When is D5996 used?
The D5996 dental code applies to a "periodontal medicament carrier with peripheral seal – laboratory processed – mandibular." This CDT code is utilized when patients need a custom-made device, usually for the lower arch, created to deliver medications directly into periodontal pockets. Dental professionals commonly recommend this device for patients with ongoing periodontitis or those who haven't responded well to standard periodontal treatments. The D5996 code specifically covers laboratory-made carriers, setting it apart from chairside or ready-made options.
D5996 Charting and Clinical Use
Accurate documentation is crucial for proper reimbursement and clinical support. When using D5996, dental practices should document:
Complete clinical records outlining the patient's periodontal condition and past treatments.
Medical justification for using a medicament carrier, including ongoing deep pockets or treatment-resistant areas.
Medication specifications for the drug to be delivered through the carrier.
Laboratory documentation or fabrication proof, since this code covers lab-made devices.
Typical clinical situations involve patients with focused or widespread periodontitis, particularly when additional therapy is needed. For instance, if a patient shows continuing 6+ mm pockets following scaling and root planing, and the clinician decides that extended-release medication is required, D5996 is the correct choice.
Billing and Insurance Considerations
Processing claims for D5996 needs careful attention and clear communication with insurance companies. Here are recommended practices:
Check coverage beforehand, since not every dental insurance plan includes medicament carriers. Call the insurance company and record the pre-approval or benefit confirmation process.
Include complete documentation with claims, such as clinical records, periodontal measurements, and laboratory receipts.
Apply correct CDT coding and prevent incorrect billing practices. When other periodontal treatments (like scaling and root planing, D4341) are done, make sure they are billed separately with proper documentation.
Check EOBs (Explanation of Benefits) thoroughly. When claims are rejected, start a claim appeal with extra supporting materials, including X-rays or clinical photographs.
Effective dental practices often assign a staff member to monitor D5996 claims and handle any processing delays or rejections, maintaining proper accounts receivable (AR) oversight.
How dental practices use D5996
Take a patient with ongoing periodontitis who has received several scaling and root planing treatments, yet continues to show deep pockets in the lower back teeth area. The periodontist orders a laboratory-made medicament carrier for the lower arch to apply a localized antimicrobial treatment. The dental staff records the clinical necessity, attaches the lab receipt, and files the claim using D5996. When the insurance company asks for more details, the practice quickly sends periodontal measurements and a written explanation, leading to claim acceptance and payment.
This case shows how important complete documentation, effective insurance communication, and determination in the billing process are when applying the D5996 dental code.
Common Questions
Is D5996 appropriate for pediatric patients or limited to adults only?
D5996 is suitable for both pediatric and adult patients when clinically indicated. The determining factor is the presence of moderate to severe periodontal disease in the mandibular arch requiring adjunctive medicament therapy, irrespective of patient age. Since periodontal disease occurs less frequently in children, pediatric applications would be uncommon and require comprehensive documentation.
Do most dental insurance plans require preauthorization for D5996?
Preauthorization requirements for D5996 differ among insurance carriers. While some plans mandate preauthorization for periodontal medicament carriers, others do not impose this requirement. Best practice involves contacting each patient's insurance provider prior to treatment to confirm preauthorization requirements and prevent potential claim rejections.
What are typical causes for D5996 claim denials?
Typical causes for D5996 claim denials include inadequate documentation (missing clinical notes or laboratory invoices), insufficient evidence of medical necessity, inappropriate use of the code for non-laboratory-processed devices or maxillary applications, and the procedure being excluded from the insurance plan's covered benefits. Maintaining thorough documentation and confirming coverage in advance can help minimize claim denials.