Understanding Dental Code D5640

When to Use D5640 dental code

The D5640 dental code is used for the replacement of broken teeth on a removable prosthesis, such as a partial or full denture. This CDT code specifically applies when one or more artificial teeth have fractured or detached from the denture base and need to be replaced. It is important to distinguish D5640 from codes used for adding teeth to a new prosthesis or for repairs that do not involve actual replacement. Proper use of this code ensures accurate billing and minimizes claim denials.

Documentation and Clinical Scenarios

Accurate documentation is essential when billing for D5640. The clinical notes should clearly state the reason for the replacement, such as accidental breakage, wear, or loss of a tooth from the prosthesis. Include the date of the original prosthesis delivery, the number and location of teeth being replaced, and any relevant patient history. Photographs and radiographs (if applicable) can further support the claim. Common clinical scenarios include a patient presenting with a fractured denture tooth after trauma or a tooth lost due to normal wear and tear.

Insurance Billing Tips

To maximize reimbursement and reduce accounts receivable (AR) delays, follow these best practices when billing D5640:

• Pre-authorization: Check with the patient’s insurance to determine if pre-authorization is required for prosthetic repairs.
• Detailed claim submission: Attach clinical notes, before-and-after photos, and a laboratory invoice if available. Clearly indicate the tooth number(s) replaced.
• Coordination with related codes: If other repairs are performed simultaneously (e.g., base repairs or clasp additions), use the appropriate CDT codes and provide a breakdown in the claim narrative. For example, if a clasp is also replaced, reference D5670 for clasp replacement.
• Appeals: If a claim is denied, review the Explanation of Benefits (EOB) for the denial reason. Submit a detailed appeal with supporting documentation, emphasizing the necessity and distinct nature of the service.

Example Case for D5640

Consider a patient who returns to the dental office with a partial denture missing a premolar tooth after accidentally dropping it. The dentist examines the prosthesis, confirms the need for replacement, and documents the incident, including photos. The office submits a claim using D5640, attaches the clinical notes and photos, and receives approval from the insurer. The laboratory fabricates and attaches the new tooth, and the patient is scheduled for delivery and adjustment. This step-by-step process demonstrates how thorough documentation and proper code selection streamline the billing workflow and improve reimbursement outcomes.