1.A history of a surgical code will limit for payment the approval of a second surgical code in a same
quadrant if three years have not passed.
2. Any surgical procedure for cosmetic purposes is excluded for payment.
3. In those covers that do not include the benefit of implants, all procedures related to the implant are excluded, such as, and not limited to, bone grafts and membranes in areas of extraction for implants and maintenance of dental implants.
4. Codes D4210 and D4211 are indicated for cases with gingival hyperplasia with none or minimal bone loss and are limited for payment to one of the two services per quadrant every 3 years.
5. Code D4210 is used when the quadrant contains a minimum of 4 teeth that need surgery. Code D4211 will be used for cases in which it is only necessary to perform surgery in three teeth or less in the same quadrant.
6. Every predetermination for soft tissue surgery requires a report indicating its necessity. You must include pictures, if they are available, as a diagnostic aid to advise in the case.
7. The fee for codes D4240, D4241, D4260 and D4261 includes the fee of codes D4341 and D4342 when these are performed in the same quadrant, on the same day.
8. Code D4245 is limited for payment to one per quadrant for life. A detailed «by report» is required and will not be considered for payment in conjunction with code D7960 if it is performed in the same visit. It will be billed using the quadrant number.
9. Code D4249 is limited to one payment per tooth per life and will be invoiced using the number of the tooth. The amount paid for codes D4249 in the same quadrant may not exceed the rate of code D4260.
10. The rate of code D4249 was included in that of D4260 and D4261 if done in the set in the same affected area of the quadrant.
11. The following codes are limited to pay one per quadrant every three years: D4210, D4211, D4240, D4241, D4260, D4261, D4270, D4273 and these are mutually exclusive. The quadrant number was used.
12. Codes D4263, D4264, D4277 and D4278 are made using the tooth number and will be limited to 1 per tooth per life. X-rays or photographs should be sent to show the need and any other diagnostic help that may facilitate the evaluation of the case.
13. Codes D4277 and D4278 on the ADA sheet in the «observation» section should indicate the classification (MILLER).
14. The codes D4263 and D4264 must indicate the SITE of the bone defect in addition to the number of the tooth.
15. The codes D4266 and D4267 will be limited to 1 per quadrant every 3 years and is billed using the tooth number.
16. The codes D4277 and D4278 are mutually exclusive of codes D4270 and D4273.
17. The following codes will only be considered for payment in type II bifurcations and interproximal infrabony defects. (D4263, D4264, D4266 and D4267).
18. Gingival grafts are limited for payment to one (1) per quadrant every three years and will be billed using the quadrant number.
