Understanding Dental Code D5919

When to Use D5919 dental code

The D5919 dental code is designated for a facial prosthesis, a specialized dental service involving the creation and placement of a prosthetic device to restore facial form and function due to congenital defects, trauma, or surgical removal of facial structures. Dental teams should use D5919 when billing for custom-fabricated facial prostheses that replace anatomical facial features such as the nose, ear, or orbital structures. It is critical to ensure that the service provided matches the CDT code description and is not confused with intraoral prostheses or less complex maxillofacial appliances. Always verify the clinical necessity and ensure the prosthesis is not purely cosmetic, as this affects insurance coverage.

Documentation and Clinical Scenarios

Accurate documentation is essential when billing for D5919. The patient’s chart should include:

• Detailed clinical notes describing the defect or loss requiring the prosthesis
• Pre-operative and post-operative photographs (when appropriate)
• Diagnostic imaging or pathology reports supporting the need for the prosthesis
• A narrative explaining the functional and medical necessity
• Lab invoices and fabrication details

Common clinical scenarios for D5919 include facial trauma from accidents, surgical removal of tumors (such as maxillectomy or rhinectomy), or congenital conditions like microtia. In each case, the documentation should clearly connect the patient’s condition to the need for a facial prosthesis, distinguishing it from other maxillofacial prosthetic codes such as D5926 (nasal prosthesis) or D5927 (auricular prosthesis).

Insurance Billing Tips

Billing for D5919 requires a proactive approach to maximize reimbursement and minimize denials:

• Insurance Verification: Confirm the patient’s coverage for maxillofacial prosthetics prior to treatment. Many plans require pre-authorization and may have exclusions for cosmetic procedures.
• Pre-Authorization: Submit a comprehensive pre-authorization request including clinical documentation, photos, and a strong medical necessity narrative. Follow up with the payer to ensure timely review.
• Claim Submission: Use the correct CDT code (D5919) and include all supporting documentation. Attach lab invoices and operative reports as needed.
• EOB Review: Carefully review Explanation of Benefits (EOBs) for denials or partial payments. If denied, use the payer’s appeal process and provide additional supporting documentation as necessary.
• Coordination of Benefits: For patients with both dental and medical insurance, coordinate benefits to optimize reimbursement. D5919 may be covered under the patient’s medical plan, especially in cases of trauma or surgical defects.

Example Case for D5919

Case Scenario: A patient presents following surgical removal of a malignant tumor resulting in the loss of the right orbital region. The dental team, in collaboration with a maxillofacial prosthodontist, fabricates a custom orbital prosthesis to restore facial symmetry and function. Documentation includes surgical reports, pre- and post-op photos, and a detailed narrative describing the impact on the patient’s daily life. The billing team verifies insurance, obtains pre-authorization, and submits a claim with the D5919 code, supporting documents, and lab invoices. The claim is approved, and the practice receives full reimbursement.

This case highlights the importance of thorough documentation, proactive insurance verification, and clear communication with payers to ensure successful billing for D5919 facial prostheses.