When is D5913 used?
The D5913 dental code applies to creating and placing a nasal prosthetic device. This CDT code is utilized when patients need a prosthetic appliance to rebuild nasal form and function following congenital abnormalities, injury, or surgical procedures (like tumor removal). Dental offices should apply D5913 specifically for custom-fabricated prostheses designed to match individual patient anatomy, not for ready-made or standard devices. Correct code usage ensures proper payment and meets insurance compliance standards.
D5913 Charting and Clinical Use
Proper documentation is crucial when submitting claims for D5913. The patient record must contain:
Complete diagnosis and justification for nasal prosthesis (such as injury, cancer treatment, birth defect).
Before and after photographs when available to demonstrate medical need.
Treatment notes outlining the construction process, materials selected, and adjustment appointments.
Patient agreement and information about the prosthetic device.
Typical situations for D5913 include:
Patients following nose removal surgery for cancer treatment.
People with traumatic nasal tissue loss.
Birth-related nasal absence or malformation requiring prosthetic replacement.
Billing and Insurance Considerations
Processing D5913 claims involves managing both dental and medical insurance processes, since coverage policies differ. Key strategies for claim success include:
Check coverage details prior to treatment. Confirm whether the patient's policy includes maxillofacial prosthetics and if prior approval is needed.
Include comprehensive documentation with claims, featuring treatment records, images, and provider necessity letters.
Apply the proper CDT code (D5913) and consider matching CPT codes when filing with medical carriers.
Monitor payment explanations carefully and prepare to contest rejected claims using additional supporting materials.
Manage multiple insurances when both dental and medical coverage apply, preventing duplicate billing.
Being thorough with coverage verification and complete record-keeping minimizes payment delays and enhances collection success.
How dental practices use D5913
Take a patient who received nose removal surgery for cancer treatment. After recovery, the prosthodontist examines the patient and decides a custom nasal prosthetic is needed for both practical and cosmetic purposes. The dental staff records the condition, captures pre-treatment images, and secures a medical necessity statement from the referring doctor. Once the prosthetic is made and adjusted, the practice files a claim with D5913, includes all required paperwork, and contacts the insurance provider. When the claim gets rejected, the staff quickly files an appeal with extra clinical information, eventually obtaining payment for the treatment.
For similar procedures, such as other maxillofacial prosthetic codes, review D5914 (Auricular prosthesis).
Common Questions
Can code D5913 be used for repairs or modifications to an existing nasal prosthesis?
No, D5913 is designated exclusively for the initial creation and delivery of a nasal prosthesis. For repairs, adjustments, or relines of an existing prosthetic device, you must use different CDT codes that are specifically designed for those particular services. Always reference the most current CDT manual to ensure proper code selection for any follow-up treatments.
What out-of-pocket expenses might patients face with D5913?
Out-of-pocket expenses for D5913 vary based on the patient's individual insurance coverage, deductible amounts, and policy limitations. While some insurance plans provide full coverage, others may require patients to pay co-payments or coinsurance amounts. It's essential to verify coverage with both dental and medical insurance providers and discuss any potential patient financial responsibility prior to beginning treatment.
What is the typical timeframe for receiving insurance payment for D5913 claims?
Insurance reimbursement timelines for D5913 claims vary significantly depending on the insurance carrier, documentation quality, and whether prior authorization was secured. Generally, claims processing takes approximately 30 to 60 days. Processing delays may occur when insurers request additional documentation or when appeals become necessary. Maintaining regular communication with the insurance provider can help accelerate the payment process.