How often can an orbital prosthesis be replaced?

Replacement frequency depends on the patient's needs and insurance coverage. Typically, replacements occur when the prosthesis is damaged or worn.

Is pre-authorization required for billing D5928?

Pre-authorization requirements vary by insurance provider. It is advisable to check with the patient's insurance to ensure compliance.

Can D5928 be used if the patient's facial structure has changed significantly?

No, significant changes would require a new mold and possibly a different CDT code.

What should be documented if the prosthesis is replaced due to aesthetic reasons?

Document the patient's request and any minor changes in the tissue bed that justify the replacement without a new mold.

D5928

Orbital Prosthesis Replacement - CDT Code Guide

Maxillofacial Prosthetics/Other Removable Prosthetic Services

Overview

CDT Code D5928 pertains to the replacement of an orbital prosthesis. This procedure involves creating a new prosthetic device using an existing mold, provided there are no significant changes in the patient's tissue bed due to surgery or age-related variations. The orbital prosthesis is crucial for patients who have lost an eye or surrounding structures due to trauma, surgery, or congenital conditions. The replacement process ensures that the prosthesis continues to fit well and function effectively, maintaining the patient's appearance and comfort. Typically, this code is used when the existing prosthesis has worn out or been damaged, and a new one is needed without the necessity of a new mold.

When to Use This Code

When the existing orbital prosthesis is damaged or worn out.
If the patient requires an updated prosthesis due to minor changes in the tissue bed.
When the patient has undergone minor surgical procedures that do not significantly alter the mold's fit.
For routine replacement of the prosthesis as part of ongoing care.
When the patient requests a new prosthesis for aesthetic reasons without changes to the mold.

Documentation Requirements

Detailed patient history and reason for replacement.
Documentation of the condition of the existing prosthesis.
Verification that no new mold is required.
Clinical notes on any minor changes in the tissue bed.
Patient consent for the replacement procedure.
Insurance pre-authorization if required.

Billing Considerations

When billing for D5928, it is important to note that the frequency of replacements may be limited by insurance providers. Ensure that the replacement is medically necessary and document any changes in the patient's condition. Common modifiers may include those indicating the replacement nature of the procedure. Verify with the patient's insurance for specific coverage details and any pre-authorization requirements.

Related CDT Codes

D5924 D5925 D5926 D5927 D5931

Frequently Asked Questions

A new orbital prosthesis requires creating a new mold, while a replacement uses the existing mold unless significant changes in the tissue bed occur.

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