D4264 Dental Code: Additional Bone Graft Site Billing Guide

What D4264 covers

D4264 reports a bone replacement graft around a natural tooth that is staying in the mouth, for each site treated after the first in that quadrant. The procedure is identical to D4263: periodontal disease has hollowed out the bone against the root, the surgeon opens and cleans the site, and graft material goes into the defect so bone can rebuild. D4264 exists only so the claim can show how many defects were treated.

Three rules follow from that:

• It never stands alone. D4263 has to be on the claim for the same quadrant.
• The count resets at every quadrant boundary. Two quadrants of regenerative surgery produce two D4263 lines, plus whatever D4264 lines each quadrant earns.
• It carries the same exclusions as the first-site code. Flap entry and closure, wound debridement, osseous contouring, the barrier membrane, and any biologic material are outside the fee. The site must have a natural tooth at it, which rules out an extraction site or an edentulous space.

Both codes are active in CDT 2026. Each took an editorial action in the 2026 code set, which tidied the entry without changing the procedure, so last year’s meaning still holds.

A site is a defect, not a tooth

Billers count teeth because the claim form asks for teeth, but the code counts bony defects. The American Academy of Periodontology’s coding guidance sets the test at whether the defects communicate:

1. Two contiguous teeth, two separate osseous defects. Two sites: D4263, then D4264.
2. Two contiguous teeth, one defect continuous through the interproximal bone. One site: D4263 only, even though two roots received graft material.
3. Three separate defects in one quadrant. D4263 once, D4264 twice.
4. The same three defects split across two quadrants. D4263 in each quadrant, D4264 for the remainder in each.

Case two costs money in both directions. Billed as two sites, the D4264 line is denied and the claim draws a records request. Billed as one site when the defects were genuinely separate, the practice writes off a line it earned.

Two counting patterns on the same claim

A regenerative surgery usually places a graft, a membrane, and sometimes a biologic at the same defect. The three count differently:

• The bone graft sequences within the quadrant. D4263 first, D4264 for each site after it.
• The membranes do not sequence. D4266 (resorbable barrier) and D4267 (non-resorbable barrier) are each reported per site, with no additional-site membrane code. A second membraned site in the same quadrant is another D4266 or D4267 line.
• Biologic materials do not sequence either. D4265 is per site.

A quadrant with three grafted defects under resorbable barriers is D4263, D4264, D4264, D4266, D4266, D4266. Keep D4266, D4267, and D4265 next to the graft codes in the PMS pick list; when they are buried, they get skipped and the surgery goes out underbilled.

The surgical access code counts on a third basis: teeth per quadrant. Osseous surgery is D4260 for four or more teeth and D4261 for one to three, and a gingival flap procedure with root planing is D4240 or D4241. A quadrant can legitimately carry D4261 for two teeth alongside three graft sites, because teeth and defects are different units.

Grafts that are not D4264

Every code below puts bone in the jaw. They are separated by the state of the tooth and the surgery the graft belongs to.

• D4264 is a periodontal graft around a tooth that is staying, at a site after the first in the quadrant.
• D7953 is a graft into a socket at the time of an extraction or implant removal, reported per site with no first-versus-additional split.
• D6104 is a graft placed at the same visit as an implant.
• D7950 is a staged augmentation of an edentulous ridge, with no extraction and no same-day implant.
• D3428 is a graft placed with periradicular surgery, with D3429 for each additional contiguous tooth in the same surgical site.

One appointment can produce more than one of these. Periodontal surgery in a quadrant that also removes one hopeless tooth carries D7953 in the empty socket and D4263 plus D4264 around the teeth that stayed. Code each graft against the tooth beside it, not the visit. The bone graft dental codes guide works through that appointment line by line.

Coverage and how carriers treat it

Plans that cover periodontal surgery generally cover D4264 on the same terms as the first site, and review it line by line rather than as an add-on.

The defect standard applies to every line. Cigna’s 2026 DPPO guidelines make the benefit available where the pocket measures 5 mm or deeper with bone loss and a vertical bony defect next to the retained natural tooth. UnitedHealthcare’s bone replacement graft policy, effective May 2026, names intrabony vertical defects and Class II furcation involvements as the indications, and excludes non-vertical defects, teeth with a hopeless prognosis, and grafts done with periradicular surgery. Horizontal bone loss, the more common radiographic pattern, meets neither standard, so each additional site has to pass the vertical test on its own.

Retreatment windows are scoped to the site. Cigna’s guidelines treat a repeat graft by the same office at the same tooth or site within 36 months as the practice’s cost, not billable to the patient. Because the window follows the site rather than the quadrant, a later graft at a previously untreated defect can still be payable in a quadrant with history. Document which site is new.

Patient history gets read. The UnitedHealthcare policy excludes patients who were non-compliant with prior periodontal therapy or who present with poor oral hygiene. A chart showing scaling and root planing, then a re-evaluation documenting the residual defects, reviews cleanly. Grafting as the first periodontal treatment on file does not.

Pocket thresholds, frequency windows, and whether a plan pays more than one regenerative procedure per site per date are plan-dependent. Verify them before the surgical appointment.

Documentation that supports the claim

UnitedHealthcare’s 2026 claim review guidelines ask for the same three attachments on D4264 as on D4263: current dated pre-operative radiographs of the area, complete six-point periodontal charting, and a narrative of necessity. Build every packet that way:

• Radiographs showing each vertical defect, covering every site billed, not just the first. The periapical showing the intrabony component answers the vertical-versus-horizontal question directly.
• Six-point charting at the grafted teeth, recent enough that the pocket depths reflect the surgical findings.
• A narrative naming each defect by tooth and surface, with the wall count and whether adjacent defects communicate. This sentence supports the site count.
• The graft material, membrane, and biologic, listed per site.
• The prior nonsurgical therapy and the re-evaluation that found the defects still present.

What to get right in your PMS

1. Stop per-tooth posting on periodontal surgery. Templates that spread a procedure across every tooth in the quadrant post four D4263 lines where the correct claim is one D4263 and three D4264.
2. Attach the quadrant to every graft line. The sequence is quadrant-scoped, so a claim without quadrants on the graft lines cannot be adjudicated as the code is written.
3. Enter D4264 as separate lines with their own tooth numbers where the system allows, not one line with a quantity. Carriers vary in how they read quantity on a site-counted code, and separate lines give you something specific to appeal.
4. Require a surgical access code with any graft line. A graft with no flap or osseous code beside it is the pattern most likely to draw a records request.

For how tooth numbers, quadrants, and the remarks field are filled in on the claim, see the ADA dental claim form guide.