Understanding Dental Code D7260

When to Use D7260 dental code

The D7260 dental code refers to the closure of an oroantral fistula, a pathological connection between the oral cavity and the maxillary sinus. This CDT code is specifically used when a patient presents with a persistent communication between the mouth and sinus, often resulting from tooth extraction, trauma, or infection. Dental teams should select D7260 when surgical intervention is required to close this abnormal opening, restoring the integrity of the oral and sinus tissues. Proper code selection ensures accurate billing and minimizes claim denials.

Documentation and Clinical Scenarios

Thorough documentation is essential when billing for D7260. Clinical notes should include:

• Detailed patient history, including the cause and duration of the fistula
• Clinical findings, such as location, size, and symptoms (e.g., fluid leakage, sinusitis)
• Diagnostic imaging results, if available (e.g., radiographs or CBCT scans)
• Description of the surgical procedure performed to close the fistula
• Postoperative instructions and follow-up care recommendations

Common clinical scenarios for D7260 include closure after extraction of maxillary molars, repair following trauma, or correction of fistulas resulting from failed previous surgeries. Accurate, detailed documentation supports medical necessity and streamlines insurance processing.

Insurance Billing Tips

Maximizing reimbursement for D7260 requires attention to detail throughout the billing process. Here are best practices:

• Verify benefits: Confirm the patient’s dental and medical coverage for surgical procedures involving the maxillary sinus. Some plans may require preauthorization.
• Submit supporting documentation: Attach clinical notes, diagnostic images, and a narrative explaining the need for oroantral fistula closure.
• Use correct coding: If additional procedures are performed (e.g., bone grafting), use the appropriate CDT codes and ensure they are not bundled incorrectly.
• Appeal denials: If the claim is denied, review the Explanation of Benefits (EOB) and submit a detailed appeal with additional documentation as needed.
• Track Accounts Receivable (AR): Monitor outstanding claims and follow up promptly to reduce delays in payment.

Staying proactive with insurance verification and documentation helps dental practices avoid common billing pitfalls and ensures timely reimbursement.

Example Case for D7260

Case Example: A 45-year-old patient presents with persistent sinus drainage following extraction of the upper right first molar. Examination and imaging confirm an oroantral fistula. The oral surgeon performs a surgical closure using a buccal advancement flap. The dental team documents the clinical findings, procedure details, and postoperative care. The claim is submitted with D7260, supported by radiographs and a narrative. Insurance approves the claim, and payment is received without delay.

This example highlights the importance of accurate coding, thorough documentation, and proactive insurance communication when billing for D7260.