When is D4266 used?
The D4266 dental code represents "Guided Tissue Regeneration – Resorbable Barrier, Per Site." This CDT code applies when dental professionals perform surgical procedures to restore lost periodontal structures (including bone and connective tissue) utilizing a resorbable barrier membrane. D4266 is suitable for addressing periodontal defects resulting from moderate to severe periodontitis, particularly when bone loss compromises tooth stability. This code should not be applied to standard cleanings or minor gum procedures; it is exclusively for regenerative treatments requiring a membrane to promote tissue development and healing.
D4266 Charting and Clinical Use
Proper documentation is essential for successful D4266 reimbursement. Clinical records must include the diagnosis (such as intrabony defect or furcation involvement), specific treatment sites, and the resorbable membrane type utilized. Incorporate pre- and post-treatment radiographs, periodontal measurements, and intraoral photographs whenever available. Typical clinical applications for D4266 encompass:
Bone regeneration around teeth with significant periodontal pockets.
Management of furcation defects in molar teeth.
Restoration of bone loss after trauma or infection, where regeneration is feasible.
Ensure the clinical documentation clearly supports the necessity for guided tissue regeneration and resorbable barrier placement.
Billing and Insurance Considerations
Processing D4266 claims demands careful attention and proactive insurer communication. Consider these practical approaches for optimizing reimbursement:
Benefits Verification: Prior to treatment, confirm the patient's periodontal coverage and any limitations on regenerative procedures. Record the representative's information and call reference number.
Prior Authorization: File a comprehensive prior authorization including supporting materials (diagnosis, radiographs, periodontal measurements, and clinical description). This minimizes claim rejection risk.
Claims Processing: On claim forms, report D4266 for each treated site. Include all supporting materials and use specific, procedure-focused terminology in descriptions.
Multiple Coverage: For patients with multiple insurance plans, coordinate benefits to optimize reimbursement and reduce patient expenses.
Appeals Process: When claims are denied, examine the explanation of benefits for rejection reasons, compile additional supporting evidence, and file timely appeals with comprehensive clinical justification.
Maintaining current knowledge of insurer guidelines and keeping detailed records are essential for successful D4266 billing.
How dental practices use D4266
Practice Example: A 52-year-old patient exhibits a 7mm intrabony defect on the mesial surface of tooth #30. Following thorough periodontal assessment and radiographic verification, the periodontist concludes that guided tissue regeneration is clinically appropriate. During the surgical procedure, a resorbable membrane is positioned to promote bone and tissue regeneration. The treatment, location, and materials are thoroughly documented, with pre- and post-operative images added to the patient file. The insurance claim is processed using D4266, accompanied by a detailed clinical description and complete supporting documentation, achieving successful reimbursement.
For similar procedures, including guided tissue regeneration using a non-resorbable barrier, refer to D4267.
Common Questions
Is it possible to bill D4266 together with other periodontal treatments?
D4266 can indeed be billed with other periodontal treatments like bone grafting procedures (D4263). Each treatment must be properly documented and billed as separate line items for appropriate reimbursement. Ensure your clinical documentation clearly identifies each distinct service performed at the surgical site.
Does D4266 have any patient age requirements or eligibility limitations?
D4266 has no age-related restrictions and is determined by clinical need rather than patient demographics. Insurance plan coverage can differ significantly, so it's essential to confirm patient benefits and eligibility prior to treatment.
What typically causes insurance companies to deny D4266 claims?
Frequent denial reasons include inadequate documentation, insufficient proof of medical necessity, incorrect application to implants rather than natural teeth, or surpassing plan frequency limits. Reduce denial risk by providing comprehensive clinical documentation, radiographic evidence, and confirming the procedure aligns with payer requirements.