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​Dental News and Notes

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July 16, 2018

Failing and Ailing Implant….How do I code the treatment?

Ever have a patient present with a chief complaint of soreness and bleeding associated with a restored implant?

Let’s assume the exam reveals 7mm pocketing surrounding the implant, bleeding on probing and suppuration. No mobility of the implant is detected. You take a periapical image and find circumferential bone loss (approaching the middle level of the bone on the implant). You determine the implant is treatable and place the patient on the appropriate antibiotic and schedule for them to return for treatment.

How do you code this visit?

  • D0140 limited oral evaluation – problem focused
  • D0220 intraoral – periapical first radiograph image


At the next visit……

Let’s assume the patient returns 10 days later with most of the swelling subsided. You provide oral sedation and local anesthesia, full thickness mucoperiosteal flaps were elevated and the implant surface was debrided with saline, scaled with an ultrasonic implant tip, and then treated with chlorhexidine solution. The site was then grafted with bone and covered with a resorbable barrier and closed with sutures.

How do you code this visit?

  • D9248 non-intravenous conscious sedation
  • D6101 debridement of a peri-implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure
  • D6103 Bone graft for repair of peri-implant defect-does not include flap entry and closure
  • D4266 Guided tissue regeneration – resorbable barrier, per site
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