Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

Plan Stipulations vs. Patient Needs: Buccal Restorations

A doctor is prepping a deep buccal restoration when they notice the decay creeps a millimeter or two onto the mesial side of the tooth. The office deserves to be fairly compensated for the doctor’s chair time, but also doesn’t want to trigger an insurance audit for incorrect billing practices. A common question in this scenario is:

“Can we bill a buccal restoration as a multi-surface restoration if the prep slightly extends into the mesial or distal of the tooth?”

Do clinical judgment and insurance rules align?

Technically speaking, if clinical judgment dictates that the decay extends far enough beyond the line angle to encompass an entirely separate surface, it can be documented as a multi-surface restoration. However, what is documented in the clinical notes and what insurance will actually reimburse for are often two very different things.

Here is a compliance reality check: many, if not most, commercial insurance plans will not reimburse a mesial (M) or distal (D) surface unless the preparation breaks contact with the adjacent tooth. Furthermore, many payors require an occlusal (O) surface to be involved before they will ever reimburse a proximal surface when an adjacent tooth is present.

If the office begins to routinely bill these buccal preps as mutli-surface restorations, like MDB or DB, payors may take notice.

In this day and age, insurance companies use advanced data analytics to track billing patterns. Almost certainly, the majority of buccal extensions only wrap a few millimeters past the line angle. If your practice submits significantly more multi-surface buccal/facial or lingual composites than the statistical average for an office’s zip code, the provider may be flagged.

Consistently “stretching” a single-surface buccal into a multi-surface code to boost revenue is considered upcoding. It is a quick way to land your practice under intense payor scrutiny, potentially leading to chart reviews, delayed payments, or even a full-scale insurance audit. 

Protect the office’s billing practices with meticulous documentation.

Are there legitimate times when a buccal/facial or lingual restoration genuinely involves a proximal surface without an occlusal component? Absolutely! An example of this would be when tunnel preparation is completed. If it is necessary to treat an unusual clinical scenario that genuinely warrants multi-surface billing, protect the practice with these three steps:

1. Write an Audit-Resistant Narrative: Don’t let the automated system play a guessing game at the office’s expense. Explicitly state the unusual nature of the preparation in the 2024 ADA claim form remarks box, keeping in mind the 80 character limit of this section of the claim form.
   1. E.g., “Tunnel preparation from facial aspect w/ significant structural involvement of the M surface.“
2. Attach Intraoral Photo(s): A picture is worth a thousand delayed or denied claims. Take clear, high-resolution intraoral photos of the prep before placing the composite to visually verify that the extension extends deep past the line angle.
3. Assess Interproximal Involvement: As a general rule of thumb, if the preparation did not break through the interproximal wall to the adjacent tooth, simply bill this as a single-surface buccal (B) or lingual (L) code.

Don’t risk an audit over a few millimeters of composite.

Clinical documentation must always reflect exactly what was performed, but billing codes must adhere to standard industry definitions set forth by the ADA and the CDT. Keep billing practices clean, back up complex cases with a strong narrative and photos, and let clinical honesty protect the practice’s bottom line.

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