When is D4264 used?
The D4264 dental code applies to bone replacement graft procedures conducted alongside a retained natural tooth, specifically for each extra site within the same quadrant. This code comes into play when multiple bone grafts are needed during periodontal treatment, such as addressing severe periodontitis or preparing several sites for future implant procedures. It's crucial to understand that D4264 should only be submitted for the second and additional graft sites in one quadrant; the initial site must be reported using D4263 (Bone replacement graft – retained natural tooth – first site in quadrant).
D4264 Charting and Clinical Use
Accurate documentation plays a vital role in securing proper reimbursement. Clinical records must clearly specify the quantity and exact locations of graft sites within the quadrant, along with the justification for each graft (such as bone deterioration from periodontal disease, injury, or implant site preparation). X-rays, periodontal measurements, and intraoral images are suggested to validate the procedure's necessity. Typical clinical situations for D4264 include:
Several neighboring teeth with vertical or horizontal bone deterioration requiring grafting
Quadrants where multiple tooth sites need regenerative treatment during one visit
Extensive periodontal surgeries treating various defects in a single quadrant
Billing and Insurance Considerations
Optimizing reimbursement for D4264 demands careful attention and following payer requirements. Here are recommended practices:
Check coverage: Ensure the patient's dental insurance covers bone grafting treatments and review any restrictions on site numbers or treatment frequency.
Provide complete documentation: Include clinical records, X-rays, and detailed explanations describing why each additional graft site is necessary.
Apply proper codes: Submit D4263 for the initial site and D4264 for each extra site in the same quadrant. Specify site locations clearly on your claim.
Examine EOBs: Thoroughly review Explanation of Benefits documents for rejections or payment reductions, and prepare to file appeals with supporting documentation when necessary.
Monitor AR: Keep track of accounts receivable for payment delays and contact payers promptly for follow-up.
How dental practices use D4264
Picture a patient with severe periodontitis affecting three neighboring teeth in the upper right quadrant. Following comprehensive assessment, the periodontist decides that bone grafting is necessary at all three locations. The office submits D4263 for the initial site and D4264 for the second and third locations. The claim includes comprehensive clinical documentation, X-rays, and detailed explanations supporting the need for multiple grafts. When the insurance company requests more information, the billing staff quickly supplies intraoral photographs and a medical necessity letter. The claim gets approved, and the practice receives complete payment for all graft sites, highlighting how proper coding and detailed documentation lead to successful outcomes.
Common Questions
Is D4264 appropriate for bone grafting procedures around dental implants?
D4264 cannot be used for bone grafts around dental implants. This code is exclusively for bone replacement grafts performed around natural teeth that are being retained. When performing bone grafts related to dental implants, you must use different CDT codes like D6104 for bone grafts placed at the time of implant placement. It's essential to confirm the correct code based on your specific treatment situation.
What are the most frequent causes of insurance claim denials for D4264?
Insurance denials for D4264 typically occur due to inadequate documentation, including missing radiographs or clinical narratives, incorrectly using D4264 for the initial graft site when D4263 should be applied, or surpassing the insurance plan's allowable frequency limits for grafting procedures per quadrant. Proper documentation and accurate code selection can significantly reduce the likelihood of claim rejections.
What approach should dental practices take regarding patient financial obligations for D4264 procedures?
Dental practices should confirm insurance benefits and clearly communicate potential patient costs prior to performing treatment. When insurance doesn't cover multiple graft procedures or when frequency limitations are reached, patients become financially responsible for the additional charges. Providing detailed written treatment estimates and securing informed consent helps prevent future billing conflicts and ensures transparency in financial arrangements.