Dental Core Build-up – Handling Core Reimbursement Challenges

Large amounts of decay or sizable cracks can leave a tooth very fragile, and in need of a crown in order to restore and protect what’s left of the original tooth structure. Core buildup is a restorative procedure where the missing portion of the tooth is restored with a dental filling material in order to support the crown restoration. The core build-up rebuilds the internal anatomy of the tooth structure as prepared for a crown. General dentists and other specialists need to properly evaluate whether there is enough structural integrity remaining to support a definitive crown by a core buildup alone or use an endodontically retained post to secure the core foundation to the root.

Indications of a Core Buildup

A core build-up must be necessary for crown retention to be considered a build-up. The core build-up should rebuild the internal anatomy of the tooth structure as prepared for a crown.

If your tooth is badly broken or missing in a large volume (due to decay), an artificial crown may be indicated to restore the function and appearance of the tooth. However, the remaining portion of the tooth can be so small that it is not adequate enough to support a dental crown. A certain amount of supporting tooth structure has to be present to support a dental crown so it can perform successfully over the long term. The rebuilding process is done with a filling material which is called a core buildup. The purpose of the core buildup is to replace the missing tooth structure, create ideal geometry for the crown restoration and protect integrity of the tooth.

Core Buildup is not covered for the following –

• As a filler to correct irregularities in preparation
• As a definitive composite or amalgam restoration
• For retention of intracoronal restorations

D2950 – Buildup versus D2949 – Foundation

Dental insurance reimbursement for core buildups is often challenging. Many dentists routinely remove all existing filling from a tooth when they do a crown preparation. This can leave several irregularities, undercuts, and divots. The dentist further places a material to fill in these irregularities, so that the final shape of the prepared tooth is “ideal”. This is often confused with a D2950 buildup, which is a similar procedure but is done for a very different reason.

D2950 – Core Buildup, Including Any Pins

• Descriptor was changed in CDT 2014 – it was simplified to clarify the purpose and intent of a buildup.
• CDT 2014 descriptor – “Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure.”
• There is no longer a reference to “tooth strength” in the descriptor.
• The purpose of a buildup is to help hold the crown on when there is not enough tooth structure left. In other words, if a buildup is not done, then the crown would not stay on.
• The CDT 2014 descriptor also states “A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.”
• It is not appropriate to use this code for fillers or bases (included in restorative procedure itself).

D2949 – Restorative Foundation for an Indirect Restoration

• New code implemented in CDT 2014.
• CDT 2014 descriptor: “Placement of restorative material to yield a more ideal form, including elimination of undercuts.”
• The procedure involves placing a restorative material in the tooth for purposes other than helping the new crown to stay. These purposes include – blocking out undercuts, eliminating a box form, filling in voids in the prep, filling in a concavity and making the shape of the prepped tooth more ideal in contour.
• This procedure is what many dentists were previously doing, but incorrectly submitting as a D2950 buildup.

Some of the important points to note here are –

• There is a difference between a buildup and a base, liner, or foundation.
• Placing a restorative material in order to protect pulp is not a buildup.
• Placing a restorative material in order to idealize the prep is not a buildup.
• Placing a restorative material in order to eliminate undercuts is not a buildup.
• Placing a restorative material in order to bond tooth structure, cusps, or cracks together is not a buildup.
• When there is sufficient tooth to retain a crown, then the shape or size of the crown prep doesn’t matter; the restorative material placed is not a buildup.

Core Buildup Post and Core and Pin Retention – Coverage Guidelines

Post and Core

Post and core are indicated for the following:

• For teeth with significant loss of coronal tooth structure in endodontically treated teeth in which insufficient tooth structure remains to adequately retain an indirect restoration
• For Posts – when there is inadequate remaining tooth structure to support a core

Post and core are not indicated for teeth with short roots. When anatomic features are available to retain the core (e.g., when canals and pulp chamber can retain a core), a Post is not indicated.

Pin Retention – This procedure is indicated for teeth with significant loss of coronal tooth structure to allow retention of a direct restoration.

Pin retention is not covered for the following –

• For restoration of teeth with significant malocclusion
• If the tooth cannot be properly restored with a direct restoration due to anatomic or functional considerations

Post Removal

Post removal is indicated for the following –

• When there has been loss of adequate retention
• In case of tooth fracture and/or Post and core
• When there are recurrent caries associated with Post and core
• When access is needed to root canal system for non-surgical endodontics
• When the tooth has a reasonable long-term prognosis for a new restoration

Coverage Limitations

• Pin retention and Post and core can be subject to a 12-month waiting period
• Pin retention is limited to 2 Pins per tooth
• Re-cementation of Post and core is limited to those performed more than 12 months after the initial insertion

Reimbursement Challenges

The code used for core buildup D2950, is often misused by many dental practices. The existence of a CDT code does not necessarily mean that the procedure is covered or reimbursed by a dental benefits plan. 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 in these instances.

In most cases, a core buildup is reimbursed for a crown placed after endodontic seal because it is common for severe loss of tooth structure from decay. 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. Payers may not provide coverage for a buildup unless there is a crown being placed and often times will not pay for the buildup without the seat date of the crown provided.

Some insurance companies consider core-buildup as part of a crown procedure and thus deny payment towards the D2950 code. In fact, numerous dentists have lodged complaints with the American Dental Association (ADA) Center for Dental Benefits, Coding and Quality, and its staff after third-party payers denied claims for crown procedures. Dentists informed the ADA that this procedure is often 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.

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 must essentially include documentation indicating that the tooth was broken down to the extent that a buildup was necessary for crown retention. Also, including Pre and Post Op xrays can increase the chances of claim approval.

Health insurance payers may deny payment for the following reasons –

• A cracked tooth. Cracked tooth syndrome occurs when a tooth has a crack that is too small to show up on X-rays or is under the gum and challenging to identify. Claims for cracked tooth syndrome often get denied because radiographs do not show the cracks or make it clearly visible.
• Some dental plans cover crowns when the teeth are broken down and have extensive structural damage (due to dental disease or accidental injury). However, if the third-party payer doesn’t see evidence of that, the claim may be denied.
• Claims may also be denied if the dental plan’s consultant indicates that the tooth has a poor prognosis. In addition, claims for abrasion and attrition are typically denied.

Knowing when to bill for a core build up has proved to be somewhat challenging in the dental world. As CDT codes are subject to frequent changes (which are often difficult to understand), billing and coding for various dental procedures, such as the D2950, and getting claims approved can also be quite complex. Claim denials can have a significant impact on patients and dentists. Dental practices, in such situations, can rely on outsourced dental billing services to overcome these challenges. It is very important for dental practices to understand the common billing and coding points that can largely affect their bottom-line.

Even in the face of denials of claims for core buildups, dentists need to treat patients with appropriate care regardless of the patient’s insurance coverage. The dentist must explain in detail why a specific procedure may not be covered before initiating the treatment procedure, as to avoid a potential large unexpected bill on the patient’s part in the future.

Applicable CDT Codes

• D2949 – Restorative foundation for an indirect restoration
• D2950 – Core buildup, including any pins when required
• D2951 – Pin retention – per tooth, in addition to restoration
• D2952 – Post and core in addition to crown, indirectly fabricated
• D2953 – Each additional indirectly fabricated post – same tooth
• D2954 – Prefabricated post and core in addition to crown
• D2955 – Post removal
• D2957 – Each additional prefabricated post – same tooth
• D2999 – Unspecified restorative procedure, by report

Dental billing services provided by experienced by dental billing companies are a great support for practices to meet their billing and claim submission requirements. Such companies will provide the services of skilled AAPC-certified coders and expert billing specialists who can ensure that your practice has fewer unresolved dental claims.