Maintenance Recall Treatment

Guideline for Maintenance Patient

Treatment type: MAINTENANCE PATIENT

Procedure codes: D4910 plus D4381

CDT descriptor:

D4910 "Periodontal maintenance procedures following active therapy."

D4381 "Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report."

When to use D4910 plus D4381:

1) During the maintenance appointment following SRP.

2) After the completion of surgical or other definitive periodontal treatment therapies.

3) During the same visit as Periodontal Maintenance.

How:

• Complete the periodontal maintenance procedure including: the removal of subgingival and supragingival plaque and calculus using an ultrasonic instrument, a periodontal evaluation, and a review of the patient's plaque control efficiency. Treat new or recurring periodontal disease (sites > 5mm and BoP) with ATRIDOX.
• Report this procedure on the claim form using Code D4910. Report each tooth separately on the claim form. For each tooth provide the tooth number, procedure Code D4381, date of treatment and fee per tooth.
• Attach a detailed narrative report (including pre and post-therapy periodontal charting of the re-treated sites) to support the claim.

More Information and Forms

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