When is D4268 used?
The D4268 dental code represents a "surgical revision procedure, per tooth." This CDT code applies when a previously completed periodontal surgery needs additional surgical work on the same tooth because of complications, poor healing, or ongoing periodontal issues. Typical situations include continuing infection, tissue separation, or the need to reshape tissue or bone following initial surgery. Keep in mind that D4268 does not cover regular post-surgical care, but rather significant surgical corrections that extend beyond normal follow-up treatments.
D4268 Charting and Clinical Use
Proper documentation is essential when using D4268. Clinical records must clearly explain why the revision was needed, what was discovered during the procedure, and which surgical techniques were used. Patient files should contain photographs, X-rays, and periodontal measurements to justify medical necessity. Common clinical situations for D4268 include:
Continuing periodontal pocket depth after original surgery
Tissue flap failure or separation requiring surgical repair
Remaining bone irregularities that need additional shaping
Returning infection at the treatment site
Make sure your documentation clearly separates this procedure from standard post-operative care or small adjustments, which cannot be billed using D4268.
Billing and Insurance Considerations
Effective billing for D4268 needs a careful approach to insurance checking and claim processing. Here are proven methods used by skilled dental billing professionals:
Prior approval: Before planning the revision surgery, check the patient's coverage and get prior approval when needed. Clearly describe the medical need for the revision in your approval request.
Complete claim filing: When filing the claim, provide thorough clinical records, before and after photos, and any supporting materials. Use the proper CDT code (D4268) and identify the specific tooth number.
Expect rejections: Insurance companies may first reject D4268 claims, confusing them with regular follow-up care. Prepare to file a claim appeal with extra documentation, including a written explanation of why the revision was medically required and not part of normal post-operative care.
Monitor payments and outstanding claims: Watch Explanation of Benefits (EOBs) and accounts receivable (AR) carefully. Quickly handle any rejections or requests for more information to prevent payment delays.
Using these approaches can help secure appropriate payment for surgical revision procedures and reduce problems in your billing process.
How dental practices use D4268
Think about a patient who had bone surgery (see D4261 osseous surgery) on tooth #19. During the 8-week checkup, the dentist finds continuing deep pocket formation and a small area where tissue has separated. When simple treatments do not work, surgical revision is done to reshape the bone and reattach the tissue. The dentist records the observations, takes mouth photos, and files a claim using D4268 for tooth #19. The first claim gets denied as "covered by previous surgery." The office files an appeal with a complete explanation and supporting records, leading to successful payment for the revision procedure.
This case shows how important complete documentation, early communication with insurance companies, and careful claim follow-up are when working with D4268.
Common Questions
Do all dental insurance plans provide coverage for D4268?
Insurance coverage for D4268 differs across various dental plans. Many insurance policies do not include benefits for surgical revision procedures, while others may impose specific exclusions or frequency restrictions on periodontal surgeries. Always confirm the patient's insurance policy coverage details prior to performing and billing this procedure.
Is it possible to bill D4268 together with other periodontal codes for the same tooth on the same visit?
Typically, D4268 cannot be billed with other surgical periodontal codes when treating the same tooth on the same service date, since most insurance carriers view it as an independent, standalone procedure. Be sure to review payer-specific policies to identify any exceptions or bundling requirements that may apply.
What are the most frequent causes for D4268 claim denials?
Frequent denial reasons include inadequate documentation, unclear medical necessity, surpassing frequency limits, or incorrectly using the code for initial procedures instead of revisions. Maintaining comprehensive clinical records, proper supporting documentation, and following payer requirements can help minimize claim denials.