Records, Risk and Reimbursement

Placement of implants - and restorations associated with them - are becoming more and more mainstream. In the past, insurance coverage of implant services was disappointing. Now, implants are a benefit of many plans, with common restrictions being the maximum allowable benefit per person, per year, and replacement once in a five-year period. ADA codes reflect the dual nature of many implant procedures and describe both surgical services and abutment placement.

Carol Tekavec

Placement of implants - and restorations associated with them - are becoming more and more mainstream. In the past, insurance coverage of implant services was disappointing. Now, implants are a benefit of many plans, with common restrictions being the maximum allowable benefit per person, per year, and replacement once in a five-year period. ADA codes reflect the dual nature of many implant procedures and describe both surgical services and abutment placement.

Endosteal Implants (also known as Endosseous Implants)

Code 06010-Surgical Placement of Implant Body: This new code describes the surgical procedure and placement of the healing cap.

Code 06020-Abutment Placement or Substitution, Endosteal Implant: This new code was designed to facilitate claims-reporting by a dentist, other than the dentist placing the original implant. Abutments may include removal of a healing cap or replacement of the original.

Eposteal Implants (also known as Subperiosteal Implants)

Code 06040-Surgical Placement, Eposteal Implant: This revised code describes a framework of material, designed to fit on the surface of the bone, with permucosal extensions to provide attachment of a prosthesis.

Transosteal Implants

Code 06050-Surgical Placement, Transosteal Implant: This code describes a device with threaded posts, penetrating mandibular superior and inferior cortical bone. Portions of the implant extend through the permucosa to support a prosthesis.

Implant-Supported Connecting Bar

Code 06055-Dental Implant-Supported Connecting Bar: This code is used to describe a connector between abutments, used to stabilize a removable overdenture. It is a separate code for a separate service, not inclusive with the placement of the implants and abutments needed. This code also does not include additional overdenture attachments or connectors, needed for use with the subsequent removable overdenture.

Code 05860-Overdenture-Complete, By Report, is the appropriate code for an implant-supported overdenture. The dentist`s fee should include any additional attachment costs as a part of the overdenture fee, as there are no separate costs for these. (Note: Code 05862-Precision Attachment, By Report, describes each set of male and female components in one precision attachment, used in a partial overdenture. Partial overdentures may require several of these. If the precision attachments are primarily for esthetics, typically no benefit will apply. If the attachments are needed for function, some benefit may apply. A detailed report, describing what type of attachments are being used and why they are needed, is essential. Even with such a report, most insurers will pay for only a standard partial.) If endodontic therapy is required for roots retained to help support a complete overdenture or partial overdenture, such treatment usually is not a benefit.

Implant Maintenance and Removal

Code 06080-Implant Maintenance Procedure: This code describes the removal of any prosthetic device and the cleaning of the device and the underlying implant abutments. It essentially is a prophylaxis for implants and includes the general examination of all parts of the implant system. Home-care instructions are considered all-inclusive. If the implant maintenance is done at a separate appointment from a general appointment (i.e., Code 01110-Prophylaxis-Adult or Code 04910-Periodontal Maintenance Procedure), this code should be used when filing for benefits. If the maintenance is done in conjunction with either of these other procedures, a separate benefit is unlikely. Most insurance companies will provide a "cleaning" benefit only twice per year, regardless of the dental necessity. The "cleaning" may be a Code 04910, 01110, or 06080. The 01110 would be a benefit before any applicable deductible, while the other two (Codes 04910 and 06080) would be after the deductible.

Code 06100-Implant Removal, By Report: This is used to describe the surgical removal of any implant. The narrative should include the original date of placement, reasons for implant failure, and treatment performed. Correction of resulting bony defects, following the removal of an implant, should be coded separately.

Dental implants are a covered benefit of many contracts. The patient`s employee-benefits booklet will detail the parameters of the patient`s reimbursable treatment. Even if treatment is considered to be medically/dentally necessary, such treatment is not payable automatically by a plan. If the patient`s contract specifically excludes implant procedures, then all such procedures will be excluded. If a patient`s contract includes prosthetic benefits, with no specific exclusion of implants, some implant reimbursement may be possible. When implants are indicated, they may fall under a "pre-existing condition" clause. While such clauses are not as common as they once were, some plans still require that for a replacement to be covered, at least one of the missing teeth to be replaced must have been lost or removed while the patient was covered by the plan. Patients requiring multiple implants might receive better benefits if the implants are "phase-treated," so the maximum benefit per year is respected, with the patient still receiving the best treatment.

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.

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