All-on-4® procedures have revolutionized the restoration of severely compromised and/or hopeless dentition. This procedure is named for the fact that all teeth in the arch are supported by four dental implants. Typically, two anterior implants are placed in a straight position and two posterior implants are placed in a tilted position. It is a technique used for patients who are completely edentulous or have a severely compromised dentition. The restoration is fixed in place with screws, as opposed to snap on removable overdentures which utilize semi-precision attachments.
This article lays out a suggested process and coverage criteria for many of the procedure codes used in an All-on-4® process.
All-on-4® Suggested Process
- Exam (D0140, D0150, or D0160)
- CT Scan (D0365-D0367; D0381-D0383)
- Diagnostic Casts (D0470)
- Case presentation (D9450)
- Treatment simulation using 3D image (D0393)
- Impressions for surgical stent (D6190) and interim denture** (D6118, D6119)
- Photos (D0350)
- Extractions (if necessary) (D7140, D7210, D7250)
- Implant placement (D6010)
- Bone grafts at time of implant placement (if necessary) (D6104)
- Interim denture inserted
Follow up Visits (number and sequencing per Dentist’s discretion)
Fourth Visit (approximately 24 weeks after 3rd visit)
- Impressions for final denture (D6114, D6115)
- Interim denture removed
- Implants inspected and cleanded
- Final denture inserted
**If patient already has an existing conventional denture that will be used as the interim denture, ADA code D5875 can be substituted for D6118/D619. After modification of the existing denture, a reline may be necessary. A reline procedure can be reported using D5730 or D5731 (direct relines), or D5750 or D5751 (indirect relines).
- Once the prosthesis is delivered, subsequent periodic maintenance is described using code D6080, implant maintenance procedures when fixed prostheses are removed and reinserted. D6080 includes the cleansing of the fixed prostheses and abutments and is reported only once when performing implant maintenance for both the upper and lower arch. Note that the descriptor makes it clear that the prosthesis must be removed and reinserted, and that D6080 includes the cleaning of the prosthesis and the abutments.
- If the All-on-4® restoration is only for one arch and natural teeth are in the other, adult prophylaxis D1110 could also be reported. Note that D1110, D120, and D4910 now include cleaning any implant crowns in the arch as well.
- If the prosthesis is damaged, D6090 describes the repair of an implant supported prosthesis, by report, as needed, and includes the replacement of any part of the prosthesis. D6090 is a broad code that can be reported for various types of repairs and replacement parts of the implant support denture. Keep in mind that D6090 is a “by report” code and requires a narrative describing the procedure performed.
- Should the abutment associated with the All-on-4® prosthesis be damaged, D6095 reports the repair of the implant abutment, by report, as needed. D6095 also includes the replacement of any part of the abutment, such as a screw used to affix the abutment to the implant body.
- If a screw is damaged and must be removed, D6096 describes the removal of the broken implant retaining screw. This is true for a screw used to attach an abutment to the implant body or a screw used to affix an implant supported denture directly to the implant body.
All-on-4® Billing - Delta Dental Policy and Based on Group Contract
|D0120||Periodic oral evaluation - established patient||2 per benefit period|
|D0120||Periodic oral evaluation - established patient||2 per benefit period|
|D0150||Comprehensive oral evaluation – new or established patient||Benefit once per dentist/dental office|
Detailed and extensive oral evaluation - problem focused, by report
|Benefit once per dentist/dental office|
|D0350||2D oral/facial photographic image obtained intra-orally or extra-orally||Generally, not a covered benefit|
|D0365||Cone beam CT capture and interpretation with field of view of one full dental arch – mandible||Generally, not a covered benefit|
Cone beam CT capture and interpretation with field of view one full dental arch – maxilla, with or without cranium
|Generally, not a covered benefit|
|D0367||Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium||Generally, not a covered benefit|
|D0393||Virtual treatment simulation using 3-D image volume or surface scan||Generally, not a covered benefit|
|D0470||Diagnostic casts||Generally, not a covered benefit|
|D9450||Case Presentation, detailed and extensive treatment planning||Generally, not a covered benefit|
|D9950||Occlusion analysis – mounted case||Generally, not a covered benefit|
|D6010||Surgical placement of implant body: endosteal implant||Once per tooth every 5 years or per contract|
|D6011||Surgical access to an implant body (second stage implant surgery)||
Considered part of D6010 and fees are Not Billable to The Patient (NBTP)
|D6190||Radiographic/surgical implant index, by report||Generally, not a covered benefit|
Interim Restorations (if the definitive restoration is not delivered immediately)
|D5730||Reline complete maxillary denture (direct)||2 in 12 months|
|D5731||Reline complete mandibular denture (direct)||2 in 12 months|
|D5750||Reline complete maxillary denture (indirect)||2 in 12 months|
|D5751||Reline complete mandibular denture (indirect)||2 in 12 months|
|D5810||Interim complete denture – maxillary||Generally, not a covered benefit|
|D5811||Interim complete denture – mandibular||Generally, not a covered benefit|
|D5875||Modification of removable prosthesis following implant surgery||Generally, not a covered benefit|
|D6051||Interim implant abutment placement (a healing cap is not an interim abutment)||Generally, not a covered benefit|
|D6104||Bone graft at time of implant placement||Generally, not a covered benefit|
|D6118||Implant/abutment supported interim fixed denture for edentulous arch – mandibular||Generally, not a covered benefit|
|D6119||Implant/abutment supported interim fixed denture for edentulous arch – maxillary||Generally, not a covered benefit|
|D6198||Remove interim implant component||
NBTP if removal of an interim implant component by the same dentist/dental office who placed the implant component; Denied if removal of an interim implant abutment by a different dentist/dental office than who placed the abutment
|D6056||Prefabricated abutment – includes modification and placement||Once every 5 years or per contract|
Custom fabricated abutment – includes placement
|Once every 5 years or per contract|
|D6114||Implant/abutment supported fixed denture for edentulous arch – maxillary||Once every 5 years or per contract|
|D6115||Implant/abutment supported fixed denture for edentulous arch – mandibular||Once every 5 years or per contract|
|D6055||Connecting bar – implant supported or abutment supported (Should only be used with D6110/D6111 below) – can only be billed once per arch. NOT to be used with D6114/D6115)||Once every 5 years or per contract|
|D6110||Implant/abutment supported removable denture for edentulous arch – maxillary||Once every 5 years or per contract|
|D6111||Implant/abutment supported removable denture for edentulous arch – mandibular||Once every 5 years or per contract|
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments
|Once every three years|
|D6090||Repair implant supported prosthesis, by report||Benefits for implants and associated procedure codes are based on the groups’ contract|
|D6095||Repair implant abutment, by report||Benefits for implants and associated procedure codes are based on the groups’ contract|
|D6096||Remove broken implant retaining screw||Benefits for implants and associated procedure codes are based on the groups’ contract|
|D6199||Unspecified Implant Procedure, by report||By report codes require submission of narrative/chart notes for consultant review|
Billing and reporting of the All-on-4® case can be complicated, and the correct coding ultimately depends on what services are provided. As with any complicated procedure, it is strongly encouraged to submit a pre-determination request.