Dental billing can be overwhelming thanks to continually updated CDT codes, ever-changing insurance regulations, and rapid advancements in dental technology. When you add in specialty treatments like periodontics, it can be even more complex. But with a little guidance, periodontal billing can become much more manageable. This guide covers everything your team needs to know — from SRP documentation to implant coverage and medical billing.
What is Periodontics?
Periodontics is the treatment of the tissues supporting the tooth, such as the gums and jawbone. Depending on the circumstances, this treatment can be completed by a dental hygienist or a periodontist. According to the American Academy of Periodontology, a periodontist “specializes in the prevention, diagnosis, and treatment of periodontal disease…and in the placement of dental implants.”
Common Periodontal CDT Codes: Quick Reference
| Code | Procedure | Key Billing Notes |
|---|---|---|
| D4341 | Scaling and root planing — 4 or more teeth per quadrant | Include quadrant treated, perio chart, x-rays, narrative, treatment time |
| D4342 | Scaling and root planing — 1 to 3 teeth per quadrant | Include specific tooth numbers, perio chart, x-rays, narrative, treatment time |
| D4910 | Periodontal maintenance | Include date of previous SRP and/or maintenance |
| D6010 | Surgical placement of implant body (endosteal implant) | Enter tooth number in Box 27 of the 2024 ADA Dental Claim Form; do not use for mini implants (D6013) or transitional implants (D6012); report second stage surgery separately as D6011 if applicable |
| D7953 | Bone replacement graft for ridge preservation — per site | Used for fresh extraction site when implant placement will occur on a later date; include graft material type (autograft, allograft, or xenograft) in chart notes |
What attachments do I need to include in a periodontal claim?
When billing periodontal treatment, the attachments vary from procedure to procedure but, at the very least, include x-rays, a clinical narrative, and a periodontal chart. The x-rays should show the affected area and, when possible, include both full mouth (FMX) and panoramic, especially when billing scaling and root planing (SRP). Also, when billing SRP, it helps to include the length of treatment time, as some insurance companies are starting to require this. If billing perio maintenance, be sure to include the date of the previous SRP and/or maintenance. For implants, include the date the tooth was extracted, and for bone grafts, document the graft material type and include the implant treatment plan, if it applies.
Do I need a referral?
When billing a PPO insurance, you don’t need a referral, but it may be required for an HMO plan. If the treatment was completed by a hygienist, a referral isn’t necessary, but if it was completed by a periodontist, the HMO plan won’t consider the claim without it. Some carriers do require treatment to be pre-authorized, especially when implants are completed. Always check when verifying insurance coverage if it is required.
How do I bill scaling and root planing?
When billing SRP, it’s essential to provide as many details as possible in the claim. If billing D4341 (4 or more teeth per quadrant) be sure to include the quadrant treated, and if billing D4342 (1-3 teeth per quadrant) be sure to include the specific tooth numbers treated. Attachments must include a recent perio chart, x-rays (ideally FMX and pano), and a clinical narrative that addresses the pocket depth and any bone loss. It is also best to include the length of treatment time.
Why was my scaling and root planing claim denied?
Currently, insurance carriers are growing suspicious of upcoding when it comes to SRPs, and they are frequently denying them. Most carriers have strictly regulated the circumstances in which they allow coverage, and no two carriers are alike. For instance, each insurance carrier has a specific pocket depth requirement for scaling and root planing, and none allow less than 4mm. In fact, several carriers are now requiring 5mm or more. In addition, most require evidence of bone loss, and without it, they won’t consider payment. Also, some carriers only allow 2 quadrants per visit, and if 4 are completed, the additional 2 won’t be covered, except in rare circumstances. Confirming insurance requirements when verifying coverage is essential if you want to get your claim paid. Consider outsourcing insurance verification if you’re struggling to find the time to do this.
What is the difference between prophy and perio maintenance?
Prophylaxis is the removal of plaque, calculus, and stains from teeth, whereas perio maintenance is a slightly more extensive cleaning that is exclusively used on patients who have had previous periodontal treatment. According to the ADA, perio maintenance can continue through the life of the teeth, but most insurance plans cover a much shorter period. Generally, they will only cover it within 24 months of SRP treatment, and, in addition, most limit coverage to once every 6 months. Sometimes, they will consider an alternative benefit downgrade of prophy, but often, they will simply deny the treatment if the frequency limits are met.
Are implants covered by insurance?
It all depends on the insurance plan. At one point, they were rarely covered, as they were considered a cosmetic treatment, but now there’s a better chance of some payment. Some carriers will cover adjunctive treatment, like bone grafts, but not the actual implant. Others may cover it at an alternative benefit downgrade of a denture. If the plan does cover it, verify if a missing tooth clause applies. If it does, and the tooth was extracted before the plan was effective, the implant will be denied.
Can Periodontal Treatment Be Billed to Medical Insurance?
Medical insurance may cover some periodontal treatments when medically necessary. While medical insurance policies generally do not cover routine periodontal procedures, there are circumstances where coverage may apply:
- Medical necessity — some policies provide partial coverage for gum surgery if it is considered a medical procedure
- Concurrent surgical procedures — medical insurance may pay for a periodontal examination and treatment if the patient is undergoing a different surgical procedure included in the plan
- Periodontal abscess — a periodontal or gum abscess can stem from periodontitis, a deep periodontal pocket, or a weak immune system. The non-surgical medical treatment “curettage of periodontal abscesses” may be billed to medical insurance
When billing periodontal treatment to medical insurance, claims are typically submitted to medical insurance first. After medical insurance processes the claim, the practice can then submit to dental insurance along with a copy of the medical EOB. Medical-dental cross-coding can be complex — only procedures and diagnoses supported by clinical documentation should be reported.
Frequently Asked Questions
Both codes report scaling and root planing, but the difference is the number of teeth treated per quadrant. D4341 is used when 4 or more teeth per quadrant are treated. D4342 is used when 1 to 3 teeth per quadrant are treated. When billing D4341, include the quadrant treated. When billing D4342, include the specific tooth numbers.
Each insurance carrier sets its own pocket depth requirement, but no carrier allows less than 4mm. Several carriers now require 5mm or more. Most also require evidence of bone loss. Always verify the specific carrier’s requirements when confirming coverage.
Prophylaxis is the removal of plaque, calculus, and stains from teeth and is performed on patients without a history of periodontal disease. Perio maintenance is a more extensive cleaning performed exclusively on patients who have had previous periodontal treatment. Most insurances cover perio maintenance within 24 months of SRP treatment and limit coverage to once every 6 months.
In some circumstances, yes. Medical insurance may cover periodontal treatment when medically necessary — such as gum surgery considered a medical procedure, treatment performed alongside another covered surgical procedure, or non-surgical treatment of a periodontal abscess. Claims are typically submitted to medical insurance first, followed by dental insurance with a copy of the medical EOB.
Periodontal billing involves many moving parts — and though manageable, it can take up a significant portion of the dental billing process. If you’re struggling to find the time, consider outsourcing your dental billing. At eAssist, our Success Consultants are knowledgeable about the various nuances of periodontal treatment and will work to get your claims billed correctly. To learn more, schedule a free consultation.
Disclaimer: Insurance administration and dental billing recommendations presented here represent the opinions of the author or our staff and are for informational purposes only. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org.
