Understanding Dental Code D6245

When to Use D6245 dental code

The D6245 dental code is designated for a pontic—porcelain/ceramic used in a fixed partial denture (bridge). This code should be used when billing for a replacement tooth (pontic) fabricated entirely of porcelain or ceramic materials, which is supported by abutment teeth or implants on either side. It is important to select D6245 only when the clinical situation meets these criteria, as using an incorrect code can result in claim denials or delays in reimbursement.

Documentation and Clinical Scenarios

Proper documentation is essential for successful claim submission with D6245. Dental teams should ensure the following are included in the patient record:

• Detailed clinical notes describing the edentulous space and justification for a fixed bridge with a porcelain/ceramic pontic.
• Radiographs or intraoral images showing the missing tooth and adjacent abutments.
• Treatment plan outlining the materials used and the rationale for selecting a porcelain/ceramic pontic over other options (such as a cast metal pontic).

Common scenarios for D6245 include esthetic zones where appearance is a priority, or when a patient has allergies to metal. Always ensure the clinical notes specifically mention the use of porcelain/ceramic material for the pontic.

Insurance Billing Tips

To maximize reimbursement and minimize delays, follow these best practices when billing D6245:

• Verify patient benefits before treatment, confirming bridge coverage and frequency limitations.
• Submit pre-authorizations with supporting documentation, especially for esthetic cases or when replacing a previously existing bridge.
• Include all required attachments (radiographs, clinical photos, and narrative) with the initial claim submission.
• Use precise narratives that clearly state why a porcelain/ceramic pontic is indicated.
• If denied, appeal with additional documentation and reference the patient’s specific clinical need for a non-metal pontic.

Review the Explanation of Benefits (EOB) carefully for any downgrades to less expensive materials, and be prepared to discuss alternate benefits with the patient if necessary.

Example Case for D6245

Consider a patient missing tooth #8 in the anterior maxilla. The treatment plan calls for a three-unit bridge with a porcelain/ceramic pontic to achieve optimal esthetics. The dental team documents the missing tooth with radiographs and notes the patient’s desire for a metal-free restoration. The claim is submitted with code D6245, accompanied by a narrative explaining the esthetic requirements and patient preference. Insurance initially requests more information, so the office responds with additional photos and a detailed narrative. The claim is approved, and the patient receives a natural-looking restoration with full insurance benefits.

By understanding when and how to use the D6245 dental code, dental practices can ensure accurate billing, reduce claim denials, and provide patients with the best possible restorative outcomes.