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Thursday Troubleshooter: Different codes for zirconia crowns vs. e.max crowns?

Aug. 24, 2017
This week's question is about coding for zirconia vs. e.max crowns, and it actually has several moving parts for coding expert Patti DiGangi to answer.

Nearly everyone has problems and concerns on the job, and sometimes you're just too close to a situation to solve something yourself. Share your concerns with Team Troubleshooter, and the experts will examine the issues and provide guidance. Send questions to [email protected].


QUESTION:HOW SHOULD WE BILL PATIENTS WITH INSURANCE when we do a zirconia or e.max crown on anterior and posterior teeth? There is a code D2740 for ceramic crowns. Does that include all types of porcelain crowns, which means patients cannot be charged an upgrade fee? And if the code for molars is D2790 or D2792, can a patient be charged the difference between the insurance fee for the covered procedure and the dental office fee for zirconia crowns?

ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology" series of books:
As asked here, this question combines and confuses related parts of billing— coding, coverage, and fees. I talked about this in a recent Thursday Troubleshooter entitled Correct use of core buildup code. Now, let’s take today’s question apart.

The role of the practice is to submit the most accurate code describing the procedure. E.max is a porcelain, and zirconia is a white metal covered over with porcelain. For most dentists, the choice between these materials is related to cosmetic and/or strength. The most accurate code, whether zirconia crowns or e.max, is D2750 crown—porcelain/ceramic substrate.

In Chapter 3 of the CDT 2017 Companion, Dr. Ronald Riggins clarifies it this way, “Dental crowns use zirconia, which is an oxide and considered chemically to be a ceramic.” There is no ambiguity here from a coding perspective.

Fees are a different question. A practice may charge whatever it chooses for the care provided. Fees should be based on the cost of doing business and a reasonable profit. Can a practice charge a different fee depending on the material used? Yes. The confusion is that the code is the same but the material is different. The cost of doing business changes with the material selected.

Coverage is a contractual agreement between parties, most often an employer and an insurance benefit carrier. Coverage or non-coverage is not based on the whim of a carrier, it is based on those contracts.

Some dental offices have contracts with dental benefits carriers that are also contract negotiations. The final part of the question does not come into play unless the practice has signed a contract with a carrier. Those type of contracts can limit the fee charged and contain language stating that no further fees can be charged other than those negotiated in the contract. This limitation does not apply otherwise.

A final word of caution. When an office attempts to code and charge according to clauses in a contract, there is the strong possibility of committing fraud. It is the responsibility of the practice and practitioners to use the most accurate codes that describe the care rendered.

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