All codes in the 2100 and 2300 sequence are considered to be chairside procedures utilizing the direct technique. Direct restorative procedures are defined as those performed directly on a tooth without the use of a dye. These codes differ from a D2710, laboratory-processed resin crown, in that they are directly constructed in the mouth. The exclusionary period for these procedures is usually limited to 36 months as opposed to 60 months for D2710s.
According to the ADA, an amalgam restoration (including polishing) is a tooth preparation in which “all adhesives (including amalgam bonding agents), liners, and bases are included as part of the restoration. If pins are used, they should be reported separately.”
The ADA says “resin-based composite refers to a broad category of materials, including, but not limited to, composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid-etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, they should be reported separately.”
Third-party payers contractually reimburse only for completed procedures and restorations. They do not reimburse for individual subcomponents or techniques required to complete the procedure. With bonded amalgam restorations, the bonding is nothing more than the technique used to complete the procedure. As such, the procedure would simply be coded as the completed procedure. The additional cost of the bonding agent should be reflected in your total fee charged for the restoration.
I do not recommend separate fees for bonded and non-bonded restorations. When calculating your usual fee for the procedure, examine the number of bonded and nonbonded restorations which you routinely perform. Your single fee should address both restoration techniques.
A restoration completes the external anatomical outline form of a tooth that is subject to oral bacteria and forces of mastication. Cavity liners and cement bases have no such function. Keep in mind that benefit plans rarely, if ever, reimburse for cavity liners or cement bases, so don’t hold your breath waiting for a check from the insurance company.
Most third-party payers do not consider preventive resin restorations (PRR) to be restorative procedures or reimbursable benefits. They are considered sealant procedures. Preventive resin restorations are not appropriately reported with Code D2391. Unfortunately, Current Dental Terminology does not yet specifically address the PRR technique. The CDT does specifically dictate that a restoration is not to be classified as such unless the outline form extends completely into the dentin. If the entire floor of the cavo-surface margin is not in dentin, the procedure is to be classified as a sealant using Code D1351.
The description for D2391 specifies, “Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure.”
Porcelain/ceramic, as well as resin, has finally been redefined. According to the ADA, “Porcelain/ceramic refers to those nonmetal, nonresin inorganic refractory compounds, processed at high temperatures (600° C / 1,112° F and above), and pressed, polished or milled - including porcelains, glasses, and glass-ceramics. Resin refers to any resin-based composite, including fiber or ceramic reinforced polymer compounds.”
Payers and plan administrators usually do not reimburse for provisional restorations, particularly if the work is performed for cosmetic reasons or to increase vertical dimension. In some cases, the dentist’s treatment plan may involve a combination of services, including restorative and periodontal care. Standards of care indicate that provisional interim treatment crowns be used.
The main criterion for provisional reimbursement is based on the fact that the laboratory-processed (indirect) resin crown (Code D2710) is only an interim crown for a designated period of time (e.g., 90 days, 120 days, 11 months and 29 days). If the permanent crown is not delivered in occlusion within the specified time period, benefits for the permanent crown become unavailable until the exclusionary period has expired. In other words, the interim crown becomes the permanent crown, and now must function for the duration of the exclusionary period stated in the contract.
Provisionals should be paid for by the patient or incorporated within the fee for the final restoration. If the benefit plan pays for provisionals, they usually are considered part of the permanent restoration. If, by chance, the benefit plan reimburses for provisionals, then that fee will generally be deducted from the amount paid for the final restoration.
Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of “Dental Insurance Today,” a bimonthly publication that addresses third-party reimbursement in the dental office. He also is 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 www.LIMOLI.com.