Billing Guide for D4341 (Periodontal scaling and root planing - four or more teeth per quadrant)
Solutions
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Description
This is an optional lesson. You are not required to take this. This contains advance billing guidelines.
February 25, 2025
This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others.
WARNING
1. It is inappropriate to complete four quadrants of periodontal scaling and root planing (SRP) in one hour. Start and Stop times are now required by certain payors on many periodontal procedures.
2. It is improper/misleading to report a "quadrant equivalent" (such as, a few teeth in different quadrants) for reimbursement using D4341. For each quadrant with one to three diseased teeth requiring scaling and root planing. report periodontal scaling and root planing - one to three teeth (D4342). Use D4341 to report scaling and root planing of four or more periodontally involved teeth in a given quadrant. There must be at least four teeth in the treated quadrant to report D4341 and those four or more teeth must have specific evidence of periodontal disease. To justify reimbursement the periodontally involved teeth must have radiographic bone loss and pockets of 4mm or more which indicates active periodontal disease. They may also have calculus on the radiographic image.
3. D4346 reports generalized moderate or severe gingivitis without attachment (bone) loss for whole mouth. See D4346.
MATCH
If no periodontal surgery is immediately treatment planned after D4341/D4342, it is expected that regularly scheduled periodontal maintenance (D4910) would follow in the future.
COMMENTS
1. SRP includes the instrumentation of both crown and root surfaces to remove plaque and calculus. See D1110 for preventive treatment and the removal of plaque, calculus, and stains. It is inappropriate to report D1110 with D4341 on the same service date. SRP (D4341) requires root planing that removes cementum and dentin that is rough, and/ or permeated by calculus or contaminated with toxins or microorganisms. (Chart notes must indicate that root planing was performed, not just scaling.) Some soft tissue curettage will occur during the root planing process.
A diagnosis of early, moderate, or advanced chronic periodontitis will include some level of clinical attachment loss (CAL). CAL may not be apparent from pocket depth measurements. CAL involves the loss of alveolar bone support and gingival attachment as the periodontal fibers migrate apically from the CEJ (cementoenamel junction) due to periodontal toxins in plaque. Attachment loss is measured from the CEJ to the bottom of the periodontal pocket.
A periodontal pocket is a pathologically deepened gingival sulcus formed when toxins produced by plaque weaken the gingival attachment and connective tissues beneath the gum line. The gingival attachment pulls away from the teeth, forming a deeper pocket. As the disease progresses through the gingiva toward the bone, the pocket fills with plaque and the bacteria causes infection and inflammation. If not treated, the bone and connective tissue surrounding the tooth may become so severely damaged over time that the attachment is lost. If periodontitis continues untreated the tooth may become loose, fall out, or need to be extracted.
Evidence of active disease may include bleeding on probing (BOP), increased pocket depth, continued attachment loss, purulent discharge, increased tooth mobility, high bacterial count, and/or evidence of sequential radiographic loss of the crestal bone.
2. Scaling and root planing provides active therapy. It is not prophylactic (preventive) in nature. Scaling and root planing can be a definitive treatment (followed by periodontal maintenance) for some patients or pre-surgical treatment (prior to osseous surgery) for other patients.
3. Conversely, prophylaxis is preventive in nature and is not a statement of oral health, but instead supports good periodontal health. It therefore does not preclude subsequent SRP.
4. Use D4341 to report scaling and root planing for four or more diseased and qualified teeth in a given quadrant.
5. The code used to report the periodontal therapy should be based on the dentist's diagnosis and the service performed. For example, if the patient exhibits bleeding on probing and radiographic evidence of bone loss in two of the four quadrants, scaling and root planing (SRP) will likely be prescribed for the two affected quadrants. The remaining two quadrants may be treated with a prophylaxis (D1110). D1110 is provided to remove plaque, calculus and stains in areas where there is a lack of evidence of periodontitis.
In this example, when sequencing treatment, it may be best to complete and report the prophylaxis (D1110) on the two healthy quadrants first and bring the patient back at a separate appointment to perform the two quadrants of SRP. If so, wait six weeks before the SRP visit. This sequencing is beneficial in that it gives the hygiene team more time to educate the patient about periodontal disease, making it clear that more extensive therapy is needed to arrest the bacterial infection in the remaining two quadrants. After SRP has been completed, D4341 should be billed for each quadrant treated with SRP, which include four qualified teeth. If one to three teeth in a quadrant require SRP, D4342 (SRP one to three teeth) should be reported for that quadrant.
6. See LANAP comments at the beginning of the D4000 section and the comments under D4999 for more information on use of lasers in periodontal treatments.
7. Current Periodontal Staging and Grading protocols can be found at http://www.perio.org/2017wwdc. The Stage and Grade of disease should be recorded in the clinical notes and included in communication with payors.
8. Enter the quadrant, tooth number(s), or tooth number range being treated in the appropriate boxes of the 2024 Dental Claim Form.
LIMITATIONS
1. For reimbursement of D4341, bleeding on probing which indicates active periodontal disease, 4 to 5mm pocket depth (plus presence of calculus), attachment loss, radiographic evidence of bone loss must be evident. Some payors do not require diagnostic images, but most do.
2. Some payors require that five teeth have evidence of periodontal disease for reimbursement of D4341. If less than five teeth are reported, some payors re-map this code to D4342, ignoring the nomenclature quadrant definition of "four or more teeth. If four teeth are treated and the payor re-maps the reimbursement to D4342, ask the patient to request a copy of the plan document from their Human Resources department. Once a copy of the plan document is received, review the language as to tooth count requirements and limitations pertaining to D4341 and respond accordingly.
3. Periodontal maintenance (D4910) should follow multi-quadrant (D4341) SRP (generally at least two quadrants). This may not apply for SRP when involving D4342 for a few, isolated teeth. See D4342 for details. Note that there is typically a ninety day exclusion period (to the day) from the last date of SRP and the subsequent date of D4910.
4. Scaling and root planing (D4341) usually has a 24 to 36 month exclusion period for retreatment (a few payors have a 12 month exclusion). Note: reimbursement for scaling and root planing is typically excluded for 24 to 36 months after a gingival flap procedure (D4240/D4241) or osseous surgery (D4260/D4261) provided in the same area.
5. Artificial Intelligence (AI) programs are now being used by many payors to measure bone loss on submitted radiographs. Many are requiring 2mm of bone loss from the CEJ to the crest of bone to consider the site for reimbursement.
TIPS
1. D4921 reports gingival irrigation, per quadrant. Payors typically consider gingival irrigation to be a global component of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for irrigation. See D4921 for comments regarding the clinical use of gingival irrigation.
2. Use D9910 to describe the application of desensitizing medicaments for one tooth or multiple teeth. Payors typically consider D9910 to be a global part of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for the application of desensitizing medicaments. See D9910 for comments.
NARRATIVES
1. A narrative should document active disease. This may include, but is not limited to: 4mm or greater pockets that bleed on probing indicating active disease, loss of periodontal attachment, radiographic evidence of alveolar bone loss, gingival recession, furcation involvement, inflammation, tooth mobility, subgingival calculus, suppuration, etc. Enclose diagnostic radiographic images to document bone loss. Also send a current periodontal chart which includes the date(s) that the chart was recorded.
2. When scaling and root planing all four quadrants on the same day, include a narrative to document the treatment of all four quadrants in the same day. This may include time spent; anesthesia required; if pre-medication was necessary; apprehensiveness; medical conditions (i.e., taking blood thinner), extensive travel time, etc. Include any other supporting documentation that might justify the treatment of all four quadrants to report four quadrants of D4341. Payors are skeptical of four quadrants on one service date and may require extensive documentation for reimbursement. A predetermination is highly recommended.
3. Start and Stop times and types and amounts of local anesthetic are now required by certain payors on many periodontal procedures. Be sure to record this information in the clinical notation and subsequent narrative. Copies of the hygiene schedule from the date of service may even be requested.
WARNING
1. It is inappropriate to complete four quadrants of periodontal scaling and root planing (SRP) in one hour. Start and Stop times are now required by certain payors on many periodontal procedures.
2. It is improper/misleading to report a "quadrant equivalent" (such as, a few teeth in different quadrants) for reimbursement using D4341. For each quadrant with one to three diseased teeth requiring scaling and root planing. report periodontal scaling and root planing - one to three teeth (D4342). Use D4341 to report scaling and root planing of four or more periodontally involved teeth in a given quadrant. There must be at least four teeth in the treated quadrant to report D4341 and those four or more teeth must have specific evidence of periodontal disease. To justify reimbursement the periodontally involved teeth must have radiographic bone loss and pockets of 4mm or more which indicates active periodontal disease. They may also have calculus on the radiographic image.
3. D4346 reports generalized moderate or severe gingivitis without attachment (bone) loss for whole mouth. See D4346.
MATCH
If no periodontal surgery is immediately treatment planned after D4341/D4342, it is expected that regularly scheduled periodontal maintenance (D4910) would follow in the future.
COMMENTS
1. SRP includes the instrumentation of both crown and root surfaces to remove plaque and calculus. See D1110 for preventive treatment and the removal of plaque, calculus, and stains. It is inappropriate to report D1110 with D4341 on the same service date. SRP (D4341) requires root planing that removes cementum and dentin that is rough, and/ or permeated by calculus or contaminated with toxins or microorganisms. (Chart notes must indicate that root planing was performed, not just scaling.) Some soft tissue curettage will occur during the root planing process.
A diagnosis of early, moderate, or advanced chronic periodontitis will include some level of clinical attachment loss (CAL). CAL may not be apparent from pocket depth measurements. CAL involves the loss of alveolar bone support and gingival attachment as the periodontal fibers migrate apically from the CEJ (cementoenamel junction) due to periodontal toxins in plaque. Attachment loss is measured from the CEJ to the bottom of the periodontal pocket.
A periodontal pocket is a pathologically deepened gingival sulcus formed when toxins produced by plaque weaken the gingival attachment and connective tissues beneath the gum line. The gingival attachment pulls away from the teeth, forming a deeper pocket. As the disease progresses through the gingiva toward the bone, the pocket fills with plaque and the bacteria causes infection and inflammation. If not treated, the bone and connective tissue surrounding the tooth may become so severely damaged over time that the attachment is lost. If periodontitis continues untreated the tooth may become loose, fall out, or need to be extracted.
Evidence of active disease may include bleeding on probing (BOP), increased pocket depth, continued attachment loss, purulent discharge, increased tooth mobility, high bacterial count, and/or evidence of sequential radiographic loss of the crestal bone.
2. Scaling and root planing provides active therapy. It is not prophylactic (preventive) in nature. Scaling and root planing can be a definitive treatment (followed by periodontal maintenance) for some patients or pre-surgical treatment (prior to osseous surgery) for other patients.
3. Conversely, prophylaxis is preventive in nature and is not a statement of oral health, but instead supports good periodontal health. It therefore does not preclude subsequent SRP.
4. Use D4341 to report scaling and root planing for four or more diseased and qualified teeth in a given quadrant.
5. The code used to report the periodontal therapy should be based on the dentist's diagnosis and the service performed. For example, if the patient exhibits bleeding on probing and radiographic evidence of bone loss in two of the four quadrants, scaling and root planing (SRP) will likely be prescribed for the two affected quadrants. The remaining two quadrants may be treated with a prophylaxis (D1110). D1110 is provided to remove plaque, calculus and stains in areas where there is a lack of evidence of periodontitis.
In this example, when sequencing treatment, it may be best to complete and report the prophylaxis (D1110) on the two healthy quadrants first and bring the patient back at a separate appointment to perform the two quadrants of SRP. If so, wait six weeks before the SRP visit. This sequencing is beneficial in that it gives the hygiene team more time to educate the patient about periodontal disease, making it clear that more extensive therapy is needed to arrest the bacterial infection in the remaining two quadrants. After SRP has been completed, D4341 should be billed for each quadrant treated with SRP, which include four qualified teeth. If one to three teeth in a quadrant require SRP, D4342 (SRP one to three teeth) should be reported for that quadrant.
6. See LANAP comments at the beginning of the D4000 section and the comments under D4999 for more information on use of lasers in periodontal treatments.
7. Current Periodontal Staging and Grading protocols can be found at http://www.perio.org/2017wwdc. The Stage and Grade of disease should be recorded in the clinical notes and included in communication with payors.
8. Enter the quadrant, tooth number(s), or tooth number range being treated in the appropriate boxes of the 2024 Dental Claim Form.
LIMITATIONS
1. For reimbursement of D4341, bleeding on probing which indicates active periodontal disease, 4 to 5mm pocket depth (plus presence of calculus), attachment loss, radiographic evidence of bone loss must be evident. Some payors do not require diagnostic images, but most do.
2. Some payors require that five teeth have evidence of periodontal disease for reimbursement of D4341. If less than five teeth are reported, some payors re-map this code to D4342, ignoring the nomenclature quadrant definition of "four or more teeth. If four teeth are treated and the payor re-maps the reimbursement to D4342, ask the patient to request a copy of the plan document from their Human Resources department. Once a copy of the plan document is received, review the language as to tooth count requirements and limitations pertaining to D4341 and respond accordingly.
3. Periodontal maintenance (D4910) should follow multi-quadrant (D4341) SRP (generally at least two quadrants). This may not apply for SRP when involving D4342 for a few, isolated teeth. See D4342 for details. Note that there is typically a ninety day exclusion period (to the day) from the last date of SRP and the subsequent date of D4910.
4. Scaling and root planing (D4341) usually has a 24 to 36 month exclusion period for retreatment (a few payors have a 12 month exclusion). Note: reimbursement for scaling and root planing is typically excluded for 24 to 36 months after a gingival flap procedure (D4240/D4241) or osseous surgery (D4260/D4261) provided in the same area.
5. Artificial Intelligence (AI) programs are now being used by many payors to measure bone loss on submitted radiographs. Many are requiring 2mm of bone loss from the CEJ to the crest of bone to consider the site for reimbursement.
TIPS
1. D4921 reports gingival irrigation, per quadrant. Payors typically consider gingival irrigation to be a global component of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for irrigation. See D4921 for comments regarding the clinical use of gingival irrigation.
2. Use D9910 to describe the application of desensitizing medicaments for one tooth or multiple teeth. Payors typically consider D9910 to be a global part of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for the application of desensitizing medicaments. See D9910 for comments.
NARRATIVES
1. A narrative should document active disease. This may include, but is not limited to: 4mm or greater pockets that bleed on probing indicating active disease, loss of periodontal attachment, radiographic evidence of alveolar bone loss, gingival recession, furcation involvement, inflammation, tooth mobility, subgingival calculus, suppuration, etc. Enclose diagnostic radiographic images to document bone loss. Also send a current periodontal chart which includes the date(s) that the chart was recorded.
2. When scaling and root planing all four quadrants on the same day, include a narrative to document the treatment of all four quadrants in the same day. This may include time spent; anesthesia required; if pre-medication was necessary; apprehensiveness; medical conditions (i.e., taking blood thinner), extensive travel time, etc. Include any other supporting documentation that might justify the treatment of all four quadrants to report four quadrants of D4341. Payors are skeptical of four quadrants on one service date and may require extensive documentation for reimbursement. A predetermination is highly recommended.
3. Start and Stop times and types and amounts of local anesthetic are now required by certain payors on many periodontal procedures. Be sure to record this information in the clinical notation and subsequent narrative. Copies of the hygiene schedule from the date of service may even be requested.