D4210 - Gingivectomy (4+ Teeth)
Gingivectomy per quadrant (4+ teeth).
- Procedure Code
- D4210
- Category
- Periodontics
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- Subject to group/individual contract frequency limitations (none)
Required Claim Attachments & Pre-Submission Checklist
- Full-mouth periodontal charting with 6-point probing depths and bleeding points
Bill When (Allowable Clinical Criteria)
- Benefits are limited to once per quadrant per 36 months.
Restrictions & Clinical Exclusions
- Periodontal surgical procedures include all necessary postoperative care, finishing procedures, oral evaluations for three months. Soft tissue grafts may be allowed on the same teeth/sites within 36 months with supporting documentation. When a surgical procedure is billed within three months of the initial surgical procedure in relation to both natural teeth and implants by the same dentist/dental office, the fee for the surgery is not billable to the patient. In the absence of documentation of extraordinary circumstances, the fee for additional surgery by the same dentist/dental office for three years is not billable to the patient. If extraordinary circumstances are present, the benefits will be denied and is chargeable to the patient up to the approved amount for the surgery. not billable to the patient
- Periodontally involved teeth which would qualify for surgical pocket reduction benefits under these procedure codes must be documented to have at least 5 mm pocket depths and bone loss beyond 1-1.5 millimeters. If pocket depths are under 5 mm, then benefits are denied.
- If surgery is performed less than four weeks after scaling and root planing, fees for the surgical procedure or the scaling and root planning by the same dentist/dental office are not billable to the patient following consultant review.
- Periodontal surgical procedures include all necessary postoperative care, finishing procedures, oral evaluations for three months, as well as any surgical re-entry for three years. When a surgical procedure is billed within three months of the initial surgical procedure by the same dentist/dental office, the fee for the surgery is not billable to the patient. In the absence of documentation of extraordinary circumstances, fees for additional surgery are not billable to the patient for three years.
- Fees for D4210 are not billable to the patient when performed within 36 months by the same unaesthetic topography is evident with normal bony configuration. dentist/dental office. If done by a different dentist, the benefits are denied.
- For benefit purposes, local anesthesia is an integral part of the periodontal procedures being performed and additional charges are not billable to the patient.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K05.30 | Chronic periodontitis, unspecified | Gingivitis and periodontal diseases | Yes (Primary) | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, unspecified |
| K05.31 | Chronic periodontitis, localized | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, localized |
| K05.311 | Chronic periodontitis, localized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, localized, slight |
| K05.312 | Chronic periodontitis, localized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, localized, moderate |
| K05.313 | Chronic periodontitis, localized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, localized, severe |
| K05.319 | Chronic periodontitis, localized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, localized, unspecified severity |
| K05.32 | Chronic periodontitis, generalized | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, generalized |
| K05.321 | Chronic periodontitis, generalized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, generalized, slight |
| K05.322 | Chronic periodontitis, generalized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, generalized, moderate |
| K05.323 | Chronic periodontitis, generalized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, generalized, severe |
| K05.329 | Chronic periodontitis, generalized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Chronic periodontitis, generalized, unspecified severity |
| K06.1 | Gingival enlargement | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant indicated for Gingival enlargement |