Carol Tekavec, RDH
Many dentists find that a core buildup is not covered when submitted with a standard crown to an insurance company. While this is a frustrating problem for our patients, it is helpful to understand some of the thinking that has resulted in the "writing out" of buildup benefits from most insurance plans.
The ADA says that Code D2950-Core Buildup, Including Any Pins, "refers to building up of the anatomical crown when a restorative crown will be placed, whether or not pins are used." While a description of exactly what portion of the anatomical crown needs to be built up is not included in the ADA definition, it is believed that "significant" tooth structure must be missing for a buildup to be appropriate. Code D2950 is not descriptive of cements, bases, or liners, nor is it considered to be proper under inlays or on previously unrestored teeth used as bridge abutments.
Many insurance carriers have received claims using the D2950 code in cases such as these. These cases mix with the thousands of other claims for D2950, resulting in what insurance carriers term "overutilization" of the procedure. When a code is overutilized, it is frequently dropped from the plan choices presented to the companies purchasing dental insurance for their employees. In other words, if a code is used too much -for whatever reason - it probably will be dropped from insurance plans. This is what has happened to D2950.
Buildups are typically considered "all inclusive" now with any crown code, except in select circumstances. Most insurance carriers will reimburse patients for buildups only in cases of previous endodontic treatment. A few will provide a benefit if the remaining anatomical tooth structure can be described as less than 50 percent and inadequate to provide proper crown retention. Documenting radiographs are essential. Intraoral photographs can be very helpful, too.
Code D2952-Cast Post and Core, in Addition to Crown, is another buildup code. It is defined by the ADA as being "separate from crown." This code differs from D2950 because it refers to a laboratory cast post that is cemented into an endodontically treated tooth to build up the anatomical crown prior to a crown preparation. Core material also is used.
When adequately documented, many plans provide a benefit for this procedure. Be sure to include a narrative describing the tooth as having had endodontic treatment and having less than 50 percent of the tooth structure remaining in the anatomical crown. Radiographs are essential as well. Most carriers will not pay for a D2952 and a D2950 on the same tooth.
D2954-Prefabricated Post and Core, in Addition to Crown, is defined by the ADA as "core is built around a prefabricated post. This procedure includes the core material." This code describes a "store-bought" post that is typically used to build up an endodontically treated tooth. To improve your chances of receiving reimbursement, include a narrative noting that the tooth has been endodontically treated and that less than 50 percent of the tooth structure is remaining. Sometimes, a core buildup will be paid if it is performed 30-90 days in advance of a crown. The same narrative and radiographic recommendations apply in this situation.
As with all insurance issues, it is best to outline the total cost of the planned treatment before the procedure is performed. Patients need to understand that insurance only will cover a portion of their treatment and that they will be responsible for any remaining amount not paid by their insurer.
If patients express unhappiness with their coverage, encourage them to contact their company`s Employee Benefits Coordinator or Human Resources Director. When an employer receives frequent complaints from employees, the existing insurance plan may be reviewed and not renewed for the next contract year.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.