Understanding Dental Code D3428

When to Use D3428 dental code

The D3428 dental code is designated for a bone graft performed in conjunction with periradicular surgery—specifically, per tooth and at a single site. This code is appropriate when a bone graft is necessary to support the tooth’s structure during surgical intervention for periapical pathology, such as cysts, abscesses, or persistent infection around the root tip. It is crucial to use D3428 only when the bone graft is performed simultaneously with the periradicular procedure and not as a stand-alone service or in conjunction with other types of oral surgery.

Documentation and Clinical Scenarios

Accurate documentation is essential for successful claim submission and reimbursement. Clinical notes should clearly indicate:

• The diagnosis necessitating periradicular surgery (e.g., chronic periapical abscess).
• The specific tooth and site treated.
• Details of the bone graft material used (allograft, xenograft, or autograft).
• Rationale for graft placement (e.g., to restore bony support after lesion removal).
• Pre- and post-operative radiographs and intraoperative photos, if possible.

Common clinical scenarios include apicoectomy with significant bone loss, or when the integrity of the alveolar bone is compromised and immediate grafting is necessary for optimal healing and future stability.

Insurance Billing Tips

To maximize reimbursement and minimize denials for D3428, follow these best practices:

• Verify coverage: Before treatment, confirm with the patient’s dental insurance whether D3428 is a covered benefit, as some plans may consider it medical or exclude grafting procedures.
• Submit supporting documentation: Always include clinical notes, radiographs, and a narrative explaining the medical necessity of the bone graft with your claim.
• Use precise coding: Ensure D3428 is not billed in conjunction with codes for bone grafts in other contexts, such as bone graft for ridge preservation, unless both procedures are distinctly documented and performed.
• Appeal denials: If a claim is denied, review the Explanation of Benefits (EOB), address the payer’s rationale, and submit a detailed appeal with additional documentation if needed.

Successful dental offices maintain a checklist for required documentation and designate a team member to track claims and follow up on Accounts Receivable (AR) for surgical procedures like D3428.

Example Case for D3428

Case: A patient presents with a persistent periapical lesion on tooth #8. After endodontic retreatment fails, the endodontist performs an apicoectomy. During surgery, significant bone loss is noted, and a bone graft is placed to fill the defect and promote healing. The procedure is documented with pre- and post-op radiographs, a detailed narrative, and the graft material is specified. The claim is submitted with D3428, supporting documentation, and a clear explanation of medical necessity. The insurance carrier approves the claim after initial review, and payment is posted to the patient’s ledger.

This real-world example highlights the importance of thorough documentation, proper code selection, and proactive insurance communication when billing for D3428.