For an updated version of this coding information, visit DentistryIQ.com and read Coding with Kyle: Codes for porcelain and ceramic onlays, written by dental office manager Kyle Summerford.By Carol Tekavec
Dentists and staff wonder why dental benefits for crowns, bridges, inlays, onlays, CEREC fabricated units, and other types of computer-assisted restorations are so limited. They wonder if there are some little known codes they might use on patient claims that could provide better results. Are there "special" codes for CAD/CAM restorations? What is the real story on coding for replacements?
Typical insurance guidelines for benefits
• Most carriers will reimburse patients for anterior or bicuspid porcelain/ceramic or resin crowns with no alternative benefits requirement. What is an alternative benefit? The carrier pays toward a less expensive, but "adequate" service, such as an all-base-metal crown instead of a porcelain/ceramic crown. The patient is typically liable for the amount not covered. However, if the dentist is a contract provider for the insurance carrier, the patient may only have to pay "up to" the carrier's listed fee, not the dentist's usual fee, for the service the patient received. Why is this? Because most dentist/carrier network contracts stipulate guidelines for fees.
• Molar teeth, with the exception of maxillary first molars, may be considered ineligible for "tooth colored" crowns. This means that the carrier will only pay toward a base metal crown. In general, most plans cover crowns at a 50% or "Major Procedure" level.
• The "delivery date" of a crown may be important for payment by a patient's plan. Many carriers now ask for both a prep date and a cementation date on the claim form. This is so the carrier can verify that a patient was covered during the time the crown was prepared and cemented. The patient's contract will specify which, or both, date requirements. If the dentist is a contract provider, his/her network contract will also spell out date stipulations.
• Most carriers require that at least four or more surfaces of a tooth be involved with decay, fractures, or broken cusps for a "crown" benefit to apply.
• Endodontically treated teeth are routinely accepted for crown benefits.
• If a crown is needed for a cracked tooth, a narrative in Section No. 35 Remarks on the claim form can be helpful. If the tooth is painful, include this information as well. Attaching a photo can also speed payment. (Note: Sometimes mailing or e-filing photos, radiographs, perio charting, or narratives to plans that do not "want" them can actually delay claims. Often the carrier's Web site can provide information about attachments. For an annual fee, other Internet sources for attachment information may be accessed by dentists.)
• Defective crowns must usually have been in place for five to seven years to be eligible for payment on replacement. Put the date of the original crown placement on the claim to avoid payment delays.
• Facial veneers may be covered if they are needed to correct decay or replace existing defective restorations that have open or decayed margins. Veneers placed for cosmetics are rarely covered by any plans.
What codes can we use, and how might they be paid?
The ADA coding system undergoes updating and revision every two years. This is under the jurisdiction of the ADA, with changes made as a cooperative effort of the dental profession and the dental insurance industry. The Code Revision Committee was established in 2001 with representatives of both the profession and insurance carriers. The Committee accepts change requests during an ongoing schedule of reviews which can be viewed at www.ada.org.
The current code in use is the CDT-2007-2008. The next edition will be for 2009-2010. There are no "other" dental codes for use in reporting dental treatment. Insurance companies may not use codes of their own devising. Everyone must use CDT codes.
Crowns, bridges, veneers, inlays, and onlays are covered by CDT-2007-2008 procedure codes. Some of the codes take into consideration the material used — for example, resin-based composite, porcelain/ceramic substrate, porcelain-fused-to-high-noble-metal, etc. — but do not reflect "technique." Just as there are currently no codes to describe providing any service by means of a laser, there are no designated codes to describe manufacturing a crown or other restoration by means of computer-aided technology, such as CEREC.
An inlay is currently defined by the ADA as an intracoronal (within the cusps of the tooth) restoration made outside the mouth to correspond to the form of the prepared cavity. It is then cemented or light-cured into the tooth. An inlay restores portions of a tooth that might also be restored using amalgam or composites in a direct technique.
An onlay is defined as a restoration made outside the mouth that replaces the cusp or cusps of a tooth. It is also cemented or light-cured onto the tooth. An onlay incorporates portions of a tooth (within the cusps of a tooth) that might correspond to areas also commonly restored using amalgam or composites or by using an inlay, with the addition of a cusp or cusps. It is not considered correct to report an inlay code along with an onlay code. The onlay code is inclusive of the inlay. Inlays are usually paid by carriers at the least expensive alternative treatment fee, frequently comparable to the fee for an amalgam.
Depending on the cusp involvement, onlays may be a paid benefit with no alternative clause; typically at 50 percent of the insurance carrier's fee schedule or maximum allowable benefit. Many carriers require that two or more cusps of a tooth be involved in the onlay and may specify how much of the cusp incline must be involved (usually 80 percent or more) in order to qualify for a benefit. When the decay or fracture involvement of a tooth would be sufficient to generate a benefit for a crown, then an onlay may also qualify.
A veneer is defined as a thin covering of the facial surface of a tooth used to restore discolored, damaged, misshapen, or misaligned teeth. When also used to correct decay, a veneer may be covered at a 50 percent or sometimes 80 percent level of a plan.
A crown is defined as a restoration covering or replacing the major part or the whole of the clinical crown of a tooth. Crowns are usually covered at a 50% or 80% level of a plan.
Inlays and onlays are currently reported using codes D2510 to D2664. Crowns are reported using codes D2390 and D2710 to D2799, including those made with indirect composite. Veneers are reported using codes D2960 to D2962. Any restoration that does not "fit" a designated code description should be reported using D2999 with a narrative. (The "99" codes are typically flagged for review, which may delay a patient's claim; however, after review, the claim may qualify for payment.)
Note: CAD/CAM dentists should be aware of the current indirect resin-based composite restoration codes. Indirect resin-based composite restorations, either inlays or onlays, may be reported with codes D2650 to D2664. For indirect resin crowns: D2710-Crown-Resin-Based-Composite-Indirect, and D2712-Crown-3/4-Resin-Based-Composite-Indirect may be used.
CAD/CAM style restorations may include slightly different variations of expected restorative configurations. For example, computer-assisted design techniques may mention an "overlay." Currently there is no code or separate definition for an "overlay" in the CDT 2007-2008. The word "overlay" is mentioned in the ADA definition for an onlay.
However, dentists using computer-assisted technology may use the word "overlay" to describe a restoration replacing the MDFO surfaces of a tooth. What codes might be used for this type of restoration? D2712-Crown-3/4-Resin-Based-Composite-Indirect, D2783-Crown-3/4-Porcelain/Ceramic, or D2999-Unspecified-Restorative-Procedure, by report.
Some have suggested that a separate section of codes be developed by the Code Revision Committee to reflect the unique nature of CEREC and other computer-assisted design restorations. Some have suggested that with the increased expense of CAD/CAM technology, an increased reimbursement from benefit plans should follow.
However, if separate "computer-assisted" codes were developed, the reverse would likely be true. Without the expense of a lab fee, due to computer-assisted design crowns, etc., being fabricated "in-house," the argument might be that reimbursement for these restorations should actually be less (although some labs also use CAD/CAM technology). As of this writing, no new codes for computer-assisted technology crowns have been planned, which does not mean that they might not be created in the future. For example, in the report "February 2007, Summary of CRC Actions" four new codes were suggested by the profession; two codes for multisurface inlays, and two for multisurface onlays, using an indirect resin composite. The Summary Report states that the suggestion was declined due to current materials development making new codes unwarranted, plus the fact that the request had not indicated an increased frequency of use. If frequency increases, will the CRC deem the new codes justified?
Crowns and lead contamination in the news
During the month of February 2008, several news organizations picked up on a story concerning dental crowns fabricated in overseas laboratories that tested positively for lead. (According to the ADA Statement on Safety Concerns With Dental Crowns, there is no appropriate use for lead in manufacturing dental prosthetics.)
Three years ago my Dental Economics® column for May 2005 mentioned the problem of unregulated overseas labs. According to some sources, in 2005 as much as 10 percent, or a possible 4 million units per year, of U.S. laboratory work was being accomplished at offshore locations. Dental labs may ship to a U.S.-based broker laboratory that sends the work offshore, or they may ship cases directly to an overseas lab. Sometimes dentists themselves send work directly overseas.
While being outsourced does not necessarily mean inferior or dangerous, the fact remains that there is no way to monitor what is going into restorations and replacements made outside the United States.
Therefore, it is up to individual dentists to require their own dental labs to certify where a restoration has been fabricated. The ADA House of Delegates in Resolution 83H-2005 called for the ADA as an organization to urge the U.S. Food and Drug Administration to require that a subcontracting dental laboratory notify dentists in advance when any components or materials are either partially or entirely made in a foreign dental laboratory. (According to the ADA News Today, online at www.ada.org posted May 19, 2006, FDA labeling regulations currently require that a finished case be labeled with a foreign dental laboratory's name and address.)
With increased publicity, it is expected that more patients will inquire as to the location and "ingredients" of their restorations. Dentists who fabricate crowns and other replacements "in-house" may, therefore, now have a new avenue of education and marketing for patients. Dentists who use dental labs may likewise provide their patients with documentation for a local laboratory or FDA material approved offshore lab. (For more from the ADA on crowns and lead content, see the March 3, 2008, issue of ADA News, in print.)