In this edition of Consultant’s Corner, we are going to address one of the more controversial procedure codes in CDT-2023, D2950, “core buildup, including any pins when required.”
As previously reported in this space, Delta Dental of Missouri receives thousands of claims for crowns and core buildups. To be eligible for benefit payments, specific clinical criteria must be met.
General policy
Core buildups or crown substructures are only a benefit when necessary to retain an indirectly fabricated restoration due to extensive loss of tooth structure from caries or fracture. A core buildup is generally indicated if all the following conditions are met:
- A significant portion of tooth structure (50% or more) is fractured or carious
- The preparation is at or below the gingival crest
- Less than 3 mm of sound dentin remains vertically above the preparation line in opposing walls where the crown margins will be located (for additional information, refer to Christensen, G.J., Building up tooth preparations for crowns – 2000 JADA, April, 2000;131:505-506)
Specifically, a material is placed in the tooth preparation for a crown when there is insufficient tooth strength and retention for the crown procedure.
D2950 vs D2949
A procedure should not be reported with code D2950 if it only involves a filler to eliminate any undercut, box form or concave irregularity in the preparation. CDT-2023 includes a procedure code for “restorative foundation for an indirect restoration,” D2949, which is for the placement of restorative material to yield a more ideal form, including the elimination of undercuts. Claims and predeterminations using this code will be denied for payment as being inclusive in the crown being performed. Benefits would not be payable under these circumstances and charges will not be payable by the patient.
The dos and don’ts of claim submissions
DDMO recognizes frustration encountered with filing claims for buildups on behalf of plan members. The following information is intended to serve as a guide to the dos and don’ts when submitting claims for core buildup restorations.
A common reason for core buildup claims and predetermination denials or requests for additional information is due to receiving radiographs that are not of diagnostic quality for review purposes. Dental office staff should perform a quality review before a claim or predetermination for a core buildup is submitted to DDMO and confirm that:
- Preferably both current intraoral bitewings (horizontal or vertical as appropriate), and periapical radiographs are submitted. NOT panoramic images
- Radiographs are properly labeled (e.g., left and/or right and with the patient’s name and exposure date
- Diagnostic quality showing appropriate structures
In addition to radiographs, especially if only marginally suitable images are available, a photo of the treated tooth taken before treatment begins or during treatment showing the buildup performed just prior to crown preparation will greatly increase the likelihood that benefits will be allowed.
Often, treating dentists will only send an x-ray of an existing serviceable crown that shows no evidence of decay or unrepairable damage. A photo of the tooth’s condition after the crown has been removed may guarantee a successful benefit payment outcome and prevent delays caused by requests for additional information.
Partial views of teeth being submitted for buildups may not be approved for payment. Frequently, anterior PA images miss critical areas such as the entire clinical crown.
Chart notes with case-specific procedure descriptions are preferred to stock or short narratives. “Tooth broke” scrawled on a claim form with no other correlating documentation will be denied.
It is also helpful to note that restorations placed to close endodontic access openings created through existing, serviceable crowns are not to be reported as core buildups. In most cases, a single surface direct restoration will meet criteria for payment.
The most important guiding principle for successful claim and predetermination submissions is to remember that DDMO is based in the “Show-Me State.” When dental staff send attachments that best demonstrate eligible benefit conditions, timely payment for services rendered follows.
Reminder – denials are not a reflection of treatment needs
Dentists providing services to DDMO members should be aware that claim and predetermination denials due to processing policies do not mean that the treatment was unnecessary; the denial is based solely on plan limitations. The American Dental Association has also recommended that dentists should advise their patients that coverage is frequently based on employer funding of the policy purchased rather than the clinical needs of the specific patients.
Questions?
Please contact your professional relations representative at professionalrelationsteam@deltadentalmo.com.
