Carol Tekavec, RDH
Implant dentistry has evolved into a popular and proven treatment modality for patients. The ADA has assigned 24 new codes to this area for 2000 and beyond.
Many dental insurance plans provide some coverage for implant services within the confines of the applicable yearly maximums (typically $1,500-$2,000) and/or according to Least Expensive Alternative Treatment (LEAT) contract parameters. LEAT clauses usually specify that the benefit may only be payable for a standard crown, bridge, removable partial, or denture. The patient`s employee-benefits booklet can provide details of reimbursable treatment.
If the patient`s contract specifically excludes implant procedures, then they will not be covered despite detailed narratives and explanations from the dentist. If a patient`s contract includes prosthetic benefits - with no specific exclusion of implants - some implants, as well as the crowns, bridges, partials, and dentures placed on them, may be reimbursable. Implants also may fall under a "pre-existing condition" clause. While such clauses are not as common as they once were, some plans still specify that, for a replacement of any kind to be considered, at least one of the missing teeth to be replaced must have been lost or removed while the patient was covered by the existing plan.
For patients who require multiple implants, a "phase-treatment" approach might result in better benefits. "Phase treatment" allows for the "maximum-benefit-per-year" to be respected, with the patient still receiving optimal care. It is a good idea to preauthorize and/or predetermine implant benefits for patients. In fact, many carriers actually have a preauthorization requirement in order for benefits to apply.
Data collection and attachments
Important elements of data collection, treatment-planning, narratives, and attachments can speed up the benefits process. The patient`s chart should include a complete and updated medical history, a detailed initial database (include prosthetic and extraction history information on the dental claim form), a detailed periodontal-evaluation form (it can be photocopied and stapled to the claim form), a general soft-tissue evaluation, a written diagnosis (include on the claim form), a written sequential treatment plan, and a written treatment estimate detailing total fees. This should be done regardless of possible insurance coverage. Make sure you have patients sign the treatment-estimate form, acknowledging that they are financially responsible for all treatment.
Radiographs and intraoral photos should accompany the claim form, as well as a written narrative that discusses pertinent details. Details might include inadequate ridge support, soft-tissue pain, ill-fitting dentures, or any other related problems.
Implant services are listed under ADA CDT-3 codes D6000-D6199. (Prosthetics not provided for under these codes should be coded under the fixed or removable prosthetic codes D5000-D5899 and D6200-D6999). Currently, the actual custom abutment crown for a fixed bridge (fixed partial-denture retainer), single crown, and full fixed-denture abutment prostheses are addressed by codes D6000-D6199. Pontics are not included in these codes.
Implant-supported prosthetics can require significantly more treatment time, detailed planning, and follow-up care than more traditional replacements. However, insurance carriers may pay for implant-supported prosthetics at the same rate as those placed on natural teeth - or even at a slightly lower rate. Carefully consider all aspects of the treatment needed before setting fees for implant services. Patients must understand their financial responsibilities, regardless of insurance coverage.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.