D5223 is the CDT code for an immediate upper partial denture on a cast metal framework, seated the same day the failing upper teeth are extracted.
- When to use: The patient keeps some upper teeth, and a cast framework partial made before surgery goes in on the same date as the extractions.
- When not to use: The same framework on a healed ridge is D5213, an all-resin immediate upper is D5221, a flexible immediate is D5227, and the lower version is D5224.
- Billing note: Some plans pay D5223 at the D5221 resin allowable, so put the dollar gap in a signed estimate before the framework is cast.
What D5223 covers
D5223 reports an immediate maxillary partial denture built on a cast metal framework with resin denture bases. The lab casts the framework and processes the saddles on a model of the arch as it will look after surgery. At the delivery visit, the failing upper teeth are extracted and the partial seats over the fresh sites.
One fee covers the framework, the resin bases, the clasps and rests, the replacement teeth, and the limited follow-up care in the code’s scope. Future relines and rebases are outside it.
Bill D5223 when the patient keeps some maxillary teeth, the framework partial was made before the surgical appointment, and it is delivered the day the teeth are extracted.
It does not cover:
- The conventional (healed-ridge) maxillary cast metal partial. That is D5213.
- The mandibular immediate cast metal partial. That is D5224.
- The all-resin immediate upper partial. That is D5221.
- The flexible-base immediate upper partial. That is D5227.
- The same-day extractions, billed per tooth on D7140 or D7210.
- Follow-up work, which uses the maxillary partial codes rather than the complete-denture ones: D5740 (chairside) or D5760 (laboratory) to reline the saddles after healing, D5622 to repair the framework, and D5421 for adjustments.
- An immediate complete upper denture when no teeth remain. That is D5130.
The downgrade to the resin rate
Cast metal is the most expensive partial, and plans that apply an alternate-benefit clause to partials generally apply it here too. The clause substitutes the least costly professionally adequate alternative, and payment issues at the resin-immediate (D5221) allowable. That is not a denial. The patient owes the gap between the cast metal fee and the resin allowable, plus coinsurance calculated on the smaller number.
Whether the clause applies, and what it downgrades to, is plan-specific. Some plans pay cast metal partials in full at the contracted fee, some exclude the upgrade, and some don’t distinguish. Only verification of the actual policy answers it, and on a case this expensive the patient’s share belongs in a signed pre-treatment estimate before the framework is cast.
Why this code draws clinical review
An immediate partial spares the patient a period without teeth; a cast metal partial exists to fit precisely. The two goals conflict, because the precise fit is taken on an arch that surgery is about to change.
Offices handle this in different legitimate ways: casting the framework to the planned post-extraction contour, planning an early saddle reline, or staging with a resin or interim appliance first. Carriers that review high-fee removable prosthetics ask why the definitive framework is going in now rather than after healing. A chart that answers it with the records listed below heads off a records request.
Top reasons D5223 gets denied or downgraded
- Alternate-benefit downgrade to resin. Paid at the D5221 (or even conventional resin) allowable, and the patient owes the difference. Plan-dependent; catch it at verification, not on the EOB.
- Frequency limit. One partial per arch inside the plan’s replacement window, and a prior covered partial of any material usually starts the clock.
- Missing-tooth clause. Teeth extracted at delivery are current, but previously missing teeth the partial also replaces can be carved out or used to deny the claim, depending on the plan.
- Records request. Without a pre-extraction radiograph or treatment plan, the claim pends while the carrier asks why a definitive cast prosthesis was seated on surgery day.
- Reline billed too soon. A saddle reline inside the plan’s post-delivery waiting window denies as included. Schedule the stage-two claim against the verified window.
Documentation that supports the claim
- Delivery-date claim with the maxillary arch designation, and the extractions listed per tooth on the same date of service.
- Pre-extraction panoramic or periapical radiographs, and the written treatment plan naming the extraction teeth and the abutment teeth.
- Chart notes on the framework try-in (if one preceded surgery), ridge condition at delivery, the reline plan for the saddles, and the reason for a definitive framework at the immediate stage.
- The fee from the office fee schedule, with the signed pre-treatment estimate on file showing the patient saw the downgrade math before consenting.
FAQs
- What's the difference between D5223 and D5213?
- Delivery timing. Both are maxillary partials on a cast metal framework with resin bases, with the clasps, rests, and teeth included. D5213 is conventional: the framework is tried in and delivered on a healed, stable ridge. D5223 is made before the extractions and seated the same day the teeth are removed.
- What's the difference between D5223 and D5221?
- The base. D5221 is the immediate upper partial on an all-resin base; D5223 adds a cast metal framework carrying resin saddles. Both are delivered the day of the extractions. Many plans treat cast metal as the premium option, and on immediate cases some pay it at the resin allowable as an alternate benefit, leaving the difference to the patient. Whether that applies is plan-dependent.
- Why would an office choose a resin immediate over a cast metal one?
- Because the ridge is about to change. A cast framework is fitted to the pre-surgical cast, so after the extraction sites remodel, the saddles need relining while the metal stays in its original position. Many treatment plans use a resin immediate (D5221) or an interim partial (D5820) through healing and place the cast metal partial on the stable ridge. When a case does call for D5223, document why, because claim reviewers ask the same question.
- How is the later reline handled on a D5223 case?
- It bills separately. D5223's scope excludes future relines, so the resin saddles are relined on D5740 (chairside) or D5760 (laboratory) for a maxillary partial. Framework repairs on the upper arch use D5622. Reline waiting periods and frequency limits are plan-dependent, so verify both before scheduling the refit.
Related codes
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CDT codes are maintained by the American Dental Association. This page is an editorial billing guide, not the official ADA code descriptor. Verify current coverage policies with each carrier before submitting claims.