D5938Resection Prosthesis, Maxillary, with Soft Tissue Support

What This Code Covers

D5938 covers resection prosthesis, maxillary, with soft tissue support. This specialized prosthetic device serves a maxillofacial rehabilitation function. Documentation should include the specific clinical indication and design rationale.

Billing Guide

Bill this code when:

• The prosthetic device described by D5938 is fabricated and delivered
• The clinical indication and device design are documented
• The specific prosthesis type matches the code description

Do not bill this code when:

• A different prosthesis type was delivered
• The procedure is a modification or adjustment rather than a new fabrication
• The prosthesis type does not match this code description
• The procedure is better described by D5919 (Facial prosthesis)

Insurance and Denial Prevention

Key Payer Rules:

• Most plans have frequency limits for denture replacement (typically once every 5-10 years)
• Relines, rebases, and repairs have separate frequency limits
• Prior authorization is commonly required for new complete and partial dentures
• Maxillofacial prosthetic codes may not be covered under standard dental plans

Common Denials and How to Respond:

• Frequency limit for replacement - Document why the current prosthesis cannot be repaired or relined and must be replaced.
• Prior authorization not obtained - Submit post-service with full documentation if prior auth was not obtained before delivery.
• Not a covered benefit - For maxillofacial prosthetics, check if coverage exists under the patient's medical plan rather than dental.