D2160

• Amalgam – three surfaces, primary or permanent

• Covers cases where three surfaces need filling, often due to more extensive decay.
  
   

WARNING

1. It is misleading to report an amalgam restoration as a filling if the caries and preparation do not extend into the dentin and/or fracture is not involved. Restoration of an active cavitated lesion where the filling material is placed in enamel only (not extending into the dentin) is considered a preventive resin restoration (D1352), which would require a resin material.

2. All bases, liners, adhesives, etching, polishing, contact and occlusal adjustments, and the use of caries detection agents are included in the overall amalgam restoration fee. If a pulp cap (D3110/D3120) is reported with an amalgam restoration placed on the same date of service, payors consider the pulp cap (as a base or liner) part of the restoration procedure. A pulp cap's purpose (promotion of healing and repair) is to assist in the formation of secondary dentin. A routine base or liner decreases sensitivity and protects the pulp. Pulp caps promote healing (secondary dentin) and repair. (See D3110/D3120 for further details.) Most PPOs disallow pulp caps (the patient may not be charged).

3. It is necessary to disclose the reason for a restoration if its purpose is to treat abfraction, erosion, wear, abrasion, attrition, or to improve esthetics/cosmetics. These situations are addressed in, and limited by most third party contract(s). Most payors require that decay and/or fracture be present to justify reimbursement for a restoration.

4. It is misleading to report amalgam restorations built to full contour as core buildups (D2950). Core buildups (after the tooth is fully prepared) are justified when they are necessary for the retention of the crown. A core buildup is followed by a temporary crown placement or final restoration placement.

5. When two or more separate restorations are performed on the same tooth on the same date of service, report each restoration separately. Reporting separate restorations on the same tooth is not considered unbundling. Always "report what you do." Note that many payors will limit reimbursement for restorations placed on the same tooth surface on the same service date.

 

COMMENTS

1. Report pins separately. See D2951.

2. Enter the tooth number and surfaces being treated in the appropriate boxes of the 2024 ADA Dental Claim Form.

LIMITATIONS

1. The exclusion period for replacement of amalgam restorations is typically 24 to 36 months, depending on the contract. In some circumstances involving accidents, new caries, or radiation therapy the typical limitations may not apply. Should one of these situations exist and the reimbursement for the replaced restoration denied, or disallowed, appeal with a written narrative explaining the dental necessity. If a restoration is replaced within the limitation period by a different provider, the new provider may be reimbursed. This is, however, dependent on contract language. 

2. Reimbursement for removing and replacing defective restorations may require that the treated tooth have decay, open margins, and/or fracture.

 

NARRATIVES

A crown placed after an amalgam restoration may be fully reimbursed (without the payor deducting the restoration fee from the crown fee) if an unexpected fracture of that tooth or failure of the restoration placed on that tooth is involved. Should this be the case, a narrative and/or appeal may be necessary to prevent the restoration fee from being deducted from the crown fee. Some payors deduct the fee for the restoration (in addition to patient co-pay) from the subsequent crown procedure if the restoration was placed within 12 to 24 months prior to the crown being seated.