Understanding Dental Code D5927

When to Use D5927 dental code

The D5927 dental code is designated for the replacement of an auricular prosthesis—an artificial ear used to restore form and function for patients with congenital or acquired ear defects. This CDT code should be used when a patient requires a new prosthesis due to wear, damage, or changes in anatomy. It is not intended for initial placement (see initial auricular prosthesis code), but specifically for replacement scenarios. Proper use of D5927 ensures accurate billing and helps avoid claim denials.

Documentation and Clinical Scenarios

Accurate documentation is essential when billing for D5927. Dental teams should include:

• A detailed clinical narrative explaining the need for replacement (e.g., prosthesis no longer fits due to anatomical changes, or is irreparably damaged).
• Photographs or diagnostic images supporting the need for a new prosthesis.
• Patient history, including the date and details of the original prosthesis placement.
• Notes on patient complaints or functional issues with the current device.

Common clinical scenarios include patients with trauma, surgical resection, or congenital absence of the ear who have previously received a prosthesis and now require a replacement due to wear or anatomical change.

Insurance Billing Tips

Billing D5927 successfully requires attention to detail and proactive communication with payers. Here are best practices:

• Verify coverage: Before treatment, check the patient’s insurance policy for prosthetic replacement frequency limitations and documentation requirements.
• Pre-authorization: Submit a pre-authorization request with supporting documentation, including clinical notes and photos, to reduce the risk of denial.
• Itemized claim submission: Clearly list D5927 on the claim form, accompanied by a narrative and supporting evidence.
• Track EOBs: Monitor Explanation of Benefits (EOBs) for payment status and reasons for any denials.
• Appeal process: If denied, promptly initiate a claim appeal with additional documentation or clarification as needed.

Consistent communication with insurance representatives and thorough documentation are key to maximizing reimbursement and minimizing accounts receivable (AR) delays.

Example Case for D5927

Consider a patient who received an auricular prosthesis three years ago following surgical resection for cancer. The prosthesis now shows signs of wear and does not fit securely due to tissue changes. The dental team documents the patient’s complaints, takes updated photographs, and submits a pre-authorization to the insurer with a detailed narrative. Upon approval, the replacement prosthesis is fabricated and delivered. The claim is submitted with D5927, and the EOB confirms payment based on the comprehensive documentation provided. This case highlights the importance of thorough records and proactive insurance coordination when billing for prosthesis replacement.