Rayan FaroukRestorative dental procedures are essential for maintaining oral health, but proper documentation and coding are crucial for accurate billing and claims processing. Whether you are a dentist, clinic owner, or practice manager, understanding how to code restorations correctly can help avoid claim denials and ensure compliance with insurance policies.
Many tricks have to go with insurance and we are here to give them to all. Let’s start with restoration.
- Multiple restorations for the same tooth should use multi-surface codes. It’s not acceptable to bill each surface separately.
- Ex: A composite filling is done on the buccal and occlusal surfaces, you should use the code: resin-based composite – two surfaces, posterior.
- Restoration provided for cosmetic purposes is non-payable, so make sure it’s a treatment.
To control excessive claims, insurance providers impose quantity limits on restorative procedures:
- A maximum of four (4) fillings per claim/per day is allowed.
- This rule does not apply to cases performed under general anaesthesia
In addition to the restriction on fillings, there is a cap on the total number of dental procedures that can be billed per visit:
- A maximum of six (6) procedures per claim per day is permitted, excluding consultation and diagnostic services.
- This rule does not apply to general anaesthesia cases where extended treatment is necessary.
A Guide on Restorations:
- Amalgam filling is limited to one per 10 years.
- Composite filling is limited every 2 years per tooth surface
- Resin-based composite refers to a broad category of materials including but not limited to composites.
Crowns are optional benefits, covered once per 10 years for permanent teeth after a root canal.
Here are some extra notes:
- X-ray approval is required for fixed prostheses, billed only upon completion, with the cementation date marking completion.
- The fee includes all related procedures, such as tooth preparation, impressions, lab fees, occlusal adjustments (within six months), and anaesthesia, which cannot be billed separately.
- You should submit a clear periapical x-ray for the approval of the crown, it does not include facial veneers.
- Provisional (D2799) and temporary crowns (D2970) serve as protective devices for damaged teeth for at least six months and should not be used as a temporary solution during routine crown fabrication.
- Permanent crown authorization can only be obtained six months after the approval of a provisional crown (D2799).
- Recementing a crown (D2920) is only billable if performed by a different provider or facility than where the crown was originally placed. It cannot be billed by the same provider on the day of delivery and is only covered six months after placement. Additionally, D2920 and D2915 cannot be billed for the same tooth on the same day by the same provider—if submitted together, D2915 will be denied.
- Stainless steel crowns are used only for deciduous teeth, and no other crown types are covered for them. The prefabricated stainless steel crown (D2930) is considered a restorative procedure for deciduous teeth, subject to medical necessity. However, no other fillings or restorative treatments can be billed alongside it.
- Protective restorations are covered only for emergency pain relief. A separate fee cannot be charged when performed alongside a restoration, endodontic access closure, or temporary filling. Additionally, no other dental procedures can be performed on the same tooth for 30 days unless prior authorization is cancelled.
- For core buildup (D2950), billing is not allowed alongside a composite filling if a crown is planned. Only one of the two—composite filling or core buildup—can be covered with the crown. The core is built around a prefabricated post and includes the core material.
- Post-removal requires X-ray submission and is covered only if the procedure is complex, deep, and time-consuming. It cannot be billed in conjunction with endodontic treatment or retreatment (D3346, D3347, D3348).
- Any code labelled “by the report” requires a report submission for payment approval.
Adhering to these restoration billing guidelines is essential for smooth claim processing, compliance with insurance regulations, and financial stability within the dental practice. Incorrect coding, overbilling, or failing to follow these guidelines can lead to:
- Claim denials and payment delays
- Audits and Potential Penalties
- Patient dissatisfaction due to unexpected out-of-pocket costs
By staying informed and ensuring that all restorations are coded and billed accurately, dental providers can focus on delivering quality care while maintaining compliance and financial integrity.
If you have any questions about dental billing, coding updates, or how Balsam Medico can streamline your practice’s billing and claims management, feel free to reach out to our team!
Connect with Us
Ready to embark on this exciting journey? Contact us today:
📍 Dubai, United Arab Emirates – Tel: +971 56 123 6043
📍 Khartoum, Sudan – Tel: +249 91 273 1048
Explore Balsam Medico and discover a world of efficient clinic management at www.balsammedico.com. Together, let’s reduce fines, elevate efficiency, and embrace a new era of dental healthcare.
Join the Balsam Medico newsletter for exclusive content and the latest news. Be the first to view valuable information and updates!
