QUESTION: When is it okay to use the core buildup code? Is it okay to use when we are filling the endodontic access prior to a crown prep?
ANSWER FROM KYLE SUMMERFORD, founder ofDDSGuru.com:
Great question. The core buildup (D2950) is commonly used incorrectly by many practices. I'll give you a quick breakdown on what insurance companies consider necessary for this code to be reimbursed.
The code (D2950) usually applies to teeth that do NOT have enough tooth structure to support a crown. Typically, 60% or more of the tooth is missing. If the procedure is billed on the same day as a root canal, the procedure may NOT be covered as it will be considered inclusive of the root canal fee.
The code cannot be billed for reasons of a clean or ideal crown prep. Should a posterior tooth undergo endo therapy, the restorative dentist would then perform a pre-fab post and core (D2954) or indirect post and core (D2952). The most common is the pre-fab post and core (D2954). Insurance companies will usually reimburse for a D2954 even if you bill for an Indirect post and core (2952).
Submit an endo prognosis, a well-detailed narrative, and pre- and post-op radiographs, and these will all support reasons of clinical necessity.
ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology," series of books:
Fees, coverage, and codes are connected yet separate issues. A practice can choose to charge the fees they want. Fees are generally based on the cost of doing business and reasonable profit. Coverage is a contractual agreement between parties, most often an employer and an insurance benefit carrier. Codes are merely alphanumeric identification for a specific procedure. The role of the dental practice is to use the codes that most accurately describe procedures.
There are several codes that could be described as core buildup codes, but the most likely is D2950 core buildup, including any pins when required.* This can be a very appropriate code if what you’re performing fits the CDT definition, “refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure….”*
Based on your question, it appears this code would be accurate and should be used. Yet that doesn’t mean there is coverage. Again, coverage is a contractual agreement. Coding based on the parameters of a contract can be inappropriate and even fraudulent. Whether or not coverage exists, the most accurate code should be documented.
Another reason coverage is often rejected is the lack of a narrative from the dental office. Narratives are often interpreted as a ponderously long explanation. Thinking about Twitter might show people a better way to write a narrative. Twitter has taught people to send and read 140-character messages, whichincludes letters, numbers, symbols, punctuation, and spaces. Tweets are concise writing.
Benefit narratives should be concisely written dental-medical necessity statements, in other words, the reason why the care was performed. For this care, the narrative might read, “Endodontically treated xx/xx/xx. 65% tooth structure missing. Needed for crown retention.”
This “tweet” narrative is only 91 characters, including spaces! Yet it has told the carrier exactly the circumstances. It can fit easily into Box 35 Remarks on a claim form. Contracts sometimes have limiting clauses. For example, a clause might define that a certain percentage of structure must be missing for coverage. Photographic support as part of a narrative tweet is the best assistance for the clinicians and the insurance carrier.
Why dental-medical necessity
Many recent studies have investigated the relationship between oral and systemic conditions. An increasing number of dental carriers are recognizing the medical nature of certain dental procedures. Dental-medical necessity is different from person-to-person and changes over time. There is benefit to all practices to document it routinely to help optimize dental benefit coverage and cross-coding opportunities.
Twitter-style documenting dental-medical necessity isn’t difficult, yet it takes team cooperation, new thinking, and practice. It’s not the role of the administrative team member alone. It can’t be. Though it starts and ends with the administration person, there are six circular steps that touch everyone in the practice. To learn more, read DentalCodeology: Jump Start Diagnostic Coding by Patti DiGangi and Christine Taxin.
*Current Dental Terminology© 2016 American Dental Association. All rights reserved.
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