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

First Visit

1. Exam (D0140, D0150, or D0160) 
2. CT Scan (D0365-D0367; D0381-D0383)
3. Diagnostic Casts (D0470)

Second Visit

1. Case presentation (D9450)
2. Treatment simulation using 3D image (D0393)
3. Impressions for surgical stent (D6190) and interim denture** (D6118, D6119)
4. Photos (D0350)

Third Visit

1. Extractions (if necessary) (D7140, D7210, D7250)
2. Implant placement (D6010)
3. Bone grafts at time of implant placement (if necessary) (D6104)
4. Interim denture inserted

Follow up Visits (number and sequencing per Dentist’s discretion)

Fourth Visit (approximately 24 weeks after 3^rd visit)

1. Impressions for final denture (D6114, D6115)

Fifth Visit

1. Interim denture removed
2. Implants inspected and cleaned
3. 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).

Maintenance Visits

1. 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.
2. 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, D1120, and D4910 now include cleaning any implant crowns in the arch as well.
3. 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.
4. 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.
5. 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

Oral Evaluation

D0120	Periodic oral evaluation - established patient	2 per benefit period
D0140	Limited oral evaluation - problem focused	2 per benefit period
D0150	Comprehensive oral evaluation – new or established patient	Benefit once per dentist/dental office
D0160	Detailed and extensive oral evaluation - problem focused, by report	Benefit once per dentist/dental office

Diagnostic Services

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
D0366	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

Implant Placement

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

Final Restorations

D6056	Prefabricated abutment – includes modification and placement	Once every 5 years or per contract
D6057	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

Note: The following procedures are not part of the All-on-4 process. These procedures should not be used/billed when fabricating an All-on-4 prosthesis.

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
D6056	Prefabricated abutment – includes modification and placement	Once every 5 years or per contract
D6057	Custom fabricated abutment – includes placement	Once every 5 years or per contract

Maintenance

D6080	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.