By Tom Limoli Jr.
Who pays for (and profits from) the bleaching and/or whitening of teeth? Is the cost entirely the financial responsibility of the patient? What about the benefit plan? Are the profits short- or long-term?
From the perspective of the patient's benefit plan, bleaching is considered a reimbursement liability with nonvital teeth only. The dental office needs to supply the benefit plan with the completion date of endodontic treatment to confirm that the tooth or teeth are not vital. Reim bursement is made on a per tooth basis - not per quadrant or arch - in accordance with the insured's specific benefit plan and exclusionary limitations.
In most cases, the bleaching of vital teeth is considered cosmetic. However, there are benefit plans in the marketplace that cover bleaching and/or bonding for other than purely cosmetic reasons. Reimbursable liabilities include severe tetracycline staining, severe fluorosis, hereditary opalescent dentin, and amelogenesis imperfecta. When the patient presents with these clinical conditions, the third-party payer will need radiographs, diagnostic photos, and a narrative report. However, keep in mind that some benefit plans specifically exclude reimbursement for the treatments and/or correction of congenital conditions.
Enamel microabrasion (Code D9970) is identified as the removal of discolored surface-enamel defects resulting from altered mineralization or decalcification of the superficial enamel layer. It is traditionally submitted to the benefit plan on a per treatment visit basis. If - and when - this technique is employed it should be identified separately.
Prior to CDT-3, Code 05999 (unspecified maxillofacial prosthesis, by report) could have identified the custom fabrication and delivery of the bleaching gel carrier. Now, with CDT-3 and its subsequent update, the fabrication and delivery of the customized tray is considered to be part of external bleaching Codes D9972 (per arch) and D9973 (per tooth). The tray is not identified separately.
When bleaching is purely cosmetic, the associated components of the procedure usually are not reimbursable by the patient's benefit plan. To deceptively use the code number for a diagnostic cast (D0470), fluoride gel carrier (D5986), occlusal orthotic device (D7880), occlusal guard (D9940), stent, etc,. to identify the individually fabricated tray is considered to be a fraudulent and unprofessional attempt to secure money from a benefit plan. Likewise, do not identify the whitening gel with Code D9630 - other drugs and/or medicaments, by report - or Code D9910 - application of desensitizing medicaments. As with all cases of bleaching/ whitening, be upfront with the patient, as well as yourself, and anticipate limited or no reimbursement from the benefit plan.
So what is a fair fee for bleaching? For the nonvital tooth in need of either internal and/or external bleaching, an appropriate fee would have a relative value in the area of 9.69. In other words, 9.69 x (your fee for D0120). This gives us a national average fee in the range of $285.
How about the bleaching/whitening of an entire arch and/or mouth? One national franchise offers the one-visit service in the fee range of $400 to $500 for both upper and lower arches. Would this be a fair fee in your office?
Consider this: What are you doing to bring new patients into your practice? We all know that the lifeblood of every profitable dental practice is dependent on the flow of new patients. What is it that these patients want and expect from their new dentist? What didn't they get from their previous dentist?
When all is said and done, would you rather produce six bleaching cases a month at $400 each or 30 cases at $125 each? Which will have the greatest - and most profitable - return for your practice?
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.