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Implant reimbursement

May 1, 2007
It is my overall intention to assist your practice in streamlining the DENTAL REIMBURSEMENT PROCESS for the treatments you perform.

by Tom Limoli Jr.

It is my overall intention to assist your practice in streamlining the DENTAL REIMBURSEMENT PROCESS for the treatments you perform. It is not my intention to drive your practice into a state of either insurance dependence or independence. At Atlanta Dental Consultants, we see the patients" benefit plans as nothing more than a means for making superior dental care both obtainable and affordable.

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To achieve these objectives, dental professionals, as well as clinical and administrative personnel, must view this as a sequential process the entire team can follow. Too often we fi nd offices that have slipped out of focus by attempting to be allknowing and all-doing when it comes to patients" benefit plans. Each of us has our individual roles in both the business office and the operatory. Harmony, growth, and overall profi tability are more easily achieved when everyone is singing from the same songbook.

My father, Tom Limoli, DDS (1924-2006), founded Atlanta Dental Consultants with my mother, Christel, in the late 1970s. One of the many cornerstones of our business teachings has been what we refer to as the "Trilogy of Reimbursement." In the simplest terms, the continuous trilogy is based on the three progressive interdependent steps of diagnosis, treatment, and documentation.

In other words, diagnose based upon documented findings, treat based upon the diagnosis and the patient"s response to that treatment, then bill and code for exactly what was performed. Your narrative report and supplemental information falls right into place because it is simply based upon your clinical fi ndings and treatment documentation. Note how the patient responded to not only the procedure, but the overall outcome.

It sounds simple enough. But if the business team is not coding and billing for the treatment performed by the clinical team, we have the beginning of a treacherous downward spiral that will manifest itself into lost revenue, wasted time, and unnecessary stress on the offi ce, as well as the doctor"s personal paycheck. As tempting as it may be to add a fourth step called "What should we tell the insurance company?" don"t do it! Tell the insurance company the truth; anything other than the truth treads on the path of insurance fraud. Let"s take this simple trilogy and apply it to the subject of implant reimbursement. The three phases of implanttherapy reimbursement are challenged if we don"t know what technique is part of what procedure code. Various implant systems have differing techniques that do not immediately correspond to the existing system of coding and nomenclature. Unfortunately, the tooth fairy was not with us when the American Dental Association"s Current Dental Terminology (CDT-2007) addressed this problem with more codes rather than less. Yes, you read that correctly, because fewer codes with nontechnique and manufacturer-driven descriptors would have made the overall system of record keeping, documentation, and reimbursement more simple.

The three parts of the implant triad are:

  1. The surgical placement of the implant body
  2. The preprosthetic, technique-sensitive abutment procedures
  3. The final prosthesis

The most common of all dental implant procedures is the endosteal procedure. According to CDT, procedure code D6010 includes the surgical placement of the implant body, the second-stage surgery, and the placement of the healing cap. The global aspects of this procedure code encompass all three completed subcomponents. In other words, D6010 is not completed until the implant is stable and ready to be loaded.

One question with procedure code D6010 is the concept of second stage -- or preabutment placement -- surgery.

This is the point where the doctor surgically exposes the implant head to test and confi rm the integration of the bone to the implant. At this visit, the original surgeon who placed the implant body may or may not place either a healing collar or tissue-contouring provisional abutment. This is the area of confusion because procedure code D6010 is not yet complete until the tissue surrounding the implant is structurally, as well as esthetically, ready for the actual abutment that will retain the prosthesis. Depending upon your desired implant system of choice, the second surgery may or may not be necessary. Confused yet?

With confirmation that the implant body has suffi ciently bonded with the bone, the abutment (if necessary) is now ready to be placed in anticipation of the fi nal prosthesis. The analog transfer process of selecting and/or modifying the abutment s intended path of prosthetic insertion is all part of either procedure code D6056 (prefabricated) or D6057 (custom). Also, the direct cost of any postsurgical custom impression trays, as well as soft tissue models -- along with any other miscellaneous assortment of screws, nuts, bolts, washers, gaskets, or socket wrenches -- are all encompassed within the single fee you charge for either the prefabricated or customized abutment. Remember: It's one code or the other -- never both!

This leaves us with coding, billing, and reimbursement for the final prosthesis. If the abutment, retainer and/or implant are supporting a single-unit crown, that crown will have the same fee as a more traditionally-placed crown. The same can be said for multiple units of a fixed partial denture or bridge. The fee is the same, provided you charge appropriately for either D6056 or D6057.

Getting paid

Now for the fun part -- how likely or to what extent is the benefit plan going to help the patient offset the overall cost of care? In other words, what is the benefit plan likely to cover?

Misguided are the few who seek surreptitious medical codes and bogus operative reports to disguise dental implants as anything other than what they actually are. For the dental prosthesis to be reimbursable by a benefi t plan, the administrator must know that an implant anchor is in place. Conversely, benefit dollars for implant placement will never be available unless an accompanying prosthetic benefit appears within the same global series of contractual arrangements.

You see, group dental benefi t plans have almost always paid for implant placement, as well as the restorations in conjunction with previously failed endodontic treatment. Trauma is not so much the issue as is the plan's participation in the original loss that generated the need for the intended root canal. Many a single-tooth implant and crown have been paid with benefit-plan dollars originally assigned to a three-unit bridge. The final prosthetic must be a reimbursable benefit before any surgical implant placements are considered. In other words, if there is a crown, bridge, or partial in place already, the coverage must be available to replace the prosthetic before the plan will reimburse for anything related to the implant placement.

This leads us to the actual challenge faced by both the patient and his or her benefit plan. Organized dentistry and the current system of dysfunctional coding see the implant and its final prosthetic as a three-part saga of implant placement, abutment, and the prosthetic. The benefit industry sees the same situation as only the prosthetic and whatever is holding it in place. Two segments, not three. The prosthetic crown replaces the tooth structure while the implant simply acts as the retained root. More procedure codes do not get dental offices more reimbursement.

In general, the group dental plans primarily focus on the prosthetic. Contract limitations withstanding, plans are in the business of paying for crowns. They also pay for single as well as multi surface restorations. They pay for the restoration of tooth structure to occlusal function. They couldn't care less if an implant or retained root is maintaining the crown.

Start the process by submitting the claim for the implant placement to the dental plan. Whatever the plan pays is great! That will simply be the amount that the patient is not directly responsible for paying to your office. If the plan does not pay a benefi t for the implant placement, at least the insurer knows it is in place and prosthetic benefits may now be available on behalf of the patient.

The key rule to reimbursement success is the fee for the implant-retained prosthetic is the same as the fee for a traditionally retained prosthetic. The difference in cost is reflected in the separate identification of the implant placement, as well as the abutment.

Take care and see you on the road!

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the author of "Dental Insurance and Reimbursement Coding and Claim Submission." He can be contacted by phone at (404) 252-7808. Visit his Web site at

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