Replace Missing or Broken Teeth — Complete Denture (Each Tooth) Template

Replace missing or broken teeth - complete denture.

RMH: Medical history reviewed/updates

Existing prosthesis age: Age/date delivered
Reason for service: Poor fit/sore spot/fracture/tooth or clasp addition/etc.
Service description: Adjustment/reline/repair/modification details
Patient adaptation/feedback: Comfort, retention, stability after service

Arch: Arch
Teeth replaced: Teeth replaced
Cause of loss: Cause of loss

Repair:
Tooth shade matched: Shade
New tooth positioned.
Tooth bonded to denture base.
Occlusion adjusted.
Denture finished and polished.

Patient instructions: Instructions reviewed.

Complications: None or describe.
Patient tolerance: Tolerance/response.

NV: Next visit

Documentation requirements

Repair codes are among the easiest CDT codes to under-document — the work is short, the fee is small, and the chart often reads "denture tooth replaced." That style invites recoupment when the carrier reviews repair frequency, multiple repairs over short windows, or pairings with D5510/D5511/D5512. Per removable prosthodontics guidance and category-level documentation principles, a defensible D5520 note must contain:

• Date of service — and start/stop time when chairside repair is extensive.
• Medical history reviewed and updated — meds, conditions, allergies. Brief but present; "no changes" is acceptable.
• Existing prosthesis age and original delivery date if known — explicitly lists prosthesis age as required for repair/reline notes. Carriers compare against their own delivery records when the original denture was billed in-network. A chart that says "denture is old" without an age is weak.
• Original delivery provider and arch — in-house, out-of-network, or unknown. Arch (maxillary, mandibular, or both) is required on the claim.
• Chief complaint — patient's words ("front tooth broke off when I was eating," "tooth fell out of my upper denture last night"). Anchors the medical necessity for repair.
• Cause of loss / fracture — trauma (drop, bite force on hard food), debonding from acrylic fatigue, prior repair failure, parafunction, or unknown. Establishes that the repair is not a workmanship issue from a recent in-house delivery (which would be inclusive in the original D5110/D5120 fee under most lab and PPO warranty policies).
• Tissue findings / fit assessment — sore spots, ridge resorption, areas of poor adaptation, denture stability and retention. A tooth that fractured because of an underlying fit problem (occlusal interference on a worn denture, ridge resorption shifting load) should drive a reline or remake recommendation rather than just a tooth replacement.
• Tooth or teeth replaced — by tooth number (universal numbering) and arch. D5520 is per tooth; the count drives the claim.
• Tooth shade matched — note the shade tab used (Vita Classical, Vita 3D-Master, Bioform, etc.) and whether it matches existing teeth. Shade match is the most common esthetic complaint after repair.
• Tooth material — acrylic vs porcelain. Most modern denture teeth are acrylic; a porcelain tooth on a worn acrylic denture will introduce occlusal mismatch.
• Repair workflow — chairside vs lab. If chairside: bonding agent, repair acrylic (e.g., self-cure PMMA, light-cure repair resin), preparation of the denture base (relief, undercuts), tooth positioning, occlusion adjustment, polishing. If lab: lab name, instructions, estimated return date, interim plan (patient with denture vs without).
• Occlusion checked and adjusted — articulating paper, marks, adjustments made. A tooth replaced without occlusal verification is a future repair waiting to happen.
• Finishing and polishing — explicit; rough repair surfaces accumulate plaque and stain quickly.
• Patient adaptation and feedback — comfort, retention, stability after the repair. Same-visit feedback is acceptable; longer-term feedback at the post-repair check.
• Photographs — pre-repair photo of the fractured/missing tooth and post-repair photo strongly support the claim and any later appeal. Not strictly required, but increasingly expected by carriers when the fee is appealed.
• Hygiene and care instructions — denture cleaning, soaking, brushing, removal at night. Reinforce on every repair visit.
• Complications — explicit "None" or describe (occlusal interference noted post-repair, patient discomfort, color mismatch noted).
• Patient tolerance / response — tolerated well, expressed satisfaction with shade and fit, etc.
• Recommended follow-up — adjustment visit (D5410/D5411) in 1-2 weeks if needed, reline (D5730/D5731 chairside or D5750/D5751 lab) when the fit problem caused the tooth loss, or new denture (D5110/D5120) when the existing prosthesis is beyond economic repair.
• Provider signature and assistant initials — required.

Two phrases that defuse the most common D5520 audit and bundling questions: an explicit "existing complete denture, delivered [date]; [tooth] fractured [cause] on [date]" line, and an explicit "tooth-base bond intact, denture base intact / fractured" line that justifies billing D5520 alone vs D5520 + a base-repair code (D5510/D5511/D5512). Both track the descriptor and the typical reviewer concern directly.

Common denial reasons

D5520 denials are usually one of three patterns: bundling against D5510/D5511/D5512 base repair, frequency caps on cumulative repairs, or arch/prosthesis-type errors that send the claim to the wrong code series. The most frequent reasons it is denied, downgraded, or recouped:

• Wrong prosthesis type — partial denture repair billed as D5520. D5520 is for complete dentures only; partial repairs use D5640 (replace broken teeth — per tooth) and D5650 (add tooth to existing partial). The claim form's prosthesis identification catches this and the carrier reprocesses or denies.
• Frequency violation — cumulative repair history exceeds 1-2 repairs per 12 months without narrative. A third repair within the same year frequently triggers chart audit and a recommendation that the prosthesis be remade. Submit a narrative documenting the new cause and repair-vs-remake decision rationale.
• Bundling with D5510/D5511/D5512 base repair on same DOS. Most carriers pay both at a combined / reduced fee, but some carriers initially deny the secondary code and require appeal with the chart documenting both base and tooth involvement. Photographs of the fractured base AND missing tooth strongly support the appeal.
• Combined repair fees approaching the new-denture allowance. When repair fees over 12-24 months approach 50% of the new-denture fee, carriers apply the alternate benefit and pay against the new-denture allowance. Document repair-vs-remake prognosis explicitly.
• Re-repair of the same tooth within 12 months without narrative — denied as workmanship. Document a new cause (trauma, parafunction, fit problem causing repeat fracture).
• Repair within the workmanship warranty window of a recent in-house denture — denied as inclusive in the original D5110/D5120 fee or as the lab's warranty responsibility. The fix is to document trauma cause when applicable; routine debonding within 6-12 months of delivery is typically not separately billable.
• Missing prosthesis age or delivery date. explicitly lists prosthesis age as required for repair/reline notes. A chart that says "denture is old" without an age is weak; carriers compare against their own delivery records.
• No tooth number on the claim or chart. D5520 is per tooth; absence of tooth identification is a missing-data rejection. Use universal numbering for the position of the replaced tooth.
• Unspecified arch on the claim. Many claim forms require the arch (maxillary or mandibular) for D5520; submission without it is rejected.
• Default-template chart notes. Identical "tooth replaced, occlusion adjusted, polished" entries across multiple repairs flag templating. Per-patient cause, shade, and findings should differ.
• Implant-supported denture repair miscoded. Implant-retained overdenture (D5863-D5866) repairs may need the implant prosthetic series rather than D5520. Confirm the original prosthesis code first.
• Same-DOS conflict with new denture or remake. D5520 + D5110 or D5120 on the same DOS is denied — the new denture fee is inclusive of any tooth setup. Bill the appropriate path: repair OR remake, not both.
• No occlusion adjustment documented. A tooth replaced without explicit occlusion verification reads as incomplete work; carriers occasionally cite this on appeal review of repeat repair claims.
• Trauma claim missing mechanism. When the cause is trauma and the carrier routes accident claims under separate benefits, the absence of a specific mechanism statement (e.g., "denture dropped on tile floor 2026-04-22") loses the trauma routing.
• Practice-level audit triggers. Elevated D5520 + D5510/D5511/D5512 same-DOS billing relative to specialty norms, repeat repairs on the same denture, and repair-to-new-denture ratios that suggest avoidance of new prostheses all draw chart audits.

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