Nearly 47.2 percent of Americans over 30 have some form of gum disease or periodontal disease, according to the American Dental Association. If left untreated, periodontal disease can infect the roots of the teeth. In a worst-case scenario, the teeth will become loose or uncomfortable. To correct the condition, dentists will advise gingivectomy, the surgical removal of gingival or gum tissue. Getting reimbursed for different types of gingivectomy procedures can be challenging. Dental offices can rely on outsourced dental billing services to submit claims with the correct CDT codes in compliance with payer guidelines to ensure accurate claim submission.
Periodontal Disease and Gingivectomy
Periodontal disease develops when bacteria present in the mouth attaches to the teeth and forms a biofilm called plaque. If oral hygiene is not maintained properly, leaving the plaque and food debris in the mouth, gingivitis will get worse. As the plaque continues to accumulate and moves below the gum line, the gum tissue becomes more inflamed. Bleeding can occur and the area between the tooth and gum tissue can deepen to form a periodontal pocket. Symptoms can also include bone loss that shows up on an x-ray, excessive tooth instability, gum recession, or the existence of exudate along or under the gumline.
Good dental hygiene can prevent periodontal disease. Getting a comprehensive annual periodontal evaluation (CPE) by a dentist is also important. A CPE involves assessing the teeth, plaque level, gums, bite, bone structure and other risk factors for periodontal disease. Identifying symptoms of gum disease early, which is key protecting the teeth and gums.
If periodontal disease is left untreated, the plaque will continue to spread below the gum line and infect the inside of the pocket, resulting in loose or uncomfortable tooth that require gum surgery or gingivectomy. The procedure involves removing a portion of the gums from in and around a tooth or teeth to treat gum disease or to lengthen the height or width of a tooth or a section of teeth. Gingivectomy may be also considered to remove extra gum tissue for cosmetic reasons, such as to modify a smile.
Gingivectomy Coding
Dental practices can ensure correct coding and claims submission by outsourcing these tasks to an experienced dental billing company.
The teeth in the mouth are divided into four quarters or sections. Let’s take a look at the CDT codes that describe gingivectomy procedures and when each CDT code should be used.
- D4210 Gingivectomy or Gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
- D4211 Gingivectomy or Gingivoplasty – one or three contiguous teeth or tooth bounded spaces per quadrant (Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal bevel. It is performed to eliminate suprabony pocketsafter adequate initial preparation, to allow access for restorative dentistry in the presence of suprabony pockets, or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration).
These procedures are performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration. D4210 is covered when four or more teeth within a section meet the allowable criteria. D4211 is covered when one to three teeth within a section meet the allowable criteria. For instance, Cigna Dental’s policies for coverage of D4210 and D4211 are as follows —
- Allowable under the following conditions:
- When periodontal pocket depths are 5mm (13/64 inch) or more.
- When it is clinically necessary to improve the shape of the gum tissue by correcting irregularities in the gum tissue around the teeth.
- When performed to remove overgrown gum tissue.
- Not allowable under the following conditions:
- When the procedure is being performed only to improve appearance and there is no disease present.
- When performed in conjunction with, and is considered incidental to, another surgical procedure.
- When a more extensive procedure is needed to gain access to and/or to treat the supporting bone.
- When this procedure is being performed at the same site on the same date of service, or within 30 days of, crown, bridge, and/or implant prosthesis preparations, impressions, and/or delivery.
- D4212 Gingivectomy or Gingivoplasty to allow access for restorative procedure, per tooth
- D4240 gingival flap procedure, including root planning – four or more contiguous teeth or tooth bounded spaces per quadrant
- D4241 gingival flap procedure, including root planning – one to three contiguous teeth or tooth bounded spaces per quadrant
- D4346 scaling in presence of generalized moderate or severe gingival inflammation- full mouth, after oral evaluation
- D4921 gingival irrigation- per quadrant
- D7971 excision of per coronal gingival
D7971 is used when inflammatory or hypertrophied tissue is being removed on a partially erupted or impacted tooth (i.e. operculectomy). D4274 can also be used for this procedure. This code does not include any osseous recontouring or removal and is used when the procedure is performed in an edentulous area adjacent to a tooth allowing removal of a tissue wedge to gain access for debridement and to reduce pocket depth. However, any benefit for this procedure will be disallowed when performed in conjunction with another surgical procedure in the same area. For instance, if bone removal is indicated or performed, D4261 should be used instead of D4274.
As medical billing and coding for dental procedures can be complex, relying on dental billing services offered by companies that have AAPC-certified coding specialists on board is an ideal option to ensure accurate coding, billing and claims submission. Dental billing companies also provide comprehensive dental eligibility verification services to verify the patient’s coverage before procedures are performed.
Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. With a rich background in dental services, her expertise ranges from insurance coordination to office management.