D6000 – D6199 Implant Services
By Linda Vidone, D.M.D.
Introduction
The CDT Code’s Implant Services category is somewhat unique compared to other categories of service because it includes separate entries for procedures that address:
• Surgical placement of the implant post (or body or fixture)
• Placement of connecting components when needed
• The final prosthetic restoration (single crowns, bridges or dentures)
Once these three basic concepts of implant procedures (addressed in greater detail below) are understood, it will become less challenging and even easy to select the appropriate CDT Code to document the procedures performed.
Basic Implant
This image illustrates all components of a single implant. Please note that the connecting element (abutment) may not be present in all cases. The dentist’s clinical decision-making determines whether the implant crown will be supported and retained by an intermediary abutment, or if it may be placed directly on the implant body.
Image courtesy of Glidewell Laboratories
Implant Fixture/Body/Post
The two most common types of implant posts are endosteal and mini implants. The size and type of implant fixture determines the proper code to document the surgical implant placement procedure.
Surgical Placement of an Implant Body: ENDOSTEAL IMPLANT (D6010): Placement of full-sized implant fixture into the jawbone.
Surgical Placement of Mini Implant (D6013): Placement of mini implant fixture into the jawbone. These are smaller in diameter than full-sized implants, yet are still considered permanent. Typically used to support removable prostheses.
Images courtesy of Glidewell Laboratories
Connecting Elements for Implant Crowns and Implant Retainer Crowns
Abutments, both prefabricated and custom D6057, are the “connecting elements” that are placed, when needed, between the implant post and the restorative crown (definitive prosthesis) or retainer crown (for a fixed partial denture). Abutments are not always needed, but when placed are reported separately from the from the crown restoration.
Prefabricated Abutment (D6056): A manufactured component. The procedure includes modification and placement.
Custom Abutment (D6057): Created by a laboratory for a specific individual, usually if there are aesthetic concerns. The procedure includes placement.
Images courtesy of Glidewell Laboratories
Connecting Elements for Implant Dentures
Semi-precision Attachment Abutment (D6052): An attachment which involves placement of the prefabricated abutment to the implant post (full sized) and includes the luting of the keeper assembly (male attachment) into the overdenture.
Connecting Bar – Implant Supported or Abutment Supported (D6055): A device to help stabilize a prosthesis. Attaches to abutments or directly to the implants themselves to make the prosthesis more secure. Hader® and Dolder® bar are two types of connecting bars. Connecting bars can be designed to use other types of retentive mechanisms, such as semi-precision attachments. The entire bar is reported as a single unit; however an abutment would be documented for each implant that supports the connecting bar.
Image courtesy of Glidewell Laboratories
Implant Prosthesis (Includes Single Crowns, Fixed Bridges and Dentures)
There are two types of single unit implant crowns – abutment supported and implant supported. Selection of the appropriate crown procedure code is determined by the type of material used for the crown, and the type of attachment.
Most of us are familiar with the type of material used (porcelain, metal, etc.). However, there is some confusion when it comes to the type of attachment system used-abutment or implant supported.
Note: Both abutment supported and implant supported crowns are either cemented or screw retained, but neither method is a determining factor in code selection.
Abutment Supported Single Unit Crowns (D6058-D6064, D6094): Implant crowns that are attached to an abutment (D6056 or D6057), not directly to the implant post. The applicable abutment procedure code is submitted with the applicable single unit crown procedure code.
Implant Supported Single Unit Crowns (D6065-D6067): Implant crowns that are attached directly to the implant post; no abutment is used with this type crown.
Image courtesy of Glidewell Laboratories
Implant Supported Fixed Partial Dentures (Implant Bridges)
There are two types of implant retainer crowns: abutment supported and implant supported. Selection of the appropriate retainer crown procedure code is based on the same criteria used for single implant crowns: the type of material used and the method of attachment.
Note: Both abutment supported and implant supported retainer crowns are either cemented or screw retained, and neither method is a determining factor in code selection.
Abutment Supported Retainer Crowns (D6068–D6074 and D6194): Implant retainer crowns that are attached to an abutment (D6056 or D6057), not directly to the implant post. The applicable abutment procedure code is submitted with the applicable retainer crown procedure code.
Implant Supported Retainer Crowns (D6075-D6077): Implant retainer crowns that are attached directly to the implant post. No abutment is used with this type crown.
Implant/Abutment Supported Dentures
There are two types of implant or abutment supported dentures: removable and fixed (also known as hybrid). Implant dentures, unlike single unit crowns and retainer crowns, are NOT determined by the type of attachment system.
Denture procedure code selection is determined by two factors:
• Is the denture replacing a full or partial complement of teeth?
• Will the patient be able to remove the denture by themselves, or is assistance needed from the dentist or dental staff?
If the patient is able to remove the denture by themselves, it is a removable implant denture. If the patient is unable to remove the denture and requires the assistance of dentist or dental staff, then the denture is a fixed implant denture.
Although a fixed implant bridge and fixed implant denture appear similar, the denture’s supporting implant locations do not have a specific relationship to the missing natural teeth. This is why a fixed implant denture is referred to as a “hybrid” denture.
Implant/Abutment Supported Removable Dentures: Overdentures that are supported by implants; the patient is able remove them. These implants typically have prefabricated abutments placed, a connecting bar, and a precision or semi-precision attachment. Codes for removable complete dentures are D6110 and D6111; codes for removable partials are D6112 and D6113.
Implant/Abutment Supported Fixed (Hybrid) Dentures: Implant dentures that the patient cannot remove and are either screwed directly on the implant or connected via abutments. Codes for fixed complete dentures are D6114 and D6115; codes for fixed partials are D6116 and D6117.
Image courtesy of Glidewell Laboratories
CDT 2018
This version of the code set contains one revision and three additions in the Implant Services category. The D6081 revision affected only the descriptor, adding D4346 (scaling in the presence of generalized moderate or severe gingival inflammation) to the list of codes (procedures) that are not performed in conjunction with D6081.
D6081 scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure
This procedure is not performed in conjunction with D1110, D4910, or D4346
The first new code enables documentation and reporting of a broken screw which cannot be routinely removed. This procedure addresses the additional time and technique to safely retrieve the broken component.
D6096 remove broken implant retaining screw
The next two new codes fill a CDT Code gap and enable a dentist to report placement of interim fixed dentures for edentulous arches during a healing period. These interim prostheses procedures, reported with D6118 or D6119 as appropriate, are typically performed to maintain the patients’ esthetic and functional needs as well as to enhance the patient’s psychological well-being before proceeding to the definitive prostheses. An interim prostheses may also allow for soft tissue contouring and to help determine the design of the definitive fixed prostheses.
D6118 implant/abutment supported interim fixed denture for edentulous arch – mandibular
Used when a period of healing is necessary prior to fabrication and placement of permanent prosthetic.
D6119 implant/abutment supported interim fixed denture for edentulous arch – maxillary
Used when a period of healing is necessary prior to fabrication and placement of permanent prosthetic
When implant procedures were first introduced in CDT-1 (effective January 1, 1990) confusion arose over the term abutment, a word with different meanings within the Implants category of service and within the Prosthodontics category of service. For Implants, “abutment” was associated with the piece that connected the implant body with the restorative prosthesis. In Prosthodontics, the term was used to describe a supporting (anchor) tooth in a fixed bridge.
The current and continuing usage for the term “abutment” applies only to the piece that connects the implant body with the restorative prosthesis. “Retainer” is the term solely used to describe the anchor tooth (natural or prosthetic) for a fixed partial denture.
The CDT to ICD tables in Appendix 1 provide appropriate guidance on linkages between Implant Services procedure codes and diagnosis codes.
In some cases dental implants maybe covered by the patient’s medial carrier. Clear communication to the medical carrier is needed to explain the purpose of the implant procedure. This communication is also aided by using the CDT-ICD tables in Appendix 1 to select a diagnosis applicable to the patient’s conditions and symptoms.
Notes:
• Claims against a patient’s medical benefit plan use the AMA’s CPT procedure codes on the medical claim format.
• Medical carriers may benefit for the implant placement and necessary bone grafting, but the final restorative prosthesis is typically never a benefit.
A sample of CPT codes for implant placement and bone grafting are in the following tables:
|
Surgical Placement and Removal of Dental Implants |
|
|
Code |
Nomenclature |
|
20670 |
Removal of implant, superficial |
|
20680 |
Removal of implant, deep |
|
21248 |
Reconstruction of maxilla/mandible endosteal implant, partial (1-3 per jaw) |
|
21249 |
Reconstruction of maxilla/mandible endosteal implant, complete (4-6 per jaw) |
|
21085 |
Diagnostic/surgical stent |
|
Bone Grafts |
|
|
Code |
Nomenclature |
|
21210 |
Graft, bone, nasal, maxillary or malar areas (includes obtaining graft) |
|
21215 |
Graft, bone, mandibular areas (includes obtaining graft) |
|
0232T |
Platelet rich plasma |
|
41899 |
Nonspecific code (Used for Guided Tissue Regeneration) |
Coding Scenarios
Abutment Supported Porcelain Implant Crown Tooth #7
The patient is 30 years old with a long history of dental treatment on #7. She got hit by a ball in her mouth when she was 14 years old. The only tooth affected was #7. She had a root canal with a post and core crown placed at the time of the accident. When she was 22 years old, she had retreatment of the root canal, apicoectomy, and a new post and core crown.
The tooth is now re-infected and the dentists suspects a possible fracture. She has class 2 mobility with 7 mm pocket on the buccal, thus having a poor prognosis. The adjacent teeth are perfectly healthy with no restorations nor do they need restorations. After all options were discussed, the patient chose the best option which was a single tooth implant.
What codes would be used to document services of the treatment plan leading to the single tooth implant?
Extraction of #7 with Ridge Preservation and Insertion of a “Flipper”
D7210 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth
D7953 bone replacement graft for ridge preservation – per site
Notes:
• Bone in this area is thin, therefore it is imperative that the ridge be preserved.
• This procedure is also referred to as “socket preservation” with the placed in the extraction site at the time of the extraction to preserve the size and shape of the bone.
D4266 guided tissue regeneration – resorbable barrier, per site
Note: The D7953 procedure does not include placement of a barrier membrane to prevent tissue from invading the bone graft site and there is no separate code for a membrane with ridge preservation. D4266 is used to document placement of the barrier membrane.
D5820 interim partial denture (maxillary)
Implant Placement Surgery and Second Stage Surgery
Note: The implant post is surgically placed and followed by second stage surgery six months later.
D6010 surgical placement of implant body: endosteal implant
D6011 second stage surgery
Final Restoration – Custom Abutment and Abutment Supported Porcelain Crown
Note: In this case, esthetics were a concern. A custom abutment was placed due to angulation concerns and final material chosen was porcelain since the patient has a high smile line.
D6057 custom abutment placed
D6058 abutment supported porcelain/ceramic crown
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