Understanding Dental Code D5914

When to Use D5914 dental code

The D5914 dental code is designated for the fabrication of an auricular prosthesis, which is a custom-made external ear replacement. This CDT code is used when a patient requires a prosthetic ear due to congenital absence, trauma, or surgical removal (such as after cancer treatment). Dental practices, especially those with maxillofacial prosthodontists, may encounter this code when working with patients who need facial prosthetics to restore function and aesthetics. It is important to use D5914 only when a complete auricular prosthesis is being fabricated and delivered, as partial repairs or adjustments may require different CDT codes.

Documentation and Clinical Scenarios

Proper documentation is essential for successful billing and insurance reimbursement. When using D5914, ensure the patient’s clinical records include:

• Detailed diagnosis and reason for prosthesis (e.g., trauma, congenital defect, surgical resection)
• Pre- and post-operative photographs
• Provider’s narrative describing medical necessity
• Procedure notes outlining the steps of impression, fabrication, fitting, and delivery
• Any supporting medical records or referrals from surgeons or oncologists

Common clinical scenarios include patients with microtia, traumatic avulsion, or post-oncologic reconstruction. In each case, documentation should clearly justify the need for a prosthetic ear, emphasizing the impact on the patient’s quality of life and function.

Insurance Billing Tips

Billing for D5914 can be complex due to its medical-dental crossover. Here are actionable steps for maximizing claim success:

1. Insurance Verification: Before treatment, verify both dental and medical benefits. Many insurers consider auricular prostheses medically necessary, so coordination of benefits is crucial.
2. Pre-authorization: Submit a pre-authorization request with all supporting documentation, including clinical notes, photographs, and a detailed narrative. This reduces the risk of denials.
3. Claim Submission: Use the correct CDT code (D5914) and include all necessary attachments. If billing medical insurance, use the appropriate CPT/HCPCS code as well and cross-reference the dental claim.
4. Follow Up: Track the claim’s status in your AR system. If denied, review the EOB for specific reasons and prepare a targeted appeal with additional documentation if needed.
5. Appeals: Successful appeals often include letters of medical necessity, additional photos, and endorsements from referring physicians.

Remember, clear and thorough documentation is your best defense against denials and delays.

Example Case for D5914

Consider a patient who lost their external ear due to surgical removal of a tumor. The dental team, in collaboration with the patient’s oncologist, determines an auricular prosthesis is needed. The office collects all medical records, takes detailed photographs, and writes a comprehensive narrative explaining the necessity for the prosthesis. Insurance verification reveals coverage under the patient’s medical plan. A pre-authorization is submitted and approved. The prosthesis is fabricated and delivered, and the claim is submitted using D5914 with all supporting documentation. The claim is paid in full after a brief follow-up call to clarify a minor documentation question. This case highlights the importance of proactive communication, thorough documentation, and diligent follow-up for successful reimbursement when using the D5914 dental code.