When is D4260 used?
The D4260 dental code applies to osseous surgery procedures that involve raising a full thickness flap and suturing, performed on four or more adjacent teeth or tooth-bounded areas within one quadrant. This CDT code is appropriate when periodontal disease has caused bone defects requiring surgical treatment to restore proper bone architecture and support. Dental professionals and periodontists commonly choose D4260 when conservative treatments like scaling and root planing have failed to address moderate to severe periodontitis, and surgical access becomes necessary for complete debridement and bone recontouring.
D4260 Charting and Clinical Use
Proper documentation is essential for successful reimbursement of D4260 procedures. Clinical records must clearly show:
The periodontitis diagnosis and surgical justification (such as ongoing pocket depths, radiographic bone loss evidence).
The count and position of affected teeth, verifying that four or more adjacent teeth or spaces receive treatment in one quadrant.
Procedure specifics, including flap raising, debridement, bone reshaping, and suturing.
Before and after radiographs and periodontal measurements.
Typical clinical situations involve widespread chronic periodontitis affecting multiple neighboring teeth, or focused aggressive periodontitis requiring surgical intervention for proper treatment. Always confirm that surgical necessity is thoroughly documented and backed by diagnostic evidence.
Billing and Insurance Considerations
Successfully billing D4260 demands careful attention and proactive insurer communication. Consider these recommended practices:
Check Coverage: Prior to treatment, validate the patient's periodontal surgery coverage, usage limits, and any pre-approval needs with their insurance company.
Provide Complete Documentation: Include thorough clinical notes, periodontal measurements, and radiographs with the claim. Inadequate documentation frequently causes claim rejections.
Apply Proper Quadrant Coding: Specify which quadrant receives treatment, since D4260 billing occurs per quadrant.
Challenge Rejections: When claims are denied, examine the Explanation of Benefits for denial reasons, collect missing documentation, and file a detailed appeal citing clinical necessity and professional standards.
Manage Multiple Coverage: For patients with dual insurance, ensure benefit coordination is processed properly to optimize reimbursement and reduce patient expenses.
How dental practices use D4260
A 52-year-old patient arrives with widespread moderate to severe periodontitis affecting the upper right quadrant. Following unsuccessful conservative treatment, pocket depths of 6-8mm remain on teeth #2-5, with radiographic signs of horizontal bone loss. The periodontist records the diagnosis, treatment approach, and surgical rationale. Following insurance pre-approval, the surgical treatment is completed on four adjacent teeth. The claim submission includes comprehensive notes, periodontal measurements, and before-and-after radiographs. The insurance company approves payment, and the practice receives prompt reimbursement, highlighting the value of complete documentation and correct D4260 dental code application.
Common Questions
How do D4260 and D4261 dental codes differ?
D4260 applies to osseous surgery performed on four or more adjacent teeth or tooth-bounded areas within one quadrant, whereas D4261 covers the identical procedure when performed on one to three teeth per quadrant. Selecting the correct code is crucial for proper billing and insurance reimbursement.
What out-of-pocket expenses might patients face with D4260 procedures?
Out-of-pocket expenses for D4260 procedures vary based on individual dental insurance plans, including coverage limits, annual benefit maximums, deductibles, and treatment frequency restrictions. Verifying insurance benefits and discussing anticipated costs with patients prior to treatment is recommended.
What is the expected recovery period following D4260 osseous surgery?
Recovery duration after D4260 osseous surgery differs among patients, though most experience preliminary healing within one to two weeks. Complete healing of the surgical area, encompassing both bone and gum tissue regeneration, typically requires several weeks. Following post-operative care guidelines provided by the dental professional is essential for successful healing outcomes.