Understanding Dental Code D5935

When to Use D5935 dental code

The D5935 dental code is designated for a mandibular resection prosthesis without guide flange. This CDT code is used when a patient has undergone a partial or complete resection of the mandible—often due to tumor removal, trauma, or congenital defects—and requires a prosthesis to restore function and aesthetics. Unlike codes that specify a guide flange, D5935 applies when the prosthesis does not include a guide flange component. Accurate code selection is crucial, as using the wrong code can result in claim denials or delays in reimbursement.

Documentation and Clinical Scenarios

Proper documentation is essential for successful billing of D5935. Clinical notes should clearly indicate the extent of the mandibular resection, the absence of a guide flange, and the patient’s functional needs. Include pre- and post-operative radiographs, surgical reports, and detailed prosthetic design descriptions. Common clinical scenarios include:

• Patients post-mandibulectomy requiring prosthetic rehabilitation without a guide flange
• Cases where a guide flange is contraindicated due to anatomical limitations
• Patients with stable occlusion who do not require mandibular guidance

Always ensure that the patient’s medical necessity for the prosthesis is well-documented, as this supports claim approval and minimizes the risk of insurance audits.

Insurance Billing Tips

Maximizing reimbursement for D5935 requires attention to detail and proactive communication with payers. Here are best practices:

• Insurance Verification: Before treatment, verify the patient’s dental and medical benefits. Some plans may cover mandibular resection prostheses under medical rather than dental benefits.
• Pre-authorization: Submit a detailed pre-authorization request, including clinical notes, radiographs, and the surgical report. Highlight the absence of a guide flange and explain why D5935 is the correct code.
• Claim Submission: Use the D5935 code on your claim form, accompanied by supporting documentation. Attach all relevant records to minimize requests for additional information.
• Explanation of Benefits (EOB) Review: Carefully review the EOB for payment accuracy. If the claim is denied or underpaid, file a timely appeal with additional documentation and a letter of medical necessity.

Staying organized and maintaining thorough records will streamline the billing process and improve your accounts receivable (AR) outcomes.

Example Case for D5935

Case Study: A 56-year-old patient underwent a partial mandibulectomy due to oral cancer. The surgical team determined that a guide flange was not necessary due to adequate remaining mandibular structure and stable occlusion. The prosthodontist fabricated a mandibular resection prosthesis without a guide flange. The dental office verified that the patient’s insurance required pre-authorization, submitted comprehensive documentation, and used the D5935 code. The claim was approved on the first submission, and payment was received within 30 days. This case underscores the importance of correct code usage, thorough documentation, and proactive insurance communication.

For cases involving a mandibular resection prosthesis with a guide flange, refer to the appropriate CDT code article.