OCCLUSAL GUARD, BY REPORT
Removable dental appliances, which are designed to minimize the effects of bruxism (grinding) and other occlusal factors.
© 2016 American Dental Association
It is misleading to report the delivery of an occlusal guard (D9940) to describe tooth whitening trays (D9975) or for TMJ treatment to increase reimbursement. Tooth whitening trays are provided for cosmetic purposes and are not a covered service. TMJ dysfunction treatment is typically not reimbursed unless there is a TMJ dysfunction rider attached to the dental insurance policy and it is reported as D7880.
The occlusal guard (D9940) and the occlusal orthotic device (D7880) are often confused. Report D9940 to describe an occlusal guard for minimizing the effects of “bruxism” and “clenching of teeth.” Report D7880 to describe an appliance provided to treat TMJ dysfunction, which includes multiple visits.
- Bruxism is the parafunctional or habitual “grinding” of teeth, often nocturnal.
- There are three basic, broad types of bruxism appliances:
- Soft suck down appliance, typically fabricated in the dental office.
- Laboratory made hard acrylic appliance with or without soft liner.
- The NTI-tss, an anterior appliance, generally worn at night.
The occlusal guard fee will typically vary from $250 to $595, depending on the type of appliance. Factors such as the laboratory bill, the clinical technique used, and the total number of visits for impressions, delivery and follow up may affect the fee charged. Occlusal guards usually require two or more visits to deliver the appliance.
- If the occlusal guard (D9940), also known as a night guard, perio guard, or bite guard is reimbursed, it is generally reimbursed under dental, not medical insurance.
- Reimbursement for an occlusal guard (D9940) may be subject to an age exclusion for children 12 years of age or younger.
- Some payers only reimburse for bruxism; others require periodontal treatment (SRP or in some cases osseous surgery) to justify reimbursement.
- Occlusal guards may be reimbursed under “preventive,” “basic,” or “major” classifications. Classification is highly variable. Waiting periods may apply for basic and major coverage.
- After delivery of the occlusal appliance, six months of follow up care (including adjustments) is typically considered integral in the global occlusal guard fee. For an occlusal guard adjustment, see D9943.
- Although the occlusal orthotic device, by report (D7880) is generally considered to be for TMJ dysfunction, few payers will reimburse the occlusal guard (for bruxism) as an alternate benefit of the TMJ dysfunction appliance code D7880.
- Pretreatment authorization may be required for D9940.
Note: D9940 does not report a TMJ dysfunction appliance or active TMJ dysfunction treatment. TMJ dysfunction is not typically a covered dental benefit without a TMJ dysfunction rider; however, it may be reimbursed through medical insurance. TMJ dysfunction treatment (for pain, symptoms) involves a splint, multiple visits, and occlusal adjustments. The dental code for an appliance used to treat TMJ dysfunction is occlusal orthotic device (D7880). See D7880 for further details.
- To determine if a splint or occlusal guard is covered by a patient’s dental plan, one must first determine the purpose of the appliance. Is it needed to minimize the effects of bruxism? Is periodontal mobility a part of the diagnosis, or is the patient experiencing headaches and pain in the temporomandibular joint area?
- If there is a history of scaling and root planing (D4341/D4342) or periodontal osseous surgery (D4260/D4261), note this in the narrative when reporting an occlusal guard. The narrative might state “This patient has undergone periodontal therapy on (date), with description of the case type.” Coverage for D9940 may vary based on whether the policy includes a supplemental “periodontal rider.” The rider could make a difference in coverage if there is a supplemental “periodontal rider” on the contract. Even so, some payers make a distinction between case types and will only reimburse for the more advanced osseous surgery. SRP (D4341/D4342) treatment may not suffice. Some plans require the occlusal guard be placed within six months of active periodontal treatment. If D9940 is reimbursed under a periodontal rider, the benefit may be available only once every five years or be limited to a lifetime maximum. The annual maximum will generally apply. Reimbursement is highly variable
- Include a narrative as indicated below:
- If the diagnosis is bruxism, state “Diagnosis = Bruxism.” An occlusal guard is necessary to minimize the effects of bruxism and clenching of teeth.”
- If the diagnosis is periodontitis, state case type, state periodontal treatment that has been performed, and include a current periodontal chart. If treatment is provided for a patient with periodontal treatment, state: “This patient has undergone active periodontal therapy (or osseous surgery, for chronic periodontitis) on mm/dd/yy and is a case Type III. If an occlusal guard (D9940) is not available for reimbursement, please consider an alternate benefit, if available.”
- Some plans require the occlusal guard be placed within six months of the active periodontal treatment (SRP or osseous surgery). If the occlusal guard is required to address periodontal mobility, include a periodontal diagnosis, current periodontal charting, and radiographs.
If a patient requires a nightguard because of night grinding or has advancing periodontal mobility, the appliance is billed using code D9940, by report. If bruxism is the problem, a simple narrative indicating such is all that is necessary. However, if periodontal mobility is the problem, then a periodontal diagnosis along with a comprehensive periodontal charting and full mouth images is recommended.
If the patient is experiencing temporomandibular joint dysfunction (TMD), the occlusal orthotic should be billed using code D7880. A narrative needs to describe the diagnosis and symptoms, e.g., joint pain, popping, clicking, crepitus, migraines, deviated opening, etc.
Some plans cover appliances for bruxism, mobility, and/or some for TMD, but few cover all three. So, make sure you know the clinical problem before you check for benefits.