Understanding Dental Code D5865

When to Use D5865 dental code

The D5865 dental code refers to the fabrication and delivery of a complete mandibular overdenture. This CDT code should be used when a patient requires a removable prosthesis that covers and is supported by implants or retained roots in the lower jaw (mandible). It is distinct from codes for conventional dentures or partials, as D5865 specifically applies to cases where the overdenture is complete and covers the entire mandibular arch. Proper code selection is essential for accurate billing and reimbursement, so ensure the clinical situation matches the code’s definition.

Documentation and Clinical Scenarios

Accurate documentation is crucial when billing for D5865. Your clinical notes should clearly state:

• The patient’s edentulous mandibular arch status.
• The presence and type of implant abutments or retained roots supporting the overdenture.
• Rationale for choosing an overdenture instead of a conventional denture (e.g., improved stability, patient’s medical history).
• Details of the fabrication process, including impressions, try-ins, and final delivery.

Common clinical scenarios include patients with significant mandibular bone loss, those who have difficulty retaining conventional dentures, or individuals seeking improved function and comfort. Always ensure radiographs and supporting documentation are included in the patient record and available for insurance review.

Insurance Billing Tips

Billing D5865 requires careful attention to payer policies and documentation standards. Here are best practices followed by successful dental offices:

• Verify coverage: Before treatment, conduct thorough insurance verification to confirm if the patient’s plan covers implant-supported overdentures. Document any frequency limitations or waiting periods.
• Submit complete claims: Include detailed clinical notes, radiographs, and a narrative explaining medical necessity. Attach pre- and post-operative images if available.
• Use correct CDT codes: If additional procedures are performed (e.g., extractions, implant placement), bill them separately using the appropriate codes, such as implant placement or extraction.
• Monitor EOBs: Review Explanation of Benefits (EOBs) carefully for denials or requests for additional information. Respond promptly to avoid delays in Accounts Receivable (AR).
• Appeal if needed: If a claim is denied, submit a detailed appeal with supporting documentation, emphasizing the patient’s need for an overdenture and the inadequacy of conventional options.

Example Case for D5865

Consider a 68-year-old patient with a fully edentulous lower arch and significant ridge resorption, making conventional dentures unstable. After clinical evaluation and radiographic assessment, two implants are placed in the mandibular arch. Once healed, a complete mandibular overdenture is fabricated to attach to the implants, providing improved retention and function. The procedure is documented thoroughly, and the claim for D5865 is submitted with all supporting records, resulting in successful reimbursement.

By following these best practices, dental teams can ensure accurate billing, minimize claim denials, and provide optimal care for patients needing complete mandibular overdentures.