D4260 is the CDT code for osseous surgery — including elevation of a full-thickness flap and closure — on four or more contiguous teeth (or tooth-bounded spaces) in a quadrant. It is the surgical reshaping or removal of bone to reduce deep periodontal pockets in advanced disease.
Informational only — confirm the official CDT descriptor and your payers' rules independently. This is general guidance, not billing, coding, or clinical advice.
When to Use the D4260 Code
Report D4260 when a full-thickness flap is elevated and bone is recontoured or removed (osseous surgery) to eliminate deep pockets and create a more maintainable architecture across four or more contiguous teeth in a quadrant. It is used for advanced periodontitis with bony defects where non-surgical therapy and access flaps alone are insufficient.
The companion code is D4261 for one to three teeth in a quadrant. The critical contrast is with the gingival flap procedure (D4240): D4240 includes flap access and root planing but no bone reshaping, while D4260 specifically includes osseous recontouring. D4260 is also distinct from non-surgical scaling and root planing (D4341).
Documentation & Clinical Scenarios
Osseous surgery is among the most heavily reviewed periodontal procedures, so the record must justify bone work:
- The teeth and quadrant(s) treated, confirming four or more contiguous teeth per quadrant.
- Pre-surgical periodontal charting showing deep residual pockets and radiographs documenting bony defects.
- A periodontal diagnosis and history of prior non-surgical therapy with a re-evaluation.
- An operative narrative describing flap elevation, the osseous recontouring performed, and closure.
Bone grafts, biologic agents, or guided tissue regeneration, if used, are separate codes and are documented and billed independently of D4260.
Insurance & Billing Tips
- Verify benefits and waiting periods first. Surgical periodontal coverage often carries waiting periods and frequency limits.
- Bill by quadrant. Each quadrant with four or more contiguous teeth is its own D4260 line; one to three teeth use D4261.
- Document the bone work clearly. The narrative must state that osseous recontouring was performed, distinguishing it from a D4240 access flap.
- Show prior therapy. Payers typically expect documented SRP and a re-evaluation before approving osseous surgery.
- Appeal with the full record. Charting, radiographs, and the operative note support an appeal if the claim is denied or down-coded to D4240.
Example Case
A 60-year-old patient with advanced periodontitis still has 7 mm pockets and a bony crater between the lower left molars after completing scaling and root planing and a re-evaluation. Radiographs confirm angular bone loss across four contiguous teeth. The dentist elevates a full-thickness flap, recontours the defective bone, and sutures the tissue — reported as D4260 for the quadrant. The narrative documents prior non-surgical therapy, the residual pockets, and the osseous recontouring, and the claim is approved after review.
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Frequently Asked Questions
How is D4260 different from D4240?
Both elevate a flap, but only D4260 includes bone work. D4260 is osseous surgery — reshaping or removing bone to reduce deep pockets — while D4240 is a gingival flap with root planing and no osseous recontouring. The deciding factor is whether bone was modified. Reporting D4260 without documented bone work, or D4240 when bone was reshaped, leads to denials, so the operative note must match the code.
Does D4260 include bone grafting?
No. D4260 covers the osseous surgery itself — flap elevation, bone recontouring, and closure. Bone grafts, biologic materials, and guided tissue regeneration have their own separate codes and are documented and billed independently. Reporting a graft under D4260 is incorrect, so each material or regenerative procedure should be coded on its own line according to payer rules.
Will insurance cover osseous surgery?
Many plans cover D4260 for advanced periodontitis when the record shows deep residual pockets and bony defects after non-surgical therapy. Coverage usually depends on documented prior SRP, a re-evaluation, charting, and radiographs. Surgical periodontal benefits often carry waiting periods and frequency limits, so verify the specific plan's rules and documentation requirements before treatment.
Does D4260 require pre-authorization?
A pre-treatment estimate is strongly advisable because osseous surgery is high-cost and closely reviewed. Submitting periodontal charting, radiographs showing bony defects, and a narrative documenting prior therapy confirms medical necessity, establishes remaining benefits, and reduces the chance of a denial, a down-code to D4240, or a large surprise balance.
Confirm the current CDT descriptor and your specific payer policies before billing — browse the full dental code library or see our insurance verification feature.