patient Visit (has not seen Dr. within last 3 years) Code Hospital Care Code Established Patient Visit Code Office Consultations
 Level I  Initial hospital care – Level 1  Level I  Level 1
 Level 2  Initial hospital care – Level 2  Level 2  Level 2
 Level 3  Initial hospital care – Level 3  Level 3  Level 3
 Level 4  Subsequent hospital care - level 1  Level 4  Level 4
 Level 5  Subsequent hospital care – level 2  Level 5  Level 5
 Subsequent hospital care – level 3  Office Emergency  Services requested on Sunday/Holiday

RADIOGRAPHY & SUPPLY CODES

 Supply/Mat’ls: Diagnostic Casts / Models
 Complete series, 10 w/ bite wings
 Single tooth x-ray - 1st film
 Partial teeth X-rays (Periapical)
INJECTION CODES
 Therapeutic injection, IM
 Injected Medication:_________________________________
PROCEDURE CODES
 Arthrocentesis, aspiration/ injection
 Costochondral Graft
 Arthrotomy, TMJ
 Exc. of bone (e.g., for osteomyelitis/ bone abscess); mand.
 Exc. of benign cyst/ tumor of mand.; simple
 Exc. of benign cyst/tumor of mand., complex
 Exc. of malignant tumor of mand.
 Condylectomy, TMJ
 Meniscectomy, partial or complete, TMJ
CDT CODES
PATIENT EVALUATION AND MANAGEMENT - (Check all that apply):
 Periodic oral evaluation
 Limited Oral evaluation
 Partial Mandible x-ray (> 4 views)  PA / Lateral skull/ facial bones(> 4 views)  TMJ x-ray, bilateral
 Complete Mandible x-rays (4 + views)  PA / Lateral skull/facial bones (4 + views)  TMJ x-ray, unilateral
 Facial bones x-rays (> 3 views)  Cephalometric x-rays  Injection for TMJ Arthrography
 Facial bones x-ray (3+ views)  Orthopantogram x-rays (Panorex)  Other unlisted
MOD ANESTHESIA CODES (Proc. Code+ MOD) MOD CPT MOD
 General Anesthesia - 1st 30 mins  Unlisted (Nitrous Oxide - other than surgeon)
 IV Sedation  Unlisted (General Anes- other than surgeon)
MOD MOD MOD
 Coronoidectomy  Closed tx. of mandibular fx.; w/out manipulation
 Impression & custom preparation; oral surgical stent  Open tx. of mandibular condylar fx.
 Application of interdental fixation device, includes removal  Closed tx. of TMJ dislocation; initial or subsequent
 Injection for TMJ Arthrogram  Closed tx of TMJ dislocation-complicated
 Arthroplasty, TMJ w/ or w/out autograft (includes obtaining graft)  Open tx of TMJ dislocation
 Arthroplasty, TMJ, w/ allograft  Interdental wiring for condition other than fx.
 Arthroplasty, TMJ, w/ prosthetic joint replacement  Arthroscopy, TMJ, diagnostic, w/ or w/out synovial biopsy
 Reconstruct. of mand. condyle w/ bone & cartilage autographs  Arthroscopy, TMJ, surgical
 Reconstruct. of zygomatic arch & glenoid fossa w/ bone & cartilage  Other Unlisted
 Comprehensive patient oral examination  Professional Consultation
 Detailed and extensive oral evaluation – problem focused  Emergency Exam

RADIOGRAPHY & SUPPLY CODES ANESTHESIA CODES

INJECTION CODES
 Diagnostic Casts/ Models
 Complete series, 10 w/ bite wings
 Periapical X-rays- 1st film
 Periapical X-rays- additional
 Occlusal
PROCEDURE CODES
 Open reduction of TMJ dislocation
 Closed reduction TMJ dislocation
 TMJ manipulation under anesthesia
 Condylectomy
 Surgical discectomy, w//w/out implant
 Panorex, extraoral- 1st film  Panoramic X-rays  General Anesth-1st 30 mins  Therapeutic Injection
 Panorex, extraoral, additional  TMJ, unilateral (70330-bilateral)  IV Sedation  Unspecified-Supp & Mat- injectable med.
 Bite wing, additional 4 films  Injection for TMJ Arthogram  Nitrous Oxide  Other
 PA/Lateral skull/ facial bones  Other Unlisted  Local Anes-other than surgeon
 Cephalometric x-ray
 Synovectomy  Arthroscopy- diagnosis, w/ or w/out biopsy  Occlusal orthotic device, by report
 Myotomy  Arthroscopy- surgical: lavage & lysis of adhesions  Unspecified TMJ therapy, by report
 Joint Reconstruct.  Arthroscopy- surgical: disc repositioned & stabilization  Osseous, osteoperiosteal or cartilage graft
 Arthrotomy  Arthroscopy- surgical: synovectomy  Repair of maxillofacial soft & hard tissue defect
 07865 Arthroplasty  Arthroscopy- surgical: discectomy  Unspecified

© 2003 American Association of Oral and Maxillofacial Surgeons

 Disc repair  Arthrocentesis  Arthroscopy- surgical: debridement  Other Unlisted

Form Completed by:__________________________________________ Dr.’s Signature______________________________________________

© 2003 American Association of Oral and Maxillofacial Surgeons