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Core Buildup Among Procedures That Prompt Denial Of Claims

CHICAGO, Illinois — The existence of a CDT code does not necessarily mean that the procedure is covered or reimbursed by a dental benefits plan. That can sometimes be the case for D2950 – core buildup, including any pins, when required.

Numerous dentists have lodged complaints with the American Dental Association (ADA) Center for Dental Benefits, Coding and Quality on Dental Benefit and its staff after claims for core buildups were denied by third-party payers. Some dentists have even informed the ADA that this procedure is bundled with a crown procedure by third-party payers, since a core buildup can be considered part of the crown preparation. Bundling of separate procedures to limit a benefit is against ADA policy.

The payers who choose not to cover core buildups do so for a variety of reasons, said Dr. Mark Mihalo, chair of the ADA Council of Dental Benefit Programs’ Subcommittee on Coding and Transactions.

“I’ve been told by payers that core buildup is one of the most abused codes in dentistry and I have been on enough peer review panels to see this abuse,” Dr. Mihalo said. “The Subcommittee on Coding and Transactions has a long-standing motto: Code for what you actually did, not for what you think you will get paid for.”

Dr. Quinn Dufurrena, chief dental officer for United Concordia Dental and an ADA member, said that approvals for core buildup require supporting X-rays. In addition, he said, though it is not required, photos of the tooth being treated gives a better idea of how much decay existed, and he recommends they should be sent along with the claim to help speed up claim approvals.

Dr. Dufurrena said there is a misperception about insurance companies, at least from his standpoint. “We are looking for reasons to approve the claims,” he said. “We give the benefit of the doubt to the provider. We want to approve the claims.”

Dr. Mihalo seconded Dr. Dufurrena’s recommendation that to minimize claim denials for core buildups, documentation of the condition that resulted in the buildup should be provided in the initial claim submission. This could include documentation indicating that the tooth was broken down to the extent that a buildup was necessary to perform the endodontic procedure.

Even in the face of denials of claims for core buildups, dentists should treat the patient with appropriate care regardless of the patient’s insurance coverage, said Dr. Mihalo. Communication is crucial, he added. “Having patients who understand the limitations of their plan prior to treatment may help avoid problems,” he said. “Dentists should help the patient understand the clinical basis for treatment, in spite of contractual limitations by the plan.”

Further guidance is available found in the ADA’s members-only manual Responding to Claim Rejections. A section is devoted to core buildups.

The ADA has created a new landing page for dental benefits information that can help dentists address and resolve even their most vexing questions, ADA.org/dentalbenefits, part of the Center for Professional Success.

Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related problems, questions and concerns. Call (800) 621-8099 or email dentalbenefits@ada.org for questions regarding denial of claims.

If dentists have a concern or question they would like addressed in a future issue of the ADA News, they can contact dentalbenefits@ada.org.

Editor’s note: This is the seventh in a series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care.

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