D4261 is the CDT code for osseous surgery that reshapes diseased bone around one to three teeth or tooth gaps in a single quadrant.
- When to use: The operative note describes osteoplasty or ostectomy, and the treated teeth or tooth-bounded spaces in that quadrant total one to three.
- When not to use: Four or more teeth in the quadrant is D4260, a flap with root cleaning but no bone work is D4241, and scaling and root planing is D4342.
- Billing note: Many plans deny it without completed, re-evaluated scaling and root planing on file, so send charting showing 5 mm or deeper pockets and that history.
What D4261 covers
D4261 reports osseous surgery on one to three contiguous teeth or tooth-bounded spaces within a single quadrant. Osseous surgery treats the bone around teeth damaged by periodontal disease. The surgeon raises a full-thickness flap, reshapes or removes the diseased and irregular bone so the tissue can heal against a cleaner form, then closes the flap. The fee includes the flap entry and the closure, so neither is billed separately.
Bill D4261 when bone is reshaped or removed, not just accessed, and the periodontal charting and diagnosis support surgery on those localized sites. It does not cover:
- The same surgery on four or more teeth in a quadrant. That is D4260.
- A flap raised for access and root cleaning without recontouring bone. That is the gingival flap procedure, D4241 (one to three teeth) or D4240 (four or more).
- Nonsurgical scaling and root planing. That is D4342 (one to three teeth) or D4341 (four or more).
- A gingivectomy or gingivoplasty, which removes or reshapes soft tissue without touching bone. That is D4211 (one to three teeth) or D4210 (four or more).
The count axis: one to three per quadrant
D4261 and D4260 describe the identical procedure. Only the number of teeth or tooth-bounded spaces treated in the quadrant separates them:
- D4261 is one to three contiguous teeth or tooth-bounded spaces per quadrant.
- D4260 is four or more.
A tooth-bounded space is an edentulous gap with a natural tooth on each side. It counts the same as a tooth, because the surgery still addresses the bone across that span. A quadrant with two teeth and one bounded space treated is three sites, which is D4261.
Keep D4261 and D4260 as distinct, labeled entries in the PMS, and let the count from the perio chart decide which one is posted. A single generic “osseous surgery” entry is how the count gets miscoded.
Osseous surgery versus the flap and scaling codes
Three periodontal procedures sit near D4261 in the treatment sequence. They differ in what is done to the tissue and bone:
- Scaling and root planing (D4342, D4341) is nonsurgical. No flap is raised; the roots are cleaned below the gumline. This is usually the first line of treatment.
- Gingival flap with root planing (D4241, D4240) raises a flap to clean the roots under direct vision, then closes. It does not reshape bone.
- Osseous surgery (D4261, D4260) raises the same flap, then reshapes or removes bone to correct the defects the disease left, then closes.
Bone recontouring is the line between the flap code and the osseous code. Carriers read the operative note to confirm the code, so the note has to name the osteoplasty or ostectomy explicitly.
Top reasons D4261 gets denied or downgraded
- The count crossed quadrants. A claim built by counting teeth across two quadrants does not match the charting. Reviewers pull records and reprocess against the per-quadrant count.
- No documented nonsurgical phase. Many plans require scaling and root planing (D4342 or D4341), completed and re-evaluated, and a waiting period before osseous surgery is eligible. A claim with no prior therapy in the record pends or denies.
- Pocket depths do not justify surgery. Carriers commonly look for 5 mm or greater on the treated teeth. Shallower pockets get the surgery denied as not medically necessary.
- Frequency limit on the quadrant or site. Plans limit how often periodontal surgery is covered on a quadrant within a defined window. A repeat D4261 inside that window denies.
- Quadrant not identified. These codes are reported per quadrant, and multi-quadrant coverage in one visit is plan-specific. A line with no quadrant is a predictable pend, especially with more than one surgical quadrant on the claim.
Documentation that supports the claim
The claim needs:
- Periodontal charting, usually dated within six months, showing pocket depths that justify surgery on the treated teeth. Many carriers look for 5 mm or greater.
- A diagnosis of periodontitis.
- The specific teeth treated and the quadrant identified.
- Radiographs showing the bone loss at the localized sites.
- Evidence that nonsurgical therapy, typically scaling and root planing, was completed and re-evaluated and did not resolve the disease at those sites.
The operative note should document the flap, the bone recontouring, and the closure. It should also name the one, two, or three teeth treated, so the count on the claim matches the chart.
Example case
A 54-year-old patient completed scaling and root planing in the upper right quadrant (D4342) four months ago. At re-evaluation, the chart shows residual 6 mm pockets on teeth #3 and #4, with an unresolved infrabony defect on the mesial of #3. Radiographs confirm the localized bone loss. The rest of the quadrant charts within normal limits.
The periodontist raises a full-thickness flap over #3 and #4, performs osteoplasty and ostectomy to recontour the defect, and closes.
Billing for the visit:
- Report D4261 on the upper right quadrant for teeth #3 and #4. Two teeth is within one to three, so it is not D4260.
- Attach the charting showing the residual 6 mm pockets, the periodontitis diagnosis, and the radiographs of the defect.
- Add a one-line narrative: “Osseous surgery, upper right quadrant, teeth #3 and #4, for a residual infrabony defect after completed SRP and re-evaluation. Flap elevation, osteoplasty and ostectomy, and closure performed.”
- Check the EOB against the plan’s periodontal-surgery rules. If the plan required a waiting period after SRP or caps frequency on the quadrant, confirm those were met before posting patient responsibility.
FAQs
- What is the difference between D4261 and D4260?
- The number of teeth treated in the quadrant. D4261 is osseous surgery on one to three contiguous teeth or tooth-bounded spaces in a quadrant; D4260 is the same surgery on four or more. Both include flap elevation and closure in the fee.
- Can I bill D4261 on more than one quadrant in the same visit?
- Yes. Report a separate line per quadrant with the quadrant identified, keeping the count within each quadrant at one to three. Three treated sites in one quadrant and two in another are two D4261 lines, not one D4260. How many surgical quadrants a plan pays in one visit is plan-dependent, so verify before scheduling.
- Does D4261 include the flap and the closure, or do I bill those separately?
- They are included. The fee covers raising the full-thickness flap, recontouring the bone, and closing. Do not bill a separate flap or suture code. A bone graft or tissue regeneration material placed in the defect may be a separate code, depending on the procedure and the plan.
- Is D4261 the same as a gingival flap procedure?
- No. The gingival flap procedure with root planing, D4241 for one to three teeth, raises a flap to clean the roots under direct vision but does not reshape bone. D4261 raises the same flap and then recontours or removes bone. An operative note describing osteoplasty or ostectomy is osseous surgery; one that stops at flap access and root debridement is the gingival flap code.
- Does D4261 require scaling and root planing first?
- On many plans, yes. Carriers commonly expect scaling and root planing (D4342 for one to three teeth, D4341 for four or more) completed and re-evaluated before they consider surgery. The sequencing is plan-dependent, but a D4261 claim with no prior nonsurgical phase in the record is a frequent denial.
- What documentation do carriers want for D4261?
- Periodontal charting, usually from within six months, showing pocket depths that justify surgery, often 5 mm or greater, plus a periodontitis diagnosis, the teeth and quadrant treated, radiographs of the bone loss, and evidence that nonsurgical therapy came first. Frequency limits and waiting periods vary by plan, so verify the periodontal benefit before scheduling.
Related codes
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CDT codes are maintained by the American Dental Association. This page is an editorial billing guide, not the official ADA code descriptor. Verify current coverage policies with each carrier before submitting claims.