D4249: Clinical Crown Lengthening – Hard Tissue

As explained by the experts at DentalRevu, the D4249 dental code is used to perform a restorative surgery on a tooth that has little or no dental structure accessible to the oral cavity. Crown lengthening necessitates the reflection of a full thickness flap and the removal of bone, resulting in a change in the crown to root ratio.

In contrast to osseous surgery, which is conducted in the presence of periodontal disease, it is performed in a healthy periodontal environment. When treatment is administered in a periodontal disease-affected location (i.e., bone loss), the procedure should be recorded using osseous surgery (D4260/D4261) codes.

When a tooth (or portion of a tooth) has broken off at, close, or just below the gumline, clinical crown lengthening is performed. When this occurs, there may not be enough tooth above the bone to support a crown while also maintaining adequate gingival health.

If crown lengthening is not done and the crown’s margin is too close to the bone, the gum tissue will get irritated. To avoid this, a full thickness flap is lifted and enough bone is excised to allow appropriate space between the bone and the crown margin. This preserves a biological “width.”

After around six weeks of recovery, the final crown preparation can be performed and the impression taken. Crown lengthening may also be done if there is caries near the bone level. In this case, a full thickness flap is raised and bone is excised to give appropriate space between the apical margin of the repair and the bone.

What are the Warnings of the D4249 Dental Code?

Reporting D4249 for a “closed” hard tissue laser treatment is deceptive unless a full thickness flap is first reflected. (See the descriptor for this code: “needs the reflection of a full thickness flap”). A full thickness flap must be mirrored and bone removed to expose more dental structure in order to properly report this code.

If you employ a laser for a component of this surgery, keep in mind that payers reimburse based on the procedure itself, not the technique or technology used to conduct it. D4999 appears to be the code for a “closed” hard tissue laser operation.

Reporting “soft-tissue crown lengthening” as “hard-tissue crown lengthening” is incorrect/misleading. Insurance payers often consider soft tissue crown lengthening to be part of the crown treatment and fee. You will have to see the Dental Code D4212 for more information about this.

Clinical crown lengthening – hard tissue (D4249) is a procedure that involves creation of a full thickness flap (usually mesial and distal to the subject tooth) and excision of hard tissue (bone) to expose sound tooth structure.

The crown to root ratio is altered with this treatment. Payers may need a healing period (usually at least six weeks) before considering reimbursement for a crown on the same tooth. If a patient requires clinical crown lengthening – hard tissue (D4249) at a healthy spot, reporting osseous surgery (D4261) is inaccurate.

Please Note: The term osseous surgery (D4261) refers to the procedure used to treat periodontal disease. Clinical crown lengthening (D4249) is performed in conjunction with a periodontal site that is healthy.

What are the Limitations of the D4249 Dental Code?

  • Typically, D4249 is compensated “once in a lifetime, per tooth” and the cost of hard tissue crown lengthening for cosmetic reasons is not reimbursable. Numerous payers need a minimum of six weeks of recuperation prior to scheduling the crown preparation session.
  • D4249 may not be paid if the crown lengthening is performed on the same service day as the crown preparation, without allowing for a healing time.
  • When a distal or proximal wedge operation (D4274) is combined with hard tissue crown lengthening (D4249) on the same service date, it is typically considered part of the combined surgery and not paid separately.
  • If osseous surgery (D4260/D4261) is performed concurrently with a crown lengthening treatment, the crown lengthening procedure is often considered part of the globalosseous surgery service and is not reimbursed separately.

Additional Information about the D4249 Dental Code

  • To report a “closed” hard tissue crown lengthening operation (in which a full thickness flap is not displayed), use an undefined periodontal technique (D4999).
  • Certain insurers reclassify clinical crown lengthening as osseous surgery — one to three teeth (D4261). In general, D4261 is reimbursed at a lesser rate than D4249. Osseous surgery is used to repair teeth that are periodontally sick.
  • For reimbursement and billing of D4249, a current periodontal chart, periapical radiographs, clinical notes, and tooth number are frequently required. If the tooth is fractured at or below the gumline and the fracture is not visible on the radiograph, photographs should be supplied with the claim.
  • Dental plans demand confirmation that sufficient bone was removed to produce an appropriate gap between the restoration’s apical edge and the bone. When combined with a crown, dental payers frequently require a sufficient healing interval before to crown preparation. Generally, a six-week or longer period of recuperation is considered appropriate.
  • Most payers demand at least six weeks of healing time prior to taking the final crown impression. The healing phase allows the tissues to contract and the dentist to identify the final margin placement.
  • Additionally, there are worries that taking a crown impression too soon after crown lengthening surgery may result in additional tissue loss as a result of the impression procedure’s impact. Bear these constraints in mind while you write your tale or file an appeal.
  • Indicate the location of decay or loss of tooth structure, e.g., ML cusp shattered off within 1 mm of bone crest or M decay at ridge crest.