Understanding Dental Code D5995

When to Use D5995 dental code

The D5995 dental code is designated for a periodontal medicament carrier with peripheral seal, laboratory processed, maxillary. This CDT code is specifically used when a custom-fabricated appliance is created in a dental laboratory to deliver medicaments directly to the maxillary (upper) arch, ensuring a tight peripheral seal for effective periodontal therapy. Dental practices should use D5995 when conservative periodontal treatment requires targeted delivery of medication, such as antimicrobials, to treat chronic periodontitis or manage localized infections that do not respond to standard therapies.

Documentation and Clinical Scenarios

Proper documentation is crucial for successful reimbursement and compliance. When using D5995, ensure the patient’s chart includes:

• Detailed periodontal diagnosis and clinical findings (e.g., pocket depths, bleeding on probing, radiographs).
• Rationale for using a medicament carrier, including prior unsuccessful treatments or contraindications to surgery.
• Type and concentration of medicament prescribed.
• Laboratory prescription and fabrication details.
• Patient consent and education regarding the appliance’s use and care.

Common clinical scenarios include patients with recurrent periodontal pockets in the maxillary arch, those unable to undergo surgical intervention, or individuals requiring adjunctive therapy alongside scaling and root planing. If a similar appliance is fabricated for the mandibular arch, refer to D5996 for proper coding.

Insurance Billing Tips

Billing for D5995 can be challenging due to variable insurance coverage. Follow these best practices to improve claim success:

• Pre-authorization: Always verify benefits and obtain pre-authorization from the payer, as many plans consider this service medical necessity-dependent or exclude it as experimental.
• Detailed narratives: Include a thorough clinical narrative and supporting documentation with the claim, highlighting failed conventional therapies and the medical necessity for a medicament carrier.
• Attach supporting documents: Submit periodontal charting, radiographs, and laboratory invoices to substantiate the claim.
• Track EOBs: Review Explanation of Benefits (EOBs) carefully for denial reasons. If denied, prepare a strong appeal with additional clinical justification and peer-reviewed literature if available.
• Patient communication: Clearly explain potential out-of-pocket costs to patients before treatment, as coverage is not guaranteed.

Example Case for D5995

Case: A 52-year-old patient with chronic periodontitis presents with persistent 6-7mm pockets in the upper molar region, unresponsive to scaling and root planing. Surgical intervention is contraindicated due to systemic health concerns. The periodontist prescribes a laboratory-processed medicament carrier for the maxillary arch to deliver a sustained-release antimicrobial agent.

Billing workflow:

1. Verify insurance coverage and obtain pre-authorization for D5995.
2. Document clinical findings, diagnosis, and rationale for appliance use in the patient’s chart.
3. Send laboratory prescription and receive the finished carrier.
4. Deliver appliance to patient, provide usage instructions, and obtain signed consent.
5. Submit claim with D5995, attaching narratives, periodontal charting, and lab invoice.
6. Monitor EOB and follow up with an appeal if necessary.

By following these steps, dental teams can maximize reimbursement potential and provide optimal care for patients needing advanced periodontal therapy.