Understanding Dental Code D6250

When to Use D6250 dental code

The D6250 dental code refers to a pontic, specifically a porcelain fused to metal (PFM) pontic, used in fixed partial dentures (bridges). This CDT code is applied when replacing a missing tooth with a prosthetic tooth that is supported by abutment teeth or implants on either side. Use D6250 when the clinical situation requires a pontic made of porcelain fused to high noble, predominantly base, or noble metal, ensuring the material selection matches the patient's needs and insurance requirements. It is not appropriate for all-ceramic or all-metal pontics—those have their own specific codes.

Documentation and Clinical Scenarios

Accurate documentation is critical when billing D6250. The clinical record should include:

• A detailed diagnosis and treatment plan indicating the need for a fixed bridge.
• Pre-operative radiographs showing the edentulous space and adjacent abutment teeth.
• Notes on the material selection for the pontic and why PFM was chosen.
• Intraoral photos, if possible, to support clinical necessity.

Common scenarios for D6250 include replacing a single missing tooth in the anterior or posterior region where esthetics and strength are required. For example, a patient missing a first molar with healthy premolar and second molar abutments is a typical candidate for a PFM pontic. Always ensure the clinical notes justify why a PFM pontic is the best solution over other materials.

Insurance Billing Tips

To maximize reimbursement and minimize denials for D6250, follow these best practices:

• Verify benefits: Before treatment, confirm the patient’s coverage for fixed bridges and specific material allowances. Some plans may downgrade benefits to a less expensive material.
• Pre-authorization: Submit a pre-treatment estimate with supporting documentation (radiographs, narrative, photos) to determine coverage and patient responsibility.
• Accurate coding: Use D6250 only for PFM pontics. If a different material is used, select the appropriate code, such as all-ceramic pontic or cast metal pontic.
• Claim submission: Attach all required documentation and a clear narrative explaining the clinical need for a PFM pontic. Clearly indicate the location (tooth numbers) and abutment teeth involved.
• Appeals: If denied, review the Explanation of Benefits (EOB), address the payer’s reason for denial, and submit a detailed appeal with additional documentation if needed.

Example Case for D6250

Case: A 52-year-old patient presents with a missing #19 (first lower molar). Both adjacent teeth (#18 and #20) are healthy and suitable as bridge abutments. The dentist recommends a three-unit fixed bridge with a PFM pontic for strength and esthetics.

Billing workflow:

1. Verify insurance coverage for fixed bridges and PFM materials.
2. Obtain pre-treatment authorization with radiographs and a narrative describing the clinical necessity.
3. Document the material choice and clinical findings in the patient chart.
4. After treatment, submit the claim with D6250 for the pontic, along with codes for the abutment crowns.
5. If the claim is denied due to material downgrades, review the EOB and appeal with additional documentation supporting the need for PFM.

This process ensures accurate billing, reduces AR delays, and supports successful reimbursement for D6250 procedures.