Should soft tissue grafts be billed per site or per tooth?

Answer

The American Academy of Periodontology instructs its members to bill soft tissue grafts on a “per tooth” basis. The first tooth involved in the graft should be reported as D4277. Each additional graph performed at the same appointment is reported as D4278. Dentists may reduce their fee for each additional tooth involved in the graft but should report each additional tooth involved on a separate line.

Dental carriers vary in how they structure soft tissue graft payments. It is common for dental plans to pay 80% for the first graft and 60% (or less) for each additional graft. If five teeth are involved in a soft tissue graft, some may pay the first two teeth as one graft and the next three teeth as a second graft (paid at a lesser rate, i.e., 60%).

Remember the following when billing soft tissue grafts:

• Soft tissue grafts should be reported per tooth. Each graft should be reported on a separate line with tooth numbers and tooth surfaces identified.
• Despite the fact that the AAP maintains that radiographs and periodontal pocket measurements provide little value in documenting soft tissue pathology, some plans still request current periodontal charting before paying for soft tissue grafts.
• Dental plans vary widely in how they calculate benefits for soft tissue grafts. Some plans require at least 3 mm of recession to receive a benefit for a soft tissue graft and will pay one soft tissue graft benefit for two contiguous grafts/teeth. Other dental plans require at least 4 mm of recession with no attached gingiva and only pay for one soft tissue graft when up to three contiguous teeth have been grafted.
• Dental plans often consider soft tissue grafts to include three months of post-operative care and surgical re-entry for three years.
• Claims for soft tissue grafts should include a separate attachment that addresses the following:

               o Tooth number and location of defect

               o Amount of recession (in millimeters)

               o Amount of attached gingiva

               o Amount of keratinized gingiva

               o Statement concerning progressive recession

               o Presence of marginal inflammation

               o Influence of frenum

               o Indications of root sensitivit

               o Cervical caries

               o Relationship to orthodontic care

               o Relationship to existing restorations (e.g., recession on an existing bridge or subgingival restoration)

               o Statement that the procedure is not cosmetic