D4000 – D4999 Periodontics
By Marie Schweinebraten, D.D.S. and Robert Rives, D.D.S.
Periodontal treatment has seen many changes over the last decade. For example, different types of grafting material, both autogenous and non-autogenous, are more common. Dental implants many times are included in periodontal treatment planning. Bone regeneration has become more predictable with the availability of new products and techniques. Periodontal procedure coding has grown with these changes as has the knowledge base required to code correctly and obtain reimbursement for the treatment completed.
Periodontics has always been a unique category because it has included both non-surgical and surgical procedures. What complicates matters is that some of the codes are site specific while others are tooth, quadrant (four or more teeth), or area (one to three teeth) specific. Adding to the confusion is that procedure codes have become differentiated as to the type of material used as well as to whether the procedure is performed on a tooth or implant. There are also many periodontal codes that overlap with codes from other categories.
Coding for periodontal procedures also may require the use of “á la carte” codes. Bone graft materials, for example, are listed separately from the procedure for achieving access – osseous surgery (D4260 or D4261). There are also separate codes for other procedures that may be required in a graft case, including placement of barrier membranes or biologic materials to aid in regeneration. Thus, for a given outcome there could be a number of separate procedures involved, each documented with its individual CDT Code.
It is especially important in the periodontal category to realize that procedure codes are meant to describe the treatment rendered, not the means that are used to accomplish the treatment. For example, a gingivectomy can be done by several techniques, including utilizing a blade, a periodontal knife or a laser. The code for the procedure, however, is the same.
With attention to detail and a basic understanding of periodontal treatment and codes, a dental office can prevent confusion for the patient and misunderstanding of plan coverage while at the same time obtain reimbursement as effectively and efficiently as possible.
Full quadrant: A section of the mouth with four or more contiguous teeth or tooth spaces.
Partial quadrant: A section of the mouth with one to three contiguous teeth or tooth spaces
Site: The term site is use to describe a single area, or position. “Site” is frequently used to describe an area of recession on a single tooth or an osseous defect adjacent to a single tooth. It can also apply to soft tissue or osseous defects in an edentulous area.
• If two contiguous teeth have areas of recession, each area is a single site.
• If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site.
• If these defects communicate, however, they would be considered a single site.
• In an edentulous area, up to two contiguous edentulous tooth positions may be considered a single site.
Tooth bounded space: a space created by one or more missing teeth that have a tooth on each side of the edentulous area.
Autogenous soft tissue graft: Graft material is taken from the patient’s oral cavity. There is a second surgical site in the patient’s mouth.
Non-autogenous: There is no second surgical site in the patient’s mouth. The graft material comes from another source. An example is AlloDerm.
D4999 unspecified periodontal procedure, by report: This code may apply when a provider feels there is no specific code for the procedure completed. In these cases, a narrative or report is necessary to explain the unusual circumstance.
There are three changes in the periodontal category in CDT 2018. All are revisions, two addressing anatomical crown exposure, and one full mouth debridement. Two revisions clarify requirements for anatomical crown exposure to be coded and bring these codes in line with other periodontal codes. The changes better define the use of four or more teeth or bounded spaces per quadrant and one to three teeth or bounded spaces per quadrant. The third change updates the descriptor for the gross debridement code and clarifies the appropriate use of the code.
D4230 anatomical crown exposure-four or more contiguous teeth or bounded tooth spaces per quadrant
This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone (ostectomy) to provide anatomically correct gingival relationship.
D4231 anatomical crown exposure-one to three teeth or bounded tooth spaces per quadrant
This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone (ostectomy) to provide an anatomically correct gingival relationship.
The changes better defines the area where the crown exposure is performed. For example, even though a tooth #10 may be missing, if anatomical crown lengthening is necessary on teeth #9 and #11, correct coding would be D4231 since treatment would involve the edentulous area. Elevation of the flap to treat teeth #9 and #11 would require some revision of the tissue where tooth #10. Thus, the correct description includes a bounded tooth space.
D4355 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit
Full mouth debridement involves the preliminary removal of plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be completed on same day as D0150, D0160, or D1080.
The purpose of this procedure is to remove deposits of calculus and plaque that prevent a thorough evaluation of the teeth and supporting gingival structures. It does not include fine scaling or subgingival scaling and root planing. Normally, moderate to severe gingival inflammation is generalized, resulting in bleeding, and gingival tissue is edematous. For these reasons, healing must occur in order to perform an accurate evaluation and diagnosis, which cannot be performed at the same appointment.
Both the D4355 nomenclature and descriptor were revised to reflect the clinical situations just described, and to emphasize that a comprehensive evaluation is be done on another day.
Diagnosis Codes – ICD-10-CM
The CDT to ICD tables in Appendix 1 provide appropriate guidance on linkages between Periodontics procedure codes and diagnosis codes. This chapter does not contain supplemental information on this topic.
CODING SCENARIO #1
A patient presented in pain and complaining about swelling around one particular tooth. The doctor’s emergency evaluation focused on the patient’s complaint and included two periapical radiographic images and pocket measurements of the teeth in the area. The swelling was clearly adjacent to tooth #3 and the sulcus gushed a purulent mixture of blood and pus when probed.
The doctor treated the patient for a periodontal abscess by debridement and draining through the sulcus, irrigating the pocket with chlorhexidine and prescribing the patient an antibiotic.
How could this encounter be coded?
Since the evaluation was both problem-focused and limited to the patient’s complaint, the appropriate codes for diagnostic procedures would be:
D0140 limited oral evaluation – problem focused
D0220 intraoral – periapical first radiographic image
D0230 intraoral – periapical each additional radiographic image
In this case there are a number of codes that might be used to document the operative services, alone or in combination. Possible procedure coding options are:
D9110 palliative (emergency) treatment of dental pain – minor procedure
This is typically reported on a “per visit” basis for emergency treatment of dental pain.
Use of this code to document the service provided may require a narrative to describe the exact treatment rendered. It may be the most appropriate code to use in this case. The following code may also be considered.
D7510 incision and drainage of abscess – intraoral soft tissue
Involves incision through mucosa, including periodontal origins.
Chronic Generalized Periodontitis
A 49-year-old male patient presents for periodontal examination with a chief complaint of sore and bleeding gums. Medical history is significant for type II diabetes being treated with metformin (glucophage), and hypertension which was being treated with a calcium channel blocker (nifedipine-adalat). His last dental appointment was five years ago and there are heavy accumulations of plaque and calculus both supra-gingival and sub-gingival.
Since the amount of calculus and plaque prevented a periodontal evaluation from being performed adequately, the patient was seen by the hygienist that same day. Without using any anesthesia, she utilized an ultrasonic scaler to debride supragingival calculus and plaque in all four quadrants. After reviewing home care instructions and giving the patient chlorhexidine rinse, provided by the office, the patient was scheduled to return in two weeks for a periodontal evaluation and appropriate radiographic images.
How would these visits be coded?
Visit #1: (assessment and debridement)
D0191 assessment of a patient
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis on a subsequent visit
D1330 oral hygiene instructions
D9630 drugs or medicaments dispensed in the office for home use
Two weeks later, the patient returned for radiographic images and a complete periodontal evaluation.
The diagnosis is chronic generalized periodontitis with pocket depths ranging from 4 to 9 millimeters, furcation invasion, mobility, and localized recession. There are interproximal papillae that exhibit swelling with a “granulated” surface appearance to the soft tissue resembling hyperplasia possibly caused by a calcium channel-blocking drug. Consultation with the patient’s internist to evaluate possibility of changing high blood pressure medication was done by the dentist.
A complete oral evaluation with panoramic and full mouth periapical radiographic images were taken. The diagnostic findings were:
1. Missing teeth #1, 5, 12, 16, 17, 21, 28 and 32. The premolars were extracted for orthodontic reasons when he was a teenager.
2. Bone loss of up to 40 percent around the posterior teeth with pocket depths ranging from 5 to 9 mm in the posterior.
3. Heavy accumulations of plaque and calculus supra and sub-gingival
4. Moderate generalized gingival overgrowth probably related to his calcium channel medication
5. Furcation involvement on the molars
6. Mobility of teeth
7. Inadequate oral hygiene
The evaluation and diagnosis led to a three appointment treatment plan for this patient – four quadrants of scaling and root planing spread across two appointments, and a third appointment four to six weeks after the SRP for a post-operative visit to assess the outcome.
CDT Codes for the services delivered and planned follow:
Visit #1 (evaluation, diagnosis and treatment planning)
D0150 comprehensive oral evaluation – new or established patient
D0210 intraoral – complete series of radiographic images
D0330 panoramic radiographic image
D1330 oral hygiene instructions
D9311 consultation with a medical health care professional
D4341 periodontal scaling and root planning – four or more teeth per quadrant
Note: This procedure is reported twice and the two quadrants treated (e.g., maxillary right and mandibular right) are identified.
Visit #3 (SRP – two quadrants)
D4341 periodontal scaling and root planning – four or more teeth per quadrant
This procedure is reported twice and the two quadrants treated (e.g., maxillary left and mandibular left) are identified.
Visit #4 (4-6 weeks after SRP completed)
D0171 re-evaluation- post operative office visit
Post-scaling and root planing re-charting was done at this appointment, noting that significant pocket depth with bleeding on probing in the posterior areas was evident. The dentist felt that the patient would benefit from osseous surgery in the posterior quadrants (D4260) at a later date. The medical consultation from the first appointment was returned and the physician plans to change the patient’s hypertension medication.