When is D6985 used?
The D6985 dental code applies to a pediatric partial denture, fixed. This CDT code is utilized when children need a fixed partial denture to restore missing primary or permanent teeth, often resulting from injury, congenital absence, or premature loss due to cavities. It's essential to understand that D6985 is exclusively for pediatric patients and should not be applied to adult treatments. Correct application of this code ensures proper claims processing and prevents rejection or payment delays.
D6985 Charting and Clinical Use
Proper documentation is essential when submitting claims for D6985. Dental professionals must document the clinical justification for the fixed partial denture, including patient age, diagnosis, and cause of tooth loss. Clinical photographs, x-rays, and comprehensive chart notes describing the edentulous area and its functional or aesthetic impact support the claim. Typical clinical situations include:
Children with congenitally absent front teeth impacting speech or aesthetics
Premature loss of primary molars requiring space preservation
Injury cases where a fixed appliance is more suitable than a removable option
Documentation must clearly demonstrate medical necessity and justify selecting a fixed rather than removable partial denture.
Billing and Insurance Considerations
Processing D6985 claims requires understanding carrier-specific guidelines and comprehensive submission procedures. Follow these practical steps for successful reimbursement:
Benefits Verification: Check patient coverage for pediatric prosthodontics and any age or frequency restrictions prior to treatment.
Prior Authorization: File a pre-treatment estimate with supporting materials (photographs, radiographs, clinical notes) to minimize denial risk.
Claims Processing: Submit claims using D6985 code, include all supporting materials, and provide a comprehensive narrative explaining clinical necessity and appliance selection rationale.
Payment Review: Examine remittance advice for payment accuracy. For denials, identify missing documentation or coverage exclusions and file timely appeals with additional supporting evidence.
Collections Management: Monitor pending claims and maintain regular follow-up to ensure timely payment and reduce outstanding receivables.
Proactive benefits verification and thorough documentation significantly enhance practice revenue cycle performance for pediatric prosthodontic treatments.
How dental practices use D6985
Case Study: A 7-year-old child arrives with congenitally absent maxillary lateral incisors. The practitioner decides a fixed pediatric partial denture is required to restore appearance and function until permanent treatment becomes appropriate. The practice confirms insurance benefits, files prior authorization with clinical photographs, panoramic radiograph, and narrative describing developmental and social implications. The claim uses D6985 code, and through consistent follow-up, the carrier approves and processes payment.
This case demonstrates how comprehensive documentation, benefits verification, and active claim management lead to successful D6985 pediatric partial denture reimbursement.
Common Questions
Is D6985 applicable for adult patients or exclusively for pediatric cases?
D6985 is exclusively intended for pediatric patients requiring a fixed partial denture. This code cannot be applied to adult cases, as adult fixed partial dentures are covered under different CDT codes. Incorrect usage of D6985 for adult patients may lead to claim rejections or potential audits.
What are typical reasons insurance companies deny D6985 claims?
Insurance denials for D6985 commonly occur due to inadequate documentation, missing pre-authorization requirements, or insurance plans that exclude coverage for pediatric fixed partial dentures. Additional denials may result when the medical necessity for choosing a fixed prosthetic over a removable alternative is not properly justified in the claim documentation.
What steps should dental practices take when appealing denied D6985 claims?
When facing a D6985 claim denial, dental practices should first examine the Explanation of Benefits to identify the specific denial rationale, compile any required supplementary documentation including comprehensive clinical records or diagnostic images, and file a formal appeal with the insurance provider. Consistent follow-up communication and clear correspondence with the insurance company can enhance the likelihood of a favorable appeal outcome.