Coding Bone Replacement Grafts for Insurance Reimbursement

Estela Vargas, CRDH, CEO Remote Sourcing

Across my pipeline of questions from dentists and their teams, I get several inquiries about claims for bone replacement grafts(D7953). Is it lucky that some get paid, and others don’t? No, luck is not in the equation. What is in the equation is good clinical charting and supporting documentation that supports the procedure and the choice of the code(s).

Defined by the ADA: D7953 bone replacement graft for ridge preservation-per site is when a graft is placed in an extraction site or implant removal site at the time of the extraction or removal to preserve ridge integrity (when clinically indicated in preparation for implant reconstruction of where alveolar contour is critical to planned prosthetic reconstruction) The code language does not include obtaining graft material. If using a membrane, this must be reported separately.

The key words are “to preserve ridge integrity” for a planned prosthetic reconstruction.

To demonstrate, let’s look at the following scenario: The patient is a 50-year-old female who is in the dental chair for a crown, and during the preparation, it is determined by the dentist that tooth #12 is no longer salvageable. The diagnosis is for an implant to be placed at a later date. The dentist places an autogenous bone graft with a membrane at the time of extracting #12 in hopes of building bone volume to preserve the integrity of the ridge for a future implant.

Coding this scenario is suggested as follows: Tooth #12 D7140 extraction, erupted tooth, or exposed root (elevation and/or forceps removal) Includes removal of tooth structure, minor smoothing of socket bone, and closure, as necessary.

Tooth #12 D7953 bone replacement graft for ridge preservation per site
Tooth #12 D7295 harvest of bone for use in the autogenous grafting procedure
Tooth #12 D7956 guided tissue regeneration, edentulous area -resorbable barrier, per site
Or
Tooth #12 D7957 guided tissue regeneration, edentulous area resorbable barrier, per site
D7957 does not include the removal of a non-resorbable barrier. Use--
Tooth #12 D4286 removal of non-resorbable barrier (when removed at a later date)

Regarding implants, the procedure is not generally reimbursed unless an implant rider is on the patient's policy (coverage for implants) and then subject to any plan limitations. Sometimes, the benefit of a graft will be applied if a conventional bridge is placed. Confirming coverage and benefits for this coding scenario is recommended as reimbursement rates (if covered) vary significantly from one payer to another.

Narratives and or clinical notes supporting the necessity for the grafts, pre-operative photos, and radiographs must be included with the claim.

Note: D7953 is not the code to use after a third molar removal.

Coding for scenarios like this requires a knowledgeable person or team familiar with coding and sequencing, building clinical narratives, and choosing the best-supporting documentation to ensure claims are paid accurately, at the maximum rate, and timely.

Remote Sourcing is available to turn your nightmare into a dream and give you the peace of mind you deserve.