Dental Insurance Reimbursement and Documentation For E4D® Restorations

In restorative cases, the utilization of chairside or lab fabricated CAD/CAM restorations are equivalent to reporting conventionally fabricated metal-free restorations (ceramic and composite) using other methods. Utilizing the correct codes (CDT – Current Dental Terminology) is now mandatory on all insurance processing and helps ensure proper claim adjudication. In order to file insurance efficiently, the doctor and business assistant must develop appropriate insurance documentation/ justification scenarios. In general, ceramic onlays, 3/4 crowns and full crowns are reimbursed with appropriate documentation.

Patient education as to the uniqueness and benefits of E4D® should be discussed chairside by the doctor and staff. The digital camera, intraoral camera, GURU (patient education) and E4D® all go hand-in-hand. With the intraoral and/or digital camera, the doctor should take photographs and x-rays to accompany the insurance claim, along with an in-depth narrative to build a strong case for reimbursement.

Explaining to patients that insurance coverage is merely supplemental, and that the longer-lasting treatment is worth the extra out-of-pocket expense, will counter most concerns. The economic decision for coverage by insurance companies is not based on what is necessarily best for the patient clinically or esthetically, but on the level of benefits the employer purchases. Understanding these dilemmas and indoctrinating the staff on proper insurance protocol of codes and narratives will lessen the continual battle between the practice, patient and insurance company.

Insurance Reimbursement for E4D® Restorations

Unfortunately, it is the case that insurance companies may not always reimburse conservative (tooth saving) techniques at the same level as more aggressive C&B procedures (full coverage) despite the fact that the materials and techniques require the same or greater effort on the part of the clinician/office team and actually provide the patient greater benefits. Most dental insurance policies will reimburse indirect intracoronal restorations at a comparable direct (composite or amalgam) rate. On the other hand, most dental insurance policies do reimburse ceramic onlays, ceramic full crowns, and 3/4 ceramic crowns. Ceramic and resin-type veneers are considered

Explaining to patients that insurance coverage is merely supplemental, and that the longer-lasting treatment is worth the extra out-of-pocket expense, will counter most concerns.

“cosmetic,” so generally expect no insurance reimbursement. However, replacing failed veneers may have a chance for reimbursement under some insurance contracts. For the private pay patient, insurance reimbursement policies are immaterial.

Documentation for E4D® Restorations

For E4D® or other indirect restorations, dental insurance reimbursement may be enhanced and delays reduced with excellent documentation. A pre-op X-ray and photo of the tooth may be provided, along with a photo of the prep. This documentation, along with the narrative, should be filed initially with each E4D® restoration for payment, greatly reducing hassles, delay, requests for additional information, etc. Expect headaches without an intraoral camera or digital camera for documentation! Photos often reveal problems that X-rays do not. Submit photos routinely.

One of the unique aspects of utilizing the E4D® Dentist system, besides being able to provide same day indirect restorations, is the fact that each scan made by the E4D® System, whether preoperative or preparation, is saved to the hard drive as a small thumbnail, which can be used to further document the procedure for patient records or insurance justification.

Get an intraoral camera and don’t delay this purchase! Intraoral photos (D0350) are generally not reimbursable – exception, orthodontic records. They are a “cost” of doing business that yields a tremendous profit.

A narrative should generally be provided that discusses fracture and decay, plus any missing, undermined, or fractured cusps. If a photo is included, describe what is seen as supplemental to that seen in the X-ray. For onlays, always mention “capping the cusp(s)” in the narrative. According to the description in the CDT 2010 ADA Glossary (page 212), an onlay requires “restoring one or more cusps and adjoining occlusal surfaces or the entire occlusal surface.” Thus, an MOD is not an onlay – it must include a facial and/or lingual cusp in its description. For example, an MODFL or MOL would be a validly reported onlay. A general rule of thumb is “if the tooth needs a crown, then an onlay will be probably be reimbursed.”

Dental Codes For The E4D® Block Materials

Ivoclar Vivadent® and 3M ESPETM manufacture the ceramic and composite blocks for the E4D® System. Milling prefabricated blocks have the advantage over other methods of fabrication for metal-free as they insure the homogeneity of the material through and through and are not subject to many of the variables of hand-stacking, pressing or fabricating restorations by hand. Each type of manufactured block has its own distinct properties, clinical advantages and application.

The Ivoclar Vivadent IPS Empress®, CAD, IPS e.maxTM CAD and 3M ESPE ParadigmTM C blocks are all considered “ceramic” as reported under CDT 2010:

CDT Code

Clinical Procedure

D2610

1-surface ceramic inlay

D2620

2-surface ceramic inlay

D2630

3+-surface ceramic inlay

D2642

2-surface ceramic onlay

D2643

3-surface ceramic onlay

D2644

4+-surface ceramic onlay

D2783

3⁄4 ceramic crown

D2740

Full ceramic crown

D2962

Porcelain (ceramic) veneer

3M ESPETM also manufactures the Paradigm MZ100 (polymer reinforced) block which is considered to be “resin-based.” CDT 2010 defines resin as “refers to any resin-based composite, including fiber or ceramic reinforced polymer compounds.”

Reimbursement-wise, a small percentage of insurance contracts specifically exclude the resin-based, composite restoration as a material. In addition, some contracts reimburse a lower fee for the resin-based restoration compared to the ceramic restoration’s fee.

The 3M ESPE Paradigm MZ100 is considered “resin-based” as reported under CDT 2010:

CDT Code

Clinical Procedure

D2650

1-surface resin-based inlay

D2651

2-surface resin-based inlay

D2652

3+-surface resin-based inlay

D2662

2-surface resin-based onlay

D2663

3-surface resin-based onlay

D2664

4+-surface resin-based onlay

D2710

Resin-based crown

D2712

Resin-based 3⁄4 crown

D2961

Resin-based veneer

How To Profit From Inlays

As previously mentioned, the reimbursement level of inlays may be lower compared to onlays or full coverage restorations. Often, the equivalent of an amalgam or composite fee is reimbursed for an inlay. Thus, many patients are reluctant to pay a large amount “out of pocket” for inlays, and dentists rarely mention them for this reason. There is a profitable strategy for E4D® inlays, however. Typically, the E4D® crown, 3/4 crown and onlay are priced at the level of a conventional lab-fabricated restoration ($895 - $1,095). If the volume of these higher-fee restorations “cover” the monthly payment, then the only additional cost to fabricate and deliver chairside inlays is the direct (fixed) cost of about $30/unit (burr, block, materials).

Thus, the concept of the “lower-fee” E4D® inlay strategy may be utilized: The long-lasting inlay is offered as an alternative to the amalgam/composite at a lower fee, say $450. If the materials are $30, the net gross profit is $420. If the dentist will delegate and work with two assistants, the dentist’s chair time for E4D® will be equal or less than an amalgam.

composite restoration. One of the assistants can work on the imaging, designing, milling and making small occlusal and interproximal adjustments outside the mouth. Thus, the dentist only preps the tooth and bonds the inlay to place. Meanwhile, the dentist produces with the other assistant elsewhere. “Lower-fee” inlays will be quite profitable if the dentist is willing to train/utilize/delegate the dental assistant properly. Many patients will accept inlay treatment if they only pay the fee difference of $450 and the regular amalgam/ composite reimbursement fee. The patient’s out-of-pocket could be less than $200 for an inlay with some plans. Thus, the patient is grateful for a single appointment and long-lasting inlay at an affordable price, while the dentist makes a substantial profit offering the best conservative dentistry available. It’s even more profitable if the inlay is fabricated in conjunction with other E4D® restorations in the same quadrant.

Shouldn’t You Consider Chairside CAD/CAM Technology?

The E4D® Dentist is economically viable for most restorative practices. The economics of a one-visit restoration plus the capacity of “same day dentistry” is compelling. The capital cost of the E4D® is often more than offset by a reduction in the fabrication fees, an increase in upgrading direct restorations and the increase in new patients wanting this type of technology. With the addition of inlays and onlays to the clinical service mix, even more additional profits are available while providing the best in patient care.

Dr. Charles Blair’s consulting services include insurance, fee and procedure mix consulting. He is a highly sought after speaker for dental meetings and conventions nationwide. Dr. Blair is available to work with E4D® users regarding specific strategies, coding and, fees. Proper insurance coding and proper alignment of fees in the practice is all important. Dentists are unaware of their many mistakes, which often leave $100 to $500 a day “on the table!” Most dentists can “get a complimentary E4D®” with Dr. Blair’s Revenue Enhancement Program, plus a $115,000 tax deduction! For further information, call 866.858.7596 or email info@drcharlesblair.com.

Insurance & revenue content discussed in this article applies to US based practitioners only