Understanding Dental Code D4261

When to Use D4261 dental code

The D4261 dental code is designated for osseous surgery (including elevation of a full thickness flap and closure) involving one to three contiguous teeth or tooth-bounded spaces per quadrant. This CDT code is appropriate when periodontal disease has resulted in bone defects that require surgical intervention to restore a healthy bony architecture. Use D4261 when the procedure is limited to a small area—specifically, one to three adjacent teeth or spaces—within a single quadrant. It is important to distinguish D4261 from D4260, which covers osseous surgery for four or more teeth per quadrant.

Documentation and Clinical Scenarios

Accurate documentation is critical for successful reimbursement and compliance. Clinical notes should clearly indicate:

• The diagnosis (e.g., chronic periodontitis with specific probing depths and radiographic bone loss)
• The teeth involved and their locations
• Preoperative findings, including periodontal charting and radiographs
• The surgical procedure performed (e.g., flap elevation, bone recontouring, closure)
• Postoperative instructions and outcomes

Common clinical scenarios for D4261 include localized moderate to severe periodontitis where osseous defects are present around a limited number of teeth, such as the lower right first and second molars. Always ensure that the clinical necessity for surgery is well-supported by documentation and diagnostic evidence.

Insurance Billing Tips

Billing for D4261 requires attention to detail to avoid denials and delays. Here are best practices:

• Insurance Verification: Before treatment, verify the patient’s periodontal benefits, frequency limitations, and history of previous osseous surgery in the same quadrant.
• Preauthorization: Submit a detailed preauthorization request with supporting clinical documentation, including periodontal charting and radiographs.
• Claim Submission: When submitting the claim, include all relevant documentation and clearly specify the teeth treated. Use the correct quadrant and tooth numbers on the claim form.
• Explanation of Benefits (EOB) Review: Carefully review the EOB for any reductions or denials. If denied, check for missing documentation or benefit limitations and be prepared to submit a claim appeal with additional information.
• Accounts Receivable (AR) Follow-Up: Track outstanding claims and follow up promptly with payers to resolve any issues.

By following these steps, dental offices can maximize reimbursement and minimize claim rejections for D4261 procedures.

Example Case for D4261

Case: A 52-year-old patient presents with localized chronic periodontitis affecting teeth #30 and #31. Periodontal charting shows 6-7mm pocket depths, and radiographs confirm vertical bone loss. Non-surgical therapy has failed to resolve the defects.

Treatment: The periodontist performs osseous surgery on teeth #30 and #31, elevating a full-thickness flap, recontouring the bone, and closing the surgical site.

Billing: The dental office bills D4261 for the lower right quadrant, specifying teeth #30 and #31. Clinical notes and radiographs are attached to the claim. Insurance preauthorization was obtained prior to treatment, and the claim is paid without delay.

This example highlights the importance of precise documentation, insurance verification, and correct code selection for successful billing of D4261.