Appendix 1: Example of Processing Policies
Payer #1:
D4341 Periodontal scaling & root planing-four or more teeth per quadrant
a. Document at least 4mm pocket depths on the diseased teeth involved. No payment is made and the fees are not billable to the patient by
a participating dentist in the absence of radiographic documentation of bone loss and documentation of clinical attachment loss.
b. Do not count teeth bounded spaces for D4210, D4341. Count only diseased teeth.
c. When there is a contractual time limitation on the frequency of benefits for scaling and root planing, and subsequent requests for scaling
and root planing benefits are submitted within that contractual time limitation, benefits are DENIED. In the absence of a contractual time
limitation for scaling and root planing, fees for D4341 are not billable to the patient by a participating dentist within 24 months when done
by the same dentist/dental office. If treatment is done by a different dentist within 24 months, benefits are DENIED.
d. Adult prophylaxis procedures (D1110), full mouth scaling (D4346) or debridement (D4355) are considered a component when submitted
on the same date of service as D4341. This time limitation, like all other contractual time limitations, should be defined in the
group/individual contract. Fees for the prophylaxis procedure by the same dentist/dental office are not billable to the patient by a
participating dentist.
e. Benefit no more than two quadrants of scaling and root planing on the same date of service. More than two quadrants on the same date
of service are not billable to the patient by the same participating dentist/dental office/DENIED-nonparticipating dentist.
f. For patients under the age of 30, clinical treatment notes, the most current (less than two years old) complete series of radiographic
images, complete periodontal charting (no more 12 months old) and a copy of the appointment schedule showing the length of the
appointment time are required. No payment is made for periodontal maintenance (D4910), scaling in presence of generalized moderate
or severe gingival inflammation (D4346) or prophylaxis (D1110) when performed on the same day as scaling and root planning (D4341).
The fee is not billable to the patient by a participating dentist.
D4342 Periodontal scaling & root planing-one to three teeth per quadrant: Scaling and root planing in the same quadrant is benefited once
every 24 months unless specified by group contract. Reporting separately for periodontal root planing is not billable to the patient by a participating
dentist on the same date as procedures D4240-D4241, D4249, D4260-4261, D4270-D4285.
Do not count tooth bounded spaces for D4341, D4342. In order to qualify for benefits probing depths must be 4mm or greater on 4 or more teeth. If
only 1-3 teeth qualify, use partial quadrant code (D4342). If no teeth in the quadrant qualify, the Dental Consultant will DENY.
Payer #2:
When supporting documentation is requested for periodontal services, please refer to the submission guidelines as outlined in this section.
• A quadrant is defined as four or more contiguous teeth per quadrant.
• A partial quadrant is defined as one to three teeth per quadrant. For billing purposes, a sextant is not a recognized designation by the
American Dental Association.
• Alveolar crestal bone loss must be evident radiographically for scaling and root planning to be covered.
When more than one periodontal service (codes D4000-D4999) is completed within the same site or quadrant on the same date of service, carrier
will pay for the more extensive treatment as payment for the total service.
Benefits for all periodontal services are limited to two quadrants per date of service. If you want to request an exception to this due to a medical
condition that may require your patient to receive extended treatment, please include a detailed narrative including general or intravenous
anesthesia record, medical condition and length of appointment time.
Payer #3:
Benefits for D4341 and D4342 require root surface calculus, radiographic bone loss and bleeding upon probing. Additional information such as gingival
recession, frenum involvement and furcation defects are also evaluated, but in general, documented 5-8 mm pockets determine benefits.
Payer #4:
Scaling and Root Planing
Scaling and Root Planing is indicated for the treatment of localized or generalized active Periodontal Disease characterized by:
Periodontal probing depths of 4-6+ mm with radiographic evidence of horizontal or vertical bone loss
Refractory or recurrent Periodontal Disease
Periodontal abscess
Scaling and Root Planing is not indicated for the following:
For the removal of heavy deposits of calculus and plaque in the absence of clinical attachment loss
Gingivitis as defined by inflammation of the gingival tissue without loss of attachment (bone and tissue)
Coverage Limitations
Scaling and Root Planing is limited to 1 time per quadrant per consecutive 24 months