When is D6250 used?
The D6250 dental code represents a pontic made from porcelain fused to metal (PFM) material, utilized in fixed partial dentures or bridge work. This CDT code applies when replacing an absent tooth with an artificial tooth supported by neighboring abutment teeth or dental implants. Apply D6250 when the treatment plan calls for a pontic constructed from porcelain bonded to high noble, noble, or predominantly base metal, making sure the material choice aligns with patient requirements and coverage guidelines. This code should not be used for all-porcelain or full-metal pontics, as these materials have designated codes.
D6250 Charting and Clinical Use
Proper documentation is essential when submitting D6250 claims. The patient record must contain:
A comprehensive diagnosis and treatment plan demonstrating the necessity for fixed bridge work.
Pre-treatment X-rays displaying the missing tooth space and surrounding abutment teeth.
Documentation explaining the material selection and rationale for choosing PFM.
Clinical photographs when available to demonstrate treatment necessity.
Typical applications for D6250 involve replacing individual missing teeth in front or back regions where both appearance and durability are important. For instance, a patient with a missing first molar and sound adjacent premolar and second molar makes an ideal candidate for a PFM pontic. Always ensure clinical documentation supports why a PFM pontic represents the optimal treatment choice compared to alternative materials.
Billing and Insurance Considerations
To optimize reimbursement and reduce claim rejections for D6250, implement these strategies:
Check coverage: Prior to treatment, validate the patient's benefits for fixed bridge work and material specifications. Certain plans may reduce benefits to cover less costly materials.
Obtain pre-approval: File a pre-treatment estimate including supporting materials (X-rays, clinical notes, photographs) to establish coverage and patient financial responsibility.
Code correctly: Apply D6250 exclusively for PFM pontics. When using different materials, choose the correct code, such as ceramic pontic or metal pontic.
Submit claims properly: Include all necessary documentation and a detailed narrative describing the clinical justification for a PFM pontic. Specify the exact location (tooth numbers) and supporting abutment teeth.
Handle denials: When claims are rejected, examine the Explanation of Benefits (EOB), address the insurer's denial reasons, and file a comprehensive appeal with supplementary documentation when appropriate.
How dental practices use D6250
Case: A 52-year-old patient has a missing #19 (lower first molar). The neighboring teeth (#18 and #20) are in good condition and appropriate for bridge support. The dentist suggests a three-unit fixed bridge featuring a PFM pontic for optimal strength and appearance.
Practice workflow:
Confirm insurance benefits for fixed bridge procedures and PFM material coverage.
Secure pre-treatment approval using X-rays and clinical narrative explaining treatment necessity.
Record material selection and clinical findings in the patient's chart.
Following treatment completion, file the claim using D6250 for the pontic plus appropriate codes for supporting crowns.
When claims are rejected due to material downgrades, examine the EOB and file an appeal with supporting documentation justifying the PFM selection.
This approach ensures proper claim submission, minimizes accounts receivable delays, and promotes successful reimbursement for D6250 treatments.
Common Questions
What distinguishes high noble metal from base metal according to D6250 requirements?
High noble metals feature elevated concentrations of precious metals including gold, platinum, and palladium, delivering enhanced strength, longevity, and biocompatibility versus base metals. D6250 mandates that the pontic must be porcelain fused to high noble metal rather than base metal. Utilizing incorrect materials may lead to claim rejections or improper reimbursement.
What are typical causes for D6250 claim rejections by insurance providers?
Frequent denial reasons include inadequate supporting documentation (like radiographs or clinical narratives), incorrect material type coding, surpassing frequency limits, or failing to satisfy replacement requirements. Comprehensive documentation and benefit verification prior to treatment help avoid these rejections.
Is D6250 applicable for bridges in both front and back areas of the mouth?
Yes, D6250 applies to both anterior and posterior bridges provided the pontic consists of porcelain fused to high noble metal. Material selection and coding should depend on clinical requirements, aesthetic factors, and insurance specifications.