Study models are payable as a diagnostic service (D0470) intended for the documentation and subsequent analysis of occlusion. The casts are usually a reimbursable benefit once per case in conjunction with an orthodontic treatment plan. Additional casts taken during or at the conclusion of an orthodontic treatment plan are not individually reimbursable by the plan and cannot be identified separately. Only the “base-line model” is identified, because the fees for all subsequent casts are usually included in the global fee for the completed treatment plan.
Excluding orthodontics, benefit plans rarely, if ever, reimburse for study models. Some of the more current, well-funded benefit plans address reimbursement for diagnostic casts with a 60-month exclusionary period.
Do not separately identify and/or bill for diagnostic casts if you are fabricating a bleaching tray, mouth guard, or any other type of appliance or splint. With any type of appliance fabrication, the “working” models are considered part of the construction process and cannot be identified separately. Diagnostic casts are for diagnostic purposes!
In addition to orthodontic documentation, examples of when diagnostic casts are clinically significant might include, but are not limited to:
Needs assessment concerning possible fixed or removable prostheticDocumentation of gingival attachment levels, whether they are rolled- or knife-edged tissue marginsNonfunctioning teeth and other issues of traumatic occlusal discrepancyWith these and other clinical conditions, more detailed occlusion analysis and possible adjustment procedures may be necessary.Now we add the analysisOcclusion analysis is the study of the relationship of the occlusal surfaces of opposing teeth and their associated functional harmonies. The primary purpose of occlusion analysis is to reveal interferences in articulation which cannot be observed directly in the mouth.Once the simple diagnostic casts are transferred to an adjustable articulator via face bow and bite fork, we begin to encompass the definition of procedure code D9950-occlusalanalysis. This detailed analysis is most often performed prior to the initiation of any comprehensive restorative, prosthetic, or periodontal treatment plan. The analysis will identify the corrective measures that are necessary to harmoniously balance the functional dynamics of occlusion. The adjustments improve functionOcclusal adjustment is the scientific grinding and/or reshaping of the occluding surfaces of teeth to develop and improve upon their harmonious relationships between each other, their supporting structures, muscles of mastication, and temporomandibular joints.This procedure is reported as either being limited (in scope) or complete. These descriptors should not be confused or correlated with either per tooth, by quadrant, or full-mouth. The descriptors do not equate.The occlusal adjustment-limited code (D9951) is frequently used to identify a single-visit procedure that addresses only a specific tooth, site or quadrant. Discing, odontoplasty, and enamoplasty are the most frequent single-visit procedures. The occlusal adjustment-complete code (D9952) refers to a multi-visit series of treatments that would include the teeth, the neuromuscular mechanisms of chewing, and/or any combination of both.Who pays for what?Don’t allow patients to assume that their benefit plans will pay for all necessary and indicated treatments. On the same note, dentistry must stop apologizing for the existence of low-dollar, cost-effective dental plans. Very few well-funded benefit contracts accept liability for the evaluation and correction of occlusal imperfections as adjunctive periodontal therapy. The old ADA codes of 04330 (limited) and 04331 (complete) had 4000-series prefixes to identify such treatments as associated periodontal therapy. While some benefit contracts address reimbursement for occlusal-adjustment therapies in conjunction with surgical-periodontal treatments, other contracts limit reimbursement to the confines of a separate TMJ rider.It is inappropriate to separately charge for occlusal adjustments in conjunction with delivering restorative or prosthetic treatments. Such necessary adjustments as grinding are considered part of the global prosthetic services, whether the final prosthesis is fixed or removable.The fees and what to chargeRemember, the fee for occlusal adjustment is separate and does not encompass the fee for the diagnostic casts and analysis. All three are identified and billed separately.When all is said and done, it’s the patient - not the patient’s benefit plan - who is responsible to your office for the total cost of dental treatment.
