Understanding Dental Code D5937

When to Use D5937 dental code

The D5937 dental code is designated for a trismus appliance (not for TMD treatment). This CDT code is specifically used when a dental provider fabricates and delivers an appliance intended to manage trismus—restricted jaw opening—due to causes other than temporomandibular disorders (TMD). Common indications include post-radiation fibrosis, trauma, or surgical complications. It is important not to use D5937 for cases where the appliance is for TMD management; in those scenarios, reference the appropriate TMD-related codes.

Documentation and Clinical Scenarios

Accurate documentation is essential for successful reimbursement and compliance. When billing D5937, ensure the patient’s clinical notes clearly state:

• The diagnosis leading to trismus (e.g., post-cancer treatment, trauma, infection)
• The absence of TMD as the primary diagnosis
• Medical necessity for the appliance, including failed conservative therapies if applicable
• Details of the appliance fabrication and delivery

Attach supporting documents such as radiographs, referral notes, or medical history summaries to strengthen your claim. Real-world clinical scenarios may include a patient recovering from oral cancer surgery or a patient with scarring from facial trauma resulting in limited jaw opening.

Insurance Billing Tips

Billing for D5937 requires attention to detail and proactive communication with payers. Follow these best practices:

• Insurance Verification: Before treatment, verify with the patient’s dental and medical insurance whether D5937 is a covered benefit. Some plans may require pre-authorization or may only cover the appliance under medical benefits.
• Claim Submission: Submit a detailed claim with the D5937 code, supporting clinical documentation, and any required attachments. Clearly indicate that the appliance is not for TMD treatment to avoid denials.
• Explanation of Benefits (EOB) Review: Carefully review EOBs for payment accuracy. If denied, check for missing documentation or misinterpretation of the diagnosis.
• Claim Appeals: If a claim is denied, submit a thorough appeal including a letter of medical necessity, additional clinical notes, and references to the CDT code descriptor. Persistence and clear documentation often lead to successful appeals.

Example Case for D5937

Case Study: A 58-year-old patient presents with severe trismus following radiation therapy for oropharyngeal cancer. Conservative stretching exercises have failed to improve jaw opening. The dentist fabricates a custom trismus appliance to aid in jaw mobility. The clinical notes detail the cancer history, failed therapies, and the specific need for the appliance. The office verifies insurance, obtains pre-authorization, and submits a claim with D5937, attaching all relevant documentation. The claim is approved, and payment is received without delay.

This example highlights the importance of proper code selection, documentation, and insurance workflow for efficient revenue cycle management.