Understanding Dental Code D5913

When to Use D5913 dental code

The D5913 dental code refers to the fabrication and placement of a nasal prosthesis. This CDT code is used when a patient requires a prosthetic device to restore the form and function of the nose due to congenital defects, trauma, or surgical removal (such as after tumor excision). Dental practices should use D5913 specifically when the prosthesis is custom-made to fit the patient’s anatomy and is not a stock or prefabricated device. Proper code selection ensures accurate reimbursement and compliance with insurance requirements.

Documentation and Clinical Scenarios

Accurate documentation is essential when billing for D5913. The clinical record should include:

• A detailed diagnosis and reason for the nasal prosthesis (e.g., trauma, cancer surgery, congenital absence).
• Preoperative and postoperative photos, if possible, to support medical necessity.
• Clinical notes describing the fabrication process, materials used, and fitting sessions.
• Patient consent and education about the prosthesis.

Common scenarios for using D5913 include:

• Patients who have undergone rhinectomy due to cancer.
• Individuals with traumatic loss of nasal tissue.
• Congenital absence or deformity of the nose requiring prosthetic restoration.

Insurance Billing Tips

Billing for D5913 requires attention to both dental and medical insurance workflows, as coverage may vary. Here are best practices for successful claims:

• Verify insurance benefits before treatment. Confirm if the patient’s plan covers maxillofacial prosthetics and whether preauthorization is required.
• Submit detailed documentation with the claim, including clinical notes, photos, and a letter of medical necessity from the provider.
• Use the correct CDT code (D5913) and consider cross-coding with the appropriate CPT code if submitting to medical insurance.
• Track EOBs (Explanation of Benefits) closely and be prepared to appeal denied claims with additional supporting documentation.
• Coordinate benefits if both dental and medical insurance are involved, ensuring no duplication of claims.

Staying proactive with insurance verification and thorough documentation reduces delays in accounts receivable (AR) and improves reimbursement rates.

Example Case for D5913

Consider a patient who has undergone surgical removal of the nose due to carcinoma. Following healing, the prosthodontist evaluates the patient and determines that a custom nasal prosthesis is necessary for both functional and esthetic reasons. The dental team documents the diagnosis, takes preoperative photos, and obtains a letter of medical necessity from the referring surgeon. After fabricating and fitting the prosthesis, the office submits a claim using D5913, attaches all supporting documentation, and follows up with the insurance company. If the claim is denied, the team promptly submits an appeal with additional clinical details, ultimately securing reimbursement for the service.

For related codes, such as those for other maxillofacial prostheses, see D5914 (Auricular prosthesis).