When is D5937 used?
The D5937 dental code applies to a trismus appliance (not for TMD treatment). This CDT code is utilized when dental professionals create and provide an appliance designed to address trismus—limited jaw opening—caused by factors other than temporomandibular disorders (TMD). Typical reasons include radiation-induced fibrosis, injury, or post-surgical complications. It's crucial to avoid using D5937 when the appliance treats TMD; instead, use the proper TMD-specific codes for those situations.
D5937 Charting and Clinical Use
Proper documentation is vital for successful payment and regulatory compliance. When using D5937, make sure the patient's records clearly document:
The condition causing trismus (such as post-cancer therapy, injury, or infection)
Confirmation that TMD is not the main diagnosis
Medical justification for the appliance, including unsuccessful conservative treatments when relevant
Specifics about appliance creation and placement
Include supporting materials like X-rays, referral letters, or medical history records to support your claim. Common clinical situations include patients healing from oral cancer procedures or individuals with scar tissue from facial injuries that limit jaw movement.
Billing and Insurance Considerations
Processing claims for D5937 demands careful attention and clear communication with insurance companies. Use these recommended approaches:
Coverage Verification: Prior to treatment, confirm with the patient's dental and medical coverage whether D5937 is included as a benefit. Some policies may need prior approval or might only provide coverage through medical benefits.
Claim Processing: File a comprehensive claim using the D5937 code, include supporting clinical records, and add any necessary attachments. Clearly specify that the appliance is not for TMD management to prevent claim rejections.
Payment Review: Thoroughly examine payment statements for correct reimbursement. When claims are rejected, look for incomplete documentation or diagnostic confusion.
Appeal Process: For denied claims, file a complete appeal with a medical necessity letter, extra clinical documentation, and CDT code references. Detailed records and persistence typically result in successful appeals.
How dental practices use D5937
Practice Example: A 58-year-old individual shows severe jaw restriction after radiation treatment for throat cancer. Traditional jaw exercises failed to restore normal opening. The dental provider creates a specialized trismus device to help improve jaw function. Patient records include cancer treatment history, unsuccessful therapies, and clear justification for the appliance. The practice confirms insurance coverage, secures prior approval, and files a claim using D5937 with complete supporting documents. The claim receives approval and payment processes smoothly.
This scenario demonstrates the value of correct code usage, thorough documentation, and proper insurance procedures for effective practice management.
Common Questions
Can D5937 be used for appliances on both upper and lower arches, or is it limited to one?
D5937 applies to trismus appliances created for either the upper arch, lower arch, or both arches, provided the appliance is not designed for TMD treatment. Your documentation must clearly identify which arch receives the appliance and include the clinical justification for its necessity.
What causes D5937 claim denials and how can providers prevent them?
Frequent denial causes include inadequate documentation, insufficient evidence that trismus is unrelated to TMD, and missing preauthorization. Prevention strategies include maintaining comprehensive clinical records, providing detailed narratives that support the non-TMD diagnosis, and securing payer preauthorization before appliance delivery.
How often can trismus appliances be replaced or refabricated under D5937?
No standard replacement schedule exists for D5937 trismus appliances as timing varies based on individual patient requirements and specific payer guidelines. Many insurance providers restrict replacements to several-year intervals unless documented medical necessity justifies earlier replacement. Always verify payer policies and maintain thorough documentation when replacement becomes necessary.