Initial/Definitive Treatment

Guidelines for New Patients

Treatment type: NEWLY DIAGNOSED CHRONIC ADULT PERIODONTITIS PATIENT

Procedure code: D4381

CDT descriptor: "Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report."

When to use D4381:

1) Following evaluation after mechanical and surgical procedures (i.e. scaling and root planing, flap surgery, etc.). Pockets > 5mm that demonstrate bleeding on gentle probing. SRP completed prior to ATRIDOX® administration.

2) During Routine Periodontal Maintenance visits.

3) Uncommon situations (i.e. pre-existing medical condition) with detailed documentation.

How:

• Report each tooth or site separately on the claim form. For each tooth provide the tooth number, procedure code, date of treatment and fee per tooth.
• Attach a detailed narrative report to support the claim.
• Additional information that may be helpful in developing your report can be found in the ATRIDOX package insert.

NOTE: The D4381 procedure code permits the filing of a separate charge for each tooth being treated with ATRIDOX. The fee for ATRIDOX therapy should be per tooth.

D4381 is a procedure code that by definition is covered on a "by report" basis. Review of the claim by a dental claims examiner is likely. Therefore, it is important to support the decision to treat the patient in this manner with sufficient and legible clinical information.

More Information and Forms

• ATRIDOX Reimbursement Guide (1013.6 KB)
• ATRIDOX Insurance Claims Submission Checklist (316.9 KB)