Understanding Dental Code D4268

When to Use D4268 dental code

The D4268 dental code is designated for a "surgical revision procedure, per tooth." This CDT code is used when a previously performed periodontal surgery requires additional surgical intervention on the same tooth due to complications, inadequate healing, or persistent periodontal defects. Common scenarios include persistent infection, flap dehiscence, or the need to recontour tissue or bone after an initial surgery. It is important to note that D4268 is not for routine post-operative care, but rather for significant surgical revisions that go beyond standard follow-up procedures.

Documentation and Clinical Scenarios

Accurate documentation is critical when billing D4268. Clinical notes should clearly state the reason for the revision, the findings during the procedure, and the specific surgical steps taken. Photographs, radiographs, and periodontal charting should be included in the patient record to support medical necessity. Typical clinical scenarios for D4268 include:

• Persistent periodontal pocketing after initial surgery
• Flap breakdown or dehiscence requiring surgical correction
• Residual bony defects that necessitate additional contouring
• Recurrent infection at the surgical site

Always ensure that the documentation distinguishes this procedure from routine post-op care or minor adjustments, which are not billable under D4268.

Insurance Billing Tips

Successfully billing D4268 requires a proactive approach to insurance verification and claims submission. Here are best practices used by experienced dental billing teams:

• Pre-authorization: Before scheduling the revision surgery, verify the patient’s benefits and obtain pre-authorization if required. Clearly explain the medical necessity for the revision in your pre-authorization request.
• Detailed claim submission: When submitting the claim, include comprehensive clinical notes, pre- and post-op images, and any supporting documentation. Use the correct CDT code (D4268) and specify the tooth number involved.
• Anticipate denials: Insurance carriers may initially deny claims for D4268, mistaking it for routine follow-up. Be prepared to submit a claim appeal with additional documentation, such as a narrative explaining why the revision was medically necessary and not part of standard post-op care.
• Track EOBs and AR: Monitor Explanation of Benefits (EOBs) and accounts receivable (AR) closely. Promptly address any denials or requests for additional information to avoid delays in reimbursement.

Following these steps can help ensure proper payment for surgical revision procedures and minimize disruptions to your revenue cycle.

Example Case for D4268

Consider a patient who underwent osseous surgery (see D4261 osseous surgery) on tooth #19. At the 8-week follow-up, the clinician notes persistent deep pocketing and a small area of flap dehiscence. After conservative measures fail, a surgical revision is performed to recontour the bone and resecure the tissue. The provider documents the findings, includes intraoral photos, and submits a claim using D4268 for tooth #19. The initial claim is denied as "included in previous surgery." The office submits an appeal with a detailed narrative and supporting documentation, resulting in successful reimbursement for the revision procedure.

This example highlights the importance of thorough documentation, proactive communication with insurers, and diligent follow-up on claims involving D4268.