Understanding Dental Code D5223

When to Use D5223 dental code

The D5223 dental code is designated for an immediate maxillary partial denture – resin base (including any conventional clasps, rests, and teeth). This CDT code should be used when a patient requires a partial denture for the upper arch (maxilla) that is delivered immediately after extractions. The intent is to provide the patient with a functional and esthetic solution right after tooth removal, minimizing the time spent without teeth. D5223 is not appropriate for delayed or conventional partial dentures, nor for mandibular (lower arch) appliances, which are billed under different codes.

Documentation and Clinical Scenarios

Proper documentation is essential for successful reimbursement of D5223. Clinical notes should clearly indicate:

• The teeth being extracted and the plan for immediate prosthesis delivery
• Pre-operative and post-operative radiographs or intraoral photos
• The patient’s medical and dental necessity for an immediate partial denture (e.g., esthetics, function, speech)
• Details about the impression, fabrication, and insertion of the appliance

Common clinical scenarios include patients with non-restorable anterior teeth, trauma cases, or those requiring multiple extractions due to periodontal disease. In all cases, the immediate nature of the delivery must be evident in the records.

Insurance Billing Tips

To maximize reimbursement for D5223, follow these best practices:

• Verify benefits: Confirm the patient’s eligibility and coverage for removable prosthodontics, including frequency limitations and waiting periods.
• Pre-authorization: Submit a pre-treatment estimate with supporting documentation (radiographs, narrative, photos) to avoid denials.
• Accurate coding: Use D5223 only for immediate maxillary partial dentures. For mandibular cases, use D5224 (immediate mandibular partial denture).
• Attach supporting documents: Include extraction dates, clinical notes, and lab invoices if requested by the payer.
• Appeals: If denied, review the EOB for the reason and submit a detailed appeal with additional clinical justification and documentation.

Example Case for D5223

Consider a patient presenting with advanced periodontal disease affecting the upper anterior teeth. The treatment plan involves extraction of teeth #7–#10 and immediate placement of a resin-based partial denture. The clinical notes document the need for immediate esthetics and function, and pre-operative photos are included. The office verifies the patient’s insurance, submits a pre-authorization with supporting materials, and receives approval. On the day of extraction, the partial is delivered, and the claim is submitted using D5223 with all required documentation. The claim is processed and paid without delay, thanks to thorough preparation and adherence to best billing practices.