Billing Guide for D4342 (Periodontal scaling and root planing - one to three 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 report periodontal scaling and root planing (SRP) for three teeth (D4342), for several quadrants in one hour. Start and Stop times are now required by certain pays on many periodontal procedures.
2. D4346 reports generalized moderate or severe gingivitis without attachment (bone) loss for whole mouth. See D4346.
MATCH
D4342/D4341 should) be followed by osseous surgery (D4260/D4261) or periodontal maintenance (D4910)/
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. Nothing prohibits reporting D1110 with D4342 on the same service date. However, it usually requires an appeal with an explanation that establishes why both services were done on the same day and especially time spent. SRP (D4342) 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 gum and connective tissues beneath the gum line. The gingiva 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 plaque 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, 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 D4342 to report scaling and root planing (active periodontal treatment) for one to three diseased 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 (BOP) 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 no evidence of periodontitis.
In this example, when sequencing treatment, it may be best to complete 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, D4342 should be billed for each quadrant treated with SRP which include one to three teeth. If four or more teeth in a quadrant require SRP, D4341 (SRP four or more 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 D4342, bleeding on probing which indicates active periodontal disease, 4 to 5 mm pocket depth (plus presence of calculus ), attachment loss and radiographic evidence of bone loss must be evident. Some payors do not request diagnostic images, but most do.
2. D4342 is typically reimbursed at 50 to 60% of the D4341 fee.
3. Periodontal maintenance (D4910) almost always follows multiquadrant (D4341), and also after (D4342) scaling and root planing (if at least two quadrants), with a typical ninety day exclusion after active treatment. However, for just a few isolated teeth with D4342 scaling and root planing, it may instead be appropriate to follow with a prophylaxis, a frequency of three or four times per year may be most appropriate to maintain health. If prophylaxis (D1110) is provided to the patient with isolated periodontitis, then the clinical notes and “remarks” should note the isolated scaling and root planing areas in the chart notes. In fact, some payors will not reimburse D4910 after a single or two quadrants D4342 visit. Reimbursement in this area is highly variable.
4. Scaling and root planing generally has a 24 to 36 month exclusion period for retreatment (a very few have a 12-month exclusion). Note: Scaling and root planing is typically excluded for 24 to 36 months after a gingival flap (D4240/D4241) or an osseous surgery (D4260/D4261) procedure is performed in the same area.
5. If both scaling and root planing (D4342) and a prophylaxis (D1110) are necessary, consider the sequence of a prophylaxis first (at the doctor’s discretion), with scaling and root planing at a second visit. Wait six weeks prior to the D4342 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 areas. If D4342 is performed first there could be a ninety-day contract limitation that would affect reimbursement for either a subsequent prophylaxis (D1110) or periodontal maintenance (D4910).
6. 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 part of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for irrigation. See D921 for comments, regarding the clinical use of irrigation.
2. Use D9910 to describe the application of desensitizing medicaments. 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 evidence of active disease. Periodontal disease is episodic - it comes and goes. This may include but is not limited to: 4mm or greater pockets that bleed on probing, radiographic evidence of bone loss, gingival recession, furcation involvement, inflammation, tooth mobility, subgingival calculus, and suppuration. 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 reason all four quads were treated in the same day, time spent, anesthesia required, pre-medication, apprehensiveness, medical conditions, travel time, etc. Include any supporting documentation that might justify the treatment of all four quadrants on the same service date. Generally speaking, thirty to forty-five minutes or more would be required to complete each quadrant of D4342. A predetermination is highly recommended.
3. If teeth #’s 4 and 5 need SRP one year after teeth #’s 2 and 3 have been treated with SRP, the 24 to 36 month frequency limitation may apply. If reimbursement initially denied when reporting D4342 for #4 and #5, appeal the denial with an explanation. To aid in this process always include a list of teeth treated with SRP on the claim form when submitting D4342 even though not necessarily required. Attach a copy of the original D4342 claim form reporting the treatment of teeth #’s 2 and 3 when submitting the subsequent D4342 claim for treatment of #’s 4 and 5. Including the documentation of the first treatment visit may increase the chances of being reimbursed for the second treatment visit.
4. When a patient requires scaling and root planing on one to three teeth in the same quadrant and prophylaxis on the remaining quadrants, and both D4342 and D1110 are provided on the same day, reimbursement for the prophylaxis is usually denied. Always appeal with an explanation outlining circumstances and the time involved, D1110 may be reimbursed upon appeal.
5. 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 report periodontal scaling and root planing (SRP) for three teeth (D4342), for several quadrants in one hour. Start and Stop times are now required by certain pays on many periodontal procedures.
2. D4346 reports generalized moderate or severe gingivitis without attachment (bone) loss for whole mouth. See D4346.
MATCH
D4342/D4341 should) be followed by osseous surgery (D4260/D4261) or periodontal maintenance (D4910)/
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. Nothing prohibits reporting D1110 with D4342 on the same service date. However, it usually requires an appeal with an explanation that establishes why both services were done on the same day and especially time spent. SRP (D4342) 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 gum and connective tissues beneath the gum line. The gingiva 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 plaque 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, 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 D4342 to report scaling and root planing (active periodontal treatment) for one to three diseased 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 (BOP) 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 no evidence of periodontitis.
In this example, when sequencing treatment, it may be best to complete 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, D4342 should be billed for each quadrant treated with SRP which include one to three teeth. If four or more teeth in a quadrant require SRP, D4341 (SRP four or more 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 D4342, bleeding on probing which indicates active periodontal disease, 4 to 5 mm pocket depth (plus presence of calculus ), attachment loss and radiographic evidence of bone loss must be evident. Some payors do not request diagnostic images, but most do.
2. D4342 is typically reimbursed at 50 to 60% of the D4341 fee.
3. Periodontal maintenance (D4910) almost always follows multiquadrant (D4341), and also after (D4342) scaling and root planing (if at least two quadrants), with a typical ninety day exclusion after active treatment. However, for just a few isolated teeth with D4342 scaling and root planing, it may instead be appropriate to follow with a prophylaxis, a frequency of three or four times per year may be most appropriate to maintain health. If prophylaxis (D1110) is provided to the patient with isolated periodontitis, then the clinical notes and “remarks” should note the isolated scaling and root planing areas in the chart notes. In fact, some payors will not reimburse D4910 after a single or two quadrants D4342 visit. Reimbursement in this area is highly variable.
4. Scaling and root planing generally has a 24 to 36 month exclusion period for retreatment (a very few have a 12-month exclusion). Note: Scaling and root planing is typically excluded for 24 to 36 months after a gingival flap (D4240/D4241) or an osseous surgery (D4260/D4261) procedure is performed in the same area.
5. If both scaling and root planing (D4342) and a prophylaxis (D1110) are necessary, consider the sequence of a prophylaxis first (at the doctor’s discretion), with scaling and root planing at a second visit. Wait six weeks prior to the D4342 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 areas. If D4342 is performed first there could be a ninety-day contract limitation that would affect reimbursement for either a subsequent prophylaxis (D1110) or periodontal maintenance (D4910).
6. 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 part of D4341, D4342 or D4910. The PPO contract may prohibit charging a separate fee for irrigation. See D921 for comments, regarding the clinical use of irrigation.
2. Use D9910 to describe the application of desensitizing medicaments. 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 evidence of active disease. Periodontal disease is episodic - it comes and goes. This may include but is not limited to: 4mm or greater pockets that bleed on probing, radiographic evidence of bone loss, gingival recession, furcation involvement, inflammation, tooth mobility, subgingival calculus, and suppuration. 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 reason all four quads were treated in the same day, time spent, anesthesia required, pre-medication, apprehensiveness, medical conditions, travel time, etc. Include any supporting documentation that might justify the treatment of all four quadrants on the same service date. Generally speaking, thirty to forty-five minutes or more would be required to complete each quadrant of D4342. A predetermination is highly recommended.
3. If teeth #’s 4 and 5 need SRP one year after teeth #’s 2 and 3 have been treated with SRP, the 24 to 36 month frequency limitation may apply. If reimbursement initially denied when reporting D4342 for #4 and #5, appeal the denial with an explanation. To aid in this process always include a list of teeth treated with SRP on the claim form when submitting D4342 even though not necessarily required. Attach a copy of the original D4342 claim form reporting the treatment of teeth #’s 2 and 3 when submitting the subsequent D4342 claim for treatment of #’s 4 and 5. Including the documentation of the first treatment visit may increase the chances of being reimbursed for the second treatment visit.
4. When a patient requires scaling and root planing on one to three teeth in the same quadrant and prophylaxis on the remaining quadrants, and both D4342 and D1110 are provided on the same day, reimbursement for the prophylaxis is usually denied. Always appeal with an explanation outlining circumstances and the time involved, D1110 may be reimbursed upon appeal.
5. 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.