When is D5986 used?
The D5986 dental code applies to a fluoride gel carrier, which is a custom-made dental appliance designed for delivering topical fluoride treatments in a home setting. Dental offices should utilize this CDT code when patients need a personalized tray for applying prescription fluoride gel, typically due to elevated caries risk, dry mouth conditions, or other factors that heighten vulnerability to dental decay. This code is not suitable for standard, store-bought trays or for fluoride treatments performed in the dental office, as these services have their own specific codes.
D5986 Charting and Clinical Use
Accurate documentation plays a crucial role in obtaining proper reimbursement and maintaining compliance standards. When submitting claims for D5986, provide comprehensive clinical records that detail the patient's condition (such as extensive decay, radiation-related dry mouth), the clinical justification for a custom fluoride delivery system, and any prior preventive treatments that were tried. Include supporting materials like caries risk evaluations, prescription information, and photographs or digital scans when possible. Typical clinical situations include:
Patients receiving radiation treatment for head and neck cancers who face heightened risk for radiation-related tooth decay
People experiencing significant dry mouth conditions caused by medications or health disorders
Pediatric or adult patients with special healthcare needs who struggle with routine oral care
Patients showing repeated cavity formation even with consistent preventive treatment
Billing and Insurance Considerations
Coverage for D5986 differs among insurance providers, making benefit verification crucial before delivering the device. Apply these recommended practices for effective claim processing:
Benefit Verification: Reach out to the insurance company to determine if D5986 falls under covered services in the patient's dental benefits and if prior approval is necessary.
Claim Processing: File a comprehensive claim including the D5986 code, relevant clinical records, and a written explanation detailing the clinical necessity.
Benefits Review: Thoroughly examine benefit statements for claim rejections or requests for more information. When claims are denied, file an appeal with additional documentation, including necessity letters or expanded clinical records.
Related Codes: When insurers need clarification, be ready to reference associated CDT codes, including those for office-based fluoride treatments (D1206 or D1208), to clearly separate the custom delivery device from other preventive procedures.
How dental practices use D5986
Practice Example: A 55-year-old individual receiving cancer radiation treatment develops severe mouth dryness and quickly advancing tooth decay. Following a thorough decay risk evaluation, the dentist recommends a custom fluoride delivery tray for daily home application. The practice staff records the patient's condition, earlier preventive approaches, and the clinical reasoning for the device. Insurance verification shows coverage is available with proper documentation and explanation. The claim gets filed using D5986, and following initial processing, the insurance company asks for more clinical information. The staff quickly supplies a comprehensive medical necessity letter, leading to successful claim payment.
Through these procedures, dental practices can maintain proper coding accuracy, complete documentation standards, and effective reimbursement for D5986 services, which supports enhanced patient treatment and improved practice financial management.
Common Questions
Does D5986 billing include the cost of fluoride gel?
No, the D5986 code covers only the fabrication and delivery of the custom fluoride gel carrier tray. The fluoride gel cost and topical application must be billed separately using different CDT codes like D1208 or D1206.
What is the billing frequency allowed for D5986 per patient?
Billing frequency for D5986 varies by insurance policy. Some plans restrict coverage to one tray every few years, while others permit more frequent replacements when medically justified. Always verify patient benefits and maintain proper documentation when requesting subsequent reimbursements.
Is it possible to bill D5986 separately for upper and lower trays?
Yes, when fabricating and delivering both upper and lower fluoride gel carriers, D5986 may typically be billed for each arch separately. Ensure proper documentation of medical necessity for both trays and confirm with the insurance provider that separate reimbursement is permitted.