Understanding Dental Code D4260

When to Use D4260 dental code

The D4260 dental code is designated for osseous surgery, which includes the elevation of a full thickness flap and closure, performed on four or more contiguous teeth or tooth-bounded spaces within a single quadrant. This CDT code should be used when periodontal disease has resulted in bone defects that require surgical intervention to restore healthy bone contours and support. Dentists and periodontists typically select D4260 when non-surgical therapies, such as scaling and root planing, have not resolved moderate to severe periodontitis, and surgical access is necessary for thorough debridement and bone reshaping.

Documentation and Clinical Scenarios

Accurate documentation is critical for successful reimbursement of D4260 claims. Clinical notes should clearly indicate:

• The diagnosis of periodontitis and justification for surgery (e.g., persistent pocket depths, radiographic bone loss).
• The number and location of teeth involved, confirming that four or more contiguous teeth or spaces are treated in the same quadrant.
• Details of the procedure, including flap elevation, debridement, bone contouring, and closure.
• Pre- and post-operative radiographs and periodontal charting.

Common clinical scenarios include generalized chronic periodontitis with multiple adjacent teeth affected, or localized aggressive periodontitis where surgical access is needed for effective management. Always ensure that the clinical necessity for surgery is well-documented and supported by diagnostic records.

Insurance Billing Tips

Billing D4260 successfully requires attention to detail and proactive communication with payers. Here are best practices:

• Verify Benefits: Before treatment, confirm the patient’s periodontal surgery benefits, frequency limitations, and any pre-authorization requirements with their insurance provider.
• Submit Comprehensive Documentation: Attach detailed clinical notes, periodontal charting, and radiographs to the claim. Insufficient documentation is a common reason for denials.
• Use Correct Quadrant Notation: Clearly indicate which quadrant is being treated, as D4260 is billed per quadrant.
• Appeal Denials: If a claim is denied, review the Explanation of Benefits (EOB) for the reason, gather any missing documentation, and submit a thorough appeal letter referencing clinical necessity and industry guidelines.
• Coordinate Benefits: If the patient has dual coverage, ensure coordination of benefits is handled correctly to maximize reimbursement and minimize patient out-of-pocket costs.

Example Case for D4260

Consider a 52-year-old patient presenting with generalized moderate to severe periodontitis in the upper right quadrant. Despite previous non-surgical therapy, pocket depths of 6-8mm persist on teeth #2-5, with radiographic evidence of horizontal bone loss. The periodontist documents the diagnosis, treatment plan, and rationale for osseous surgery. After obtaining insurance pre-authorization, the surgical procedure is performed on four contiguous teeth. The claim is submitted with detailed notes, periodontal charting, and pre- and post-op radiographs. The insurance carrier approves the claim, and the practice receives timely reimbursement, demonstrating the importance of thorough documentation and proper use of the D4260 dental code.