D6240 - Pontic PFM HN
Pontic – porcelain fused to high noble metal.
- Procedure Code
- D6240
- Clinical Category
- Prosthodontics
- Primary ICD-10 Justification
- K08.409 (Partial loss of teeth, unspecified cause, unspecified class)
- Reference Fee & Claim Types
- BOTH
Insurance Verification Benchmarks & Billing Guidelines
Payer policy benchmarks, pre-submission attachment requirements, and denial prevention rules for D6240.
- Frequency Limitation
- 1 per tooth/space in a 60-month interval (5 years) (rolling_12_months)
- Age Limitation Criteria
- Restricted to patients age 16 or older (complete skeletal development required).
Required Claim Attachments & Pre-Submission Checklist
- Pre-operative treatment narrative and clinical rationale
Bill When (Allowable Clinical Criteria)
- Indicated for medically and clinically necessary treatment as documented in patient's dental record.
Restrictions & Clinical Exclusions
- Fixed partial denture prosthetic procedures include the routine use of temporary prosthetics during the time for normal laboratory fabrication of the completed prosthesis. Participating dentists have agreed that these temporary prostheses are part of the fee for the fixed prosthetic device. Fees for interim or provisional appliances are not billable to the patient when reported less than six months prior to placement of the permanent prosthesis.
- For benefit purposes, anesthesia is an integral part of the procedures being performed and additional fees are not billable to the patient.
- A posterior fixed bridge and partial denture are not benefits in the same arch within the frequency limitations. Benefit is limited to the allowance for the partial denture.
- Fixed prosthodontics are not a benefit for children under 16 years of age. Benefits for children under age 16 are denied.
- Benefits for porcelain and resin inlay bridges are denied.
- The fees for indirectly fabricated restorations and prosthetic procedures include all models, temporaries, laboratory charges and materials, and other associated procedures. Any fees charged for these procedures by the same dentist/dental office in excess of the approved amounts for the indirectly fabricated restorations or prosthetic procedures are not billable to the patient on same date of service.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10-CM Justification & Crosswalk Mappings for D6240 (6)
Click any ICD-10-CM diagnosis code below to inspect its reverse procedure mappings and differential coding guide.
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K08.409 | Partial loss of teeth, unspecified cause, unspecified class | Other disorders of teeth and supporting structures | ★ Yes (Primary) | BOTH | pontic – porcelain fused to high noble metal indicated for Partial loss of teeth, unspecified cause, unspecified class |
| K00.00 | Anodontia | Disorders of tooth development and eruption | Secondary | BOTH | pontic – porcelain fused to high noble metal indicated for Anodontia |
| K08.419 | Partial loss of teeth due to trauma, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | pontic – porcelain fused to high noble metal indicated for Partial loss of teeth due to trauma, unspecified class |
| K08.429 | Partial loss of teeth due to periodontal diseases, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | pontic – porcelain fused to high noble metal indicated for Partial loss of teeth due to periodontal diseases, unspecified class |
| K08.439 | Partial loss of teeth due to caries, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | pontic – porcelain fused to high noble metal indicated for Partial loss of teeth due to caries, unspecified class |
| K08.499 | Partial loss of teeth due to other specified cause, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | pontic – porcelain fused to high noble metal indicated for Partial loss of teeth due to other specified cause, unspecified class |
Frequently Asked Questions — D6240 (Pontic PFM HN)
Quick answers for dental billers and treatment coordinators submitting claims for D6240.
What ICD-10 diagnosis codes link to dental procedure D6240?▾
Common ICD-10-CM justification codes for CDT D6240 (Pontic PFM HN) include: K08.409 - Partial loss of teeth, unspecified cause, unspecified class (Primary); K00.00 - Anodontia; K08.419 - Partial loss of teeth due to trauma, unspecified class; K08.429 - Partial loss of teeth due to periodontal diseases, unspecified class; K08.439 - Partial loss of teeth due to caries, unspecified class; K08.499 - Partial loss of teeth due to other specified cause, unspecified class.
Can CDT code D6240 be billed to medical insurance?▾
Billing CDT D6240 (Pontic PFM HN) to medical insurance depends on the underlying clinical necessity and trauma/pathology documentation. Supported claim types across linked diagnoses: BOTH.
What attachments and documentation are required for billing CDT D6240?▾
Required claim attachments for CDT D6240 (Pontic PFM HN) include: Pre-operative treatment narrative and clinical rationale.
What is the insurance frequency limitation for CDT D6240?▾
Standard commercial insurance frequency for D6240: 1 per tooth/space in a 60-month interval (5 years) (rolling_12_months). Age criteria: Restricted to patients age 16 or older (complete skeletal development required)..
What are common insurance denial reasons and appeal tips for CDT D6240?▾
Denial Code CO-119 (Benefit maximum or frequency limitation exceeded for procedure): Overturn appeal strategy - Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria.