D4276 is the CDT code for a combined procedure in which a connective tissue graft is placed at a tooth and covered by a double pedicle flap of adjacent tissue, reported per tooth.
Two techniques in one surgery invite two codes on one claim, and that is the mistake this code exists to prevent. A connective tissue graft covered by a double pedicle flap at the same tooth is a single D4276, not a D4273 stacked with a D4270, and unlike its siblings, the unit is the tooth, so there is no first-position line and no contiguous add-on to build.
What D4276 covers
D4276 reports a combined mucogingival procedure at a single tooth: a connective tissue graft placed over the defect, covered by a double pedicle flap, tissue mobilized from both neighboring areas that remains attached at its base while it is positioned over the graft. The pedicle coverage brings a blood supply over the grafted tissue, which is the clinical point of combining the techniques on difficult recession defects.
For billing, the important facts are structural. One code covers both components. The unit is the tooth. There is no add-on.
Per tooth, unlike everything around it
The rest of the graft family counts positions and pairs first-position codes with contiguous add-ons: D4273 with D4283, D4275 with D4285, D4277 with D4278. D4276 does not participate in that structure. Each tooth that received the combined procedure is its own D4276 line with its own tooth number.
Two practical consequences:
- No add-on exists. D4276 plus a D4283 line for the neighboring tooth mixes the per-tooth code with another family’s positional add-on. If the second tooth also got the combined procedure, it is a second D4276. If it got a plain connective tissue graft as part of a separate graft, code that graft’s own family correctly.
- Multi-tooth combined cases are line-per-tooth. The claim’s line count should match the operative note’s tooth count exactly.
The unbundling trap
The procedure contains a connective tissue graft and pedicle flaps, and both components have standalone codes, which is exactly why the combination gets billed wrong. Submitting D4273 and D4270 at the same tooth for one combined surgery unbundles a procedure CDT prices as a unit. Depending on the carrier’s edits, the result is a bundling denial on one line, a re-adjudication to D4276, or a records request that delays the whole claim.
The reverse check matters too: D4276 asserts both components. An operative note that shows only a connective tissue graft with a standard coronally positioned flap, no double pedicle, supports D4273, not D4276, and the higher-fee combined code without the documented pedicle work is the kind of upcode that surfaces in audit.
Coverage and common denials
- Alternate benefit to a simpler graft. Where the record does not show why the combined technique was needed, some plans price the case at a lesser graft’s allowance. Plan-dependent; the defense is a note that documents the defect severity and both surgical components.
- The standard mucogingival screen. Recession and attached-gingiva measurements from charting within the plan’s window, a functional rationale, and photos where requested, the same review the whole family gets, with one published policy benchmark at 2 mm recession and 1 mm or less attached gingiva absent other findings.
- Cosmetic exclusion. Grafting solely for appearance is not benefited on many plans.
- Frequency at the site. One perio surgical procedure per site per 36- or 60-month window is common contract language, and a prior graft of any type at the tooth can count against it.
- Unbundled or double-billed components. D4273, D4270, or a separate line for graft handling billed alongside D4276 at the same tooth.
Documentation that supports the claim
- An operative note that separately describes the connective tissue graft (source and placement) and the double pedicle flap (where each pedicle was raised, that both remained attached, how they were positioned over the graft).
- The tooth number on the claim line, matching the note.
- Recession depth, attached-gingiva width, and pocket charting for the tooth, dated within the carrier’s documentation window.
- The functional driver, progressive recession, sensitivity, restorative need, stated in the narrative.
- Pre-authorization records where the plan reviews mucogingival surgery prospectively.
What to get right in your PMS
- One line per treated tooth, tooth number required. No add-on codes attach to D4276.
- Build an edit against same-tooth D4273 or D4270 on the same date. That combination is the unbundle; the system should force a choice.
- Set the fee to reflect the combined procedure, since it replaces two components’ worth of work in one code, and expect plan allowances to vary more than on the plain graft codes.
- Route these cases through pre-authorization by default. A combined graft that a plan would alternate-benefit is better discovered before surgery than on the EOB.
FAQs
- What procedure does D4276 describe?
- A combined mucogingival surgery at one tooth: the surgeon places a connective tissue graft over the defect and covers it with a double pedicle flap, tissue mobilized from both adjacent areas that stays attached at its base. The pedicle coverage keeps the graft vascularized, which is why the combination is used on demanding recession defects. The code is reported per tooth.
- Can I bill D4273 and D4270 together instead of D4276?
- Not for the combined procedure at the same tooth. CDT gives the combination its own code, and a claim listing the connective tissue graft and a pedicle graft separately at one site is the unbundled version of D4276. Carriers that catch it re-adjudicate to the single code. D4273 and D4270 remain the right codes when the procedures happen at different, independent sites.
- Is D4276 billed per tooth or per site?
- Per tooth. That makes it the odd one out in the graft family: D4273, D4275, and D4277 bill a first tooth, implant, or edentulous position and pair with add-on codes D4283, D4285, and D4278 for additional contiguous positions. D4276 has no first-versus-additional structure and no add-on. A combined graft performed at two teeth is two D4276 lines, each with its own tooth number.
- Why did the carrier downgrade or deny D4276?
- Combined grafts draw the same mucogingival review as the rest of the family, plus an alternate-benefit question: some plans pay the case at the allowance of a simpler graft when the record does not justify the combined technique. The claim needs the standard measurements, recession and attached gingiva from recent charting, and an operative note that documents both components, the connective tissue graft and the double pedicle coverage. Coverage and downgrade behavior are plan-dependent, so pre-authorize where the plan allows.
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.