Understanding Dental Code D5226

When to Use D5226 dental code

The D5226 dental code is designated for a mandibular partial denture, flexible base (including any clasps, rests, and teeth). This CDT code is specifically used when fabricating and delivering a removable partial denture for the lower arch (mandible) that utilizes a flexible base material, such as nylon, instead of traditional acrylic. Dental practices should select D5226 when a patient requires a partial denture due to missing teeth in the lower jaw, and a flexible base is clinically appropriate—often for patients seeking improved comfort, aesthetics, or who have allergies to acrylic materials.

Documentation and Clinical Scenarios

Accurate documentation is essential for successful reimbursement and compliance. When billing D5226, ensure the patient’s chart clearly records:

• The clinical need for a mandibular partial denture (e.g., number and location of missing teeth, impact on function and aesthetics).
• Why a flexible base was chosen over a conventional acrylic base (e.g., patient allergies, anatomical considerations, patient preference).
• Detailed treatment notes, including pre-op and post-op photos, radiographs, and diagnostic models if available.
• Signed consent forms and documentation of patient education regarding care and maintenance of the appliance.

Common clinical scenarios include patients with multiple missing lower teeth, intolerance to rigid bases, or those seeking a more esthetic, metal-free option. If the case involves a maxillary partial denture with a flexible base, refer to D5225 for the corresponding code.

Insurance Billing Tips

To maximize reimbursement and minimize denials when submitting claims for D5226:

• Verify coverage: Always check the patient’s dental benefits for removable prosthetics and any frequency limitations or waiting periods.
• Pre-authorization: Submit a pre-treatment estimate with supporting documentation to determine patient responsibility and avoid surprises.
• Use accurate narratives: Include a clear narrative explaining the clinical rationale for a flexible base, especially if the patient has a history of allergies or failed previous prosthetics.
• Attach supporting documentation: Upload radiographs, photos, and chart notes with the claim to support medical necessity.
• Track EOBs and follow up: Monitor Explanation of Benefits (EOBs) for underpayments or denials, and be prepared to submit appeals with additional documentation if needed.

Staying proactive with insurance verification and thorough documentation streamlines the revenue cycle and reduces accounts receivable (AR) delays.

Example Case for D5226

Case Scenario: A 62-year-old patient presents with four missing mandibular posterior teeth and a documented allergy to acrylic. The dentist recommends a flexible base partial denture for improved comfort and aesthetics. The office verifies the patient’s insurance, confirms coverage for flexible partials, and submits a pre-authorization with supporting clinical notes and allergy documentation. After approval, the denture is fabricated and delivered. The claim is submitted with a detailed narrative and supporting images. The insurance pays according to the fee schedule, and the patient is satisfied with the result.

This example highlights the importance of thorough documentation, insurance verification, and clear communication with both the patient and the payer to ensure a smooth billing process for D5226.