| Subject | DENTAL IMPLANT CODING: A CLARIFICATION |
| Source | AAOMS Newsletter |
| Publication | Coding Corner May/June 2009 |
| Effective Date | May 31, 2009 |
| Publish Date | May 31, 2009 |
Dental Implant Coding: A Clarification
The American Dental Association's Current Dental Terminology (CDT) includes codes to describe the placement of dental implants. The one most commonly used is:
D6010 surgical placement of implant body; endosteal implant
Includes second stage surgery and placement of healing cap
This code is to be reported per implant placed, by listing the code the appropriate number of times and indicating the tooth number in the appropriate column of the dental claim form.
The American Medical Association's Current Procedural Terminology (CPT) also includes codes to describe placement of dental implants. Those most frequently reported are:
21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder);
partial
21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder)
complete
While neither the CPT Manual nor CPT Assistant specifically define partial v. complete, the difference between these two terms is taught in the AAOMS Coding Workshops. Below is the relevant excerpt of the manual:
Partial is interpreted as the restoration of three or less teeth or less than ½ of the dental arch. As compared, complete is the restoration of four or more teeth or more than ½ of the dental arch. These codes include the surgical placement of the implant device and the second procedure to expose the implant and abutment posts. If healing posts are not provided, reduce the procedure with modifier -52.
Attendees are instructed to report the total number of implants actually placed in the "units" column of the claim form and adjust the fee accordingly. A problem arises, however, when a carrier pays the code at one flat rate, regardless of the total number of implants placed.
For instance, some carriers follow the AAOMS instruction advising OMSs to report either 21248 or 21249 one time, indicating the total number of implants placed in the "units" column of the claim form and the total fee for that number of implants. For instance, if placing two implants, one would report 21248 once, indicating two units of service and the total fee for two implants.
On the other hand, some carriers instruct OMSs to report either 21248 or 21249 just one time, disregarding the total number of implants indicated in the "units" column assuming that the procedure includes multiple implants by definition. For example, if placing twelve implants, one would report 21249 with a flat fee for four or more teeth or more than ½ of the dental arch. Using this method, whether an OMS were to place twelve implants or just four, 21249 would be the only code reported, units would be disregarded, and the OMS would be reimbursed at the same rate for both claims.
According to coding guidelines, codes must be reported to the highest degree of specificity. The CDT codes for dental implants most appropriately describe the service as rendered by OMSs. As such, the AAOMS Committee on Health Care and Advocacy recommends the reporting of dental implants to both medical and dental carriers alike using the CDT / HCPCS codes of D6010, D6040 or D6050 as appropriate. By following this recommendation, the potential to prevent variances in carrier interpretation of the CPT codes for this service is optimized and therefore the manner in which they are to be reported and subsequently adjudicated.
Both CDT and HCPCS (the Health Care Procedure Coding System) are recognized as official code sets under the Electronic Transaction and Code Set Standards of the Health Insurance Portability and Accountability Act (HIPAA). As such, a medical carrier stating a D code is "invalid" on the medical claim form is technically in violation of HIPAA and can be reported to the Centers for Medicare and Medicaid Services' (CMS) Office of HIPAA Standards. Members reporting CPT dental implant placement codes to medical carriers without incident, meaning those who are having their claims properly adjudicated and reimbursed, should not feel the need to alter current reporting. However, this recommendation can be implemented by those who submit to carriers that do not interpret the CPT codes in the same manner as the AAOMS.