Blue Cross Blue Shield FEP Dental
Class C Major
Class C Major
Periodontal Services
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant - Limit 1 every 36 months
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months
D4240 Gingival flap procedure, including root planing- four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only
D4249 Clinical crown lengthening – hard tissue
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth only
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months
D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient surgical site) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) – Limit 1 every 36 months, permanent teeth only
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limit 1 every 36 months
D4276 Combined connective tissue and pedicle graft, per tooth – Limit 1 every 36 months
D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site – Limit 1 every 36 months
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material), each additional contiguous tooth, implant, or edentulous tooth position in same graft site – Limit 1 every 36 months
D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limit 1 per lifetime
D4999 Unspecified periodontal procedure, by report
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months
D4240 Gingival flap procedure, including root planing- four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only
D4249 Clinical crown lengthening – hard tissue
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months
D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth only
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months
D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient surgical site) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) – Limit 1 every 36 months, permanent teeth only
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limit 1 every 36 months
D4276 Combined connective tissue and pedicle graft, per tooth – Limit 1 every 36 months
D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site – Limit 1 every 36 months
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material), each additional contiguous tooth, implant, or edentulous tooth position in same graft site – Limit 1 every 36 months
D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limit 1 per lifetime
D4999 Unspecified periodontal procedure, by report
Class C Periodontal Services Notes:
Supporting documentation and criteria:
Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration and will not be reimbursed.
Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and soft tissue following clinical crown lengthening.
Supporting documentation and criteria:
- Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs, labeled and dated (within 12 months of submitted procedure)
- Periodontal charting: 6-point periodontal pocket depth charting as described by the ADA and AAP labeled and dated (within 12 months of submitted procedure)
- Teeth to be treated must demonstrate at least 5 mm pocket depths
- Gingival flap procedure must be a surface adjacent to an edentulous/terminal tooth area
Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration and will not be reimbursed.
Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and soft tissue following clinical crown lengthening.