Free Soft Tissue Graft - CDT Code Guide
Overview
The CDT code D4278 refers to the free soft tissue graft procedure, which includes both the recipient and donor surgical sites. This code is used for each additional contiguous tooth, implant, or edentulous tooth position graft site in conjunction with the primary procedure coded as D4277. This procedure is typically performed to enhance the thickness and health of the gum tissue around teeth or implants, which can be crucial for patients with periodontal disease or those requiring additional support for dental implants. The procedure involves harvesting soft tissue, usually from the palate, and grafting it to the desired site to improve gum health and aesthetics.
In clinical practice, this procedure is often necessary when there is a need to cover exposed roots, reduce sensitivity, or prepare the site for further restorative work. It is a common treatment in periodontics aimed at preventing further gum recession and protecting the underlying bone structure. Understanding the specific use of D4278 helps ensure proper treatment planning and billing compliance.
When to Use This Code
- When performing a free soft tissue graft for an additional contiguous tooth in conjunction with D4277.
- For grafting around an implant that is adjacent to a site being treated with D4277.
- In cases of severe gum recession where multiple contiguous sites require grafting.
- When preparing multiple adjacent edentulous sites for future restorative procedures.
- To enhance gingival aesthetics and health around multiple contiguous teeth.
Documentation Requirements
- Detailed clinical notes describing the necessity of the graft for each additional site.
- Pre-operative and post-operative photographs to document the condition and treatment.
- Patient consent forms specifically for the graft procedure.
- A comprehensive treatment plan outlining the use of D4278 in conjunction with D4277.
- Operative report detailing the surgical procedure and sites treated.
Billing Considerations
When billing for D4278, it is important to note that this code is used in conjunction with D4277 for additional contiguous sites. Ensure that the primary procedure is also documented and billed. Frequency limitations may apply depending on the patient's insurance plan, and it is crucial to verify coverage beforehand. Common modifiers for periodontal procedures may be applicable, and understanding the patient's specific insurance policy will help in avoiding denied claims.
Related CDT Codes
Frequently Asked Questions
D4277 is used for the primary site of the free soft tissue graft, while D4278 is used for each additional contiguous site treated in the same session.
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