by Carol Tekavec, RDH
Loss of teeth results in atrophy of remaining alveolar bone. In the first three years following tooth extractions, there is a loss of 40-60 percent in bone volume. After that, bone is lost at a rate of .25 percent to .5 percent per year for the life of the person.
The resulting deformity can lead to impaired chewing and speech, soft-tissue pain, and muscle dysfunction. In addition, a patient may not have sufficient bone or soft-tissue support for prosthetic replacements.
Many dentists are beginning to use various bone-grafting materials for augmentation of these bony defects. One type of bone graft is done with organic materials composed of living tissues that can encourage bone formation. Also used for bone-graftings are nonbiological "scaffoldings" that encourage bone growth across their surfaces. Some of the defects that can benefit from grafting include trauma or surgery defects, bone loss due to periodontal disease, general alveolar deterioration, and extraction sites. Grafts provide a matrix for bone growth in defective areas, as well as filling in extraction sites to preserve the height and width of the alveolar ridge. They also are commonly performed to improve the success rates of implants, such as in connection with the immediate post-extraction implant. Grafts may be combined with various types of guided-tissue regeneration (GTR) or they may be done without them.
Bone-grafting and ridge augmentation can greatly improve the aesthetics and function of crowns, implants, and dentures, as well as eliminating future problems that are common to bone loss situations. Bone-replacement grafts in the aesthetic, anterior region can preserve ridge topography for the health and appearance of fixed bridgework.
While few can argue about the benefits of bone-grafting, insurance payment for these procedures is limited. Many carriers will not pay a benefit toward guided-tissue regeneration or bone-grafting on "routine" posterior extractions. If the extraction is done in conjunction with a proposed implant — and implant services are a benefit of the patient's contract — some payment may apply. (Keep in mind that implant services typically run over the annual limits of $1,000-$1,500 a year for most dental plans.) In addition, many insurers will cover anterior socket bone-grafting, but not posterior sockets. ADA codes that may apply to bone replacement grafts include:
D4263-Bone Replacement Graft — "Procedure involves the use of osseous autografts, osseous allografts, or nonosseous grafts to stimulate bone formation or periodontal regeneration when the disease process has led to a deformity of the bone."
D7950 — Osseous, Osteoperiosteal, or Cartilage Graft of the Mandible or Facial Bones — "Includes obtaining autograft and/or allograft material. This code may be used for a ridge augmentation and/or sinus lift procedure."
D7955 — Repair of Maxillofacial Soft- and Hard-Tissue Defect — "Procedures may be used ... to augment or repair the defect and restore anatomic structure to required form and function." Note: This code is proper for ridge augmentation or "plumping," but is not considered appropriate when used on the same claim form as any tooth extractions.
These codes do not include GTR (D4266 and D4267), which can be coded separately. However, if GTR is used, most patient contracts exclude a separate benefit. With any of the codes, the use of a brief narrative written directly on the claim form is advised.
If no dental benefit is available, oral and maxillofacial surgical procedures may be covered under a patient's medical plan. When filing a medical claim, be sure to use a standard medical HCFA form, as well as ICD Diagnosis codes and CPT Treatment Codes (manuals and forms are available from the American Medical Association). Indicate that medical and dental insurance are being applied for in the appropriate sections of the claim forms.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.