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19.15.7 Periodontal Services
Procedure codes D4210 and D4211, when billed for clients younger than 13 years of age, will be initially denied, but may be appealed with documentation of medical necessity. Additionally, preoperative and postoperative photographs will be required for the following procedure codes: D4210, D4211, D4270, D4271, D4273, D4275, D4276, D4355, and D4910.
Preoperative and postoperative photographs will be required when medical necessity is not evident on radiographs for the following procedure codes: D4240, D4241, D4245, D4266, and D4267.
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Procedure Code
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Limitations
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Maximum Fee
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Surgical Services (Including Usual Postoperative Care)
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D4210
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A 13-20, N, PPXR, CCP
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$162.50
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D4211
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A 13-20, N, PHO, PXR, CCP
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$50.00
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D4230
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Not considered medically necessary.
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NC
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D4231
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Not considered medically necessary.
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NC
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D4240
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A 13-20, N, FMX, PHO, PXR when medical necessity is not evident on radiographs, PC, CCP
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$181.25
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D4241
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Limited to once per year. A 13-20, N, FMX, PXR, PHO when medical necessity is not evident on radiographs, PC
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$55.00
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D4245
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Per quadrant. A 13-20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP
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$181.25
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D4249
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A six- to eight-week healing period following crown lengthening before final tooth preparation, impression making, and fabrication of a final restoration is required for billing of this code. A 13-20, N, PPXR, CCP
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$162.50
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D4260
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A 13-20, N, FMX, PXR, PC, CCP
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$225.00
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D4261
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Limited to once per year. A 13-20, N, FMX, PXR, PC
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$67.00
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D4265
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Deny as global to other services.
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NC
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D4266
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Considered upon submission of an appeal with the following documentation:
• Third molar sites: Medical/dental history documenting need due to inadequate healing of bone following third molar extraction, including date of third molar extraction; secondary procedure several months post-extraction; position of the third molar preoperatively; post-extraction probing depths to document continuing bony defect; post-extraction radiographs documenting continuing bony defect; and bone graft and barrier material utilized.
•Other than third molar sites: Medical and dental history indicating a co-morbid condition; preoperative radiographs that show evidence of the bony defect; postoperative radiographs that show evidence of the procedure being performed; intra-oral photographs, if the bony defect is not evident on radiographs (this documentation may also be requested by HHSC and/or its agent as deemed necessary); periodontal probing depths documenting bony defect; number of intact walls associated with an angular bony defect; and bone graft and barrier material utilized.
A 13-20, N, PPXR, CCP
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$275.00
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D4267
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Considered upon submission of an appeal with the following documentation:
•Third molar sites: Medical/dental history documenting need due to inadequate healing of bone following third molar extraction, including date of third molar extraction; secondary procedure several months post-extraction; position of the third molar preoperatively; post-extraction probing depths to document continuing bony defect; post-extraction radiographs documenting continuing bony defect; and bone graft and barrier material utilized.
•Other than third molar sites: Medical and dental history indicating a co-morbid condition; preoperative radiographs that show evidence of the bony defect; postoperative radiographs that show evidence of the procedure being performed; intra-oral photographs, if the bony defect is not evident on radiographs (this documentation may also be requested by HHSC and/or its agent as deemed necessary); periodontal probing depths documenting bony defect; and final restoration treatment plan for edentulous site(s).
A 13-20, N, PPXR, CCP
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$325.00
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D4270
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A 13-20, N, PPXR, CCP
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$193.75
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D4271
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A 13-20, N, PPXR, CCP
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$206.25
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D4273
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This procedure is performed to create or augment gingiva, to obtain root coverage or to eliminate frenum pull, or to extend the vestibular fornix. A 13-20, N, PPXR, CCP
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$225.00
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D4274
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This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are used to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation. A 13-20, N, PXR, CCP
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$125.00
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D4275
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Limited to once per day. A 13-20, PPXR
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$225.00
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D4276
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Prior authorization is required; Not payable in addition to D4273 or D4275 on the same date of service. A 13-20, PPXR
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$225.00
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Nonsurgical Periodontal Services
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D4320
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A 1-20, PXR
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$62.50
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D4321
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A 1-20, PXR
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$100.00
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D4341*
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D4341 is not payable if provided within 21 days of D4355. A 13-20, FMX, PC, PXR, CCP
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$56.25
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D4342
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May not be paid in addition to procedure codes D4210, D4211, D4240, D4241, D4245, D4249, D4260, D4261, D4266, D4267, D4270, D4271, D4273, D4274, D4275, D4276, D4320, D4321, D4341, D4355, D4381, D4910, D4920, and D4999 on the same day. A 13-20, PC, FMX
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$7.00
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D4355*
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D4355 is not payable if provided within 21 days of D4341. A 13-20, N, PPXR, CCP
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$75.00
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D4381
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A 13-20, N, PXR, CCP
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$30.00
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Other Periodontal Services
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D4910
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Payable only following active periodontal therapy by any provider as evidenced either by a billed claim for D4240, D4241, D4260, or D4261 or by evidence through client records of periodontal therapy while not Medicaid-eligible.
Limited to once per 12 months for the same provider.
A 13-20, N, PPXR, CCP (not payable with or after D4355)
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$37.50
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D4920
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A 13-20, N, PXR, CCP
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$25.00
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D4999
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A 13-20, N, PXR, CCP
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Manually priced
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