D4264 - Bone Graft (Addl)
Bone replacement graft – each addl site.
- Procedure Code
- D4264
- 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 for bone replacement grafts are limited to once per tooth per 36 months on natural teeth only.
- Benefits are limited to up to two teeth per quadrant per 36 months. wound debridement, osseous contouring, the placement of biologic materials or the placement of barrier membranes to aid in osseous tissue regeneration or barrier membranes. This procedure is performed concurrently with one or more bone replacement grafts to document the number of sites involved. Not to be reported for an edentulous space or an extraction site.
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.
- Benefits for bone replacement grafts are denied when submitted with apicoectomy sites, implants, mucogingival/soft tissue grafts, periradicular surgery, ridge augmentation or preservation procedures, sinus elevation, defects from cyst removal, hemisections or with extractions.
- 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 |
|---|---|---|---|---|---|
| K05.313 | Chronic periodontitis, localized, severe | Gingivitis and periodontal diseases | Yes (Primary) | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, localized, severe |
| K05.211 | Aggressive periodontitis, localized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, localized, slight |
| K05.212 | Aggressive periodontitis, localized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, localized, moderate |
| K05.213 | Aggressive periodontitis, localized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, localized, severe |
| K05.219 | Aggressive periodontitis, localized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, localized, unspecified severity |
| K05.221 | Aggressive periodontitis, generalized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, generalized, slight |
| K05.222 | Aggressive periodontitis, generalized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, generalized, moderate |
| K05.223 | Aggressive periodontitis, generalized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, generalized, severe |
| K05.229 | Aggressive periodontitis, generalized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Aggressive periodontitis, generalized, unspecified severity |
| K05.30 | Chronic periodontitis, unspecified | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, unspecified |
| K05.311 | Chronic periodontitis, localized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, localized, slight |
| K05.312 | Chronic periodontitis, localized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, localized, moderate |
| K05.319 | Chronic periodontitis, localized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, localized, unspecified severity |
| K05.321 | Chronic periodontitis, generalized, slight | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, generalized, slight |
| K05.322 | Chronic periodontitis, generalized, moderate | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, generalized, moderate |
| K05.323 | Chronic periodontitis, generalized, severe | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, generalized, severe |
| K05.329 | Chronic periodontitis, generalized, unspecified severity | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Chronic periodontitis, generalized, unspecified severity |
| K05.6 | Periodontal disease, unspecified | Gingivitis and periodontal diseases | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Periodontal disease, unspecified |
| K08.20 | Unspecified atrophy of edentulous alveolar ridge | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Unspecified atrophy of edentulous alveolar ridge |
| K08.21 | Minimal atrophy of the mandible | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Minimal atrophy of the mandible |
| K08.22 | Moderate atrophy of the mandible | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Moderate atrophy of the mandible |
| K08.23 | Severe atrophy of the mandible | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Severe atrophy of the mandible |
| K08.24 | Minimal atrophy of the maxilla | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Minimal atrophy of the maxilla |
| K08.25 | Moderate atrophy of the maxilla | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Moderate atrophy of the maxilla |
| K08.26 | Severe atrophy of the maxilla | Other disorders of teeth and supporting structures | Secondary | BOTH | bone replacement graft – retained natural tooth – each additional site in quadrant indicated for Severe atrophy of the maxilla |