D4278 is the CDT code for each additional contiguous tooth, implant, or edentulous tooth position covered by a free soft tissue (gingival) graft in the same graft site, reported alongside D4277 for the first position.
An add-on code lives or dies by its parent line, and D4278 denials are mostly pairing failures: submitted without a D4277 on the claim, attached to the wrong parent from a different graft family, or counted across positions that were never contiguous. Getting the arithmetic right, one parent, then one add-on per touching position, is nearly the whole job.
What D4278 covers
D4278 extends a free gingival graft past its first position. When one continuous graft covers several adjacent positions, the first tooth, implant, or edentulous tooth position is billed as D4277 and every additional contiguous position in that same graft site is one D4278 line. Like its parent, the code’s fee structure already accounts for the donor and recipient surgical work: there is no separate harvest line anywhere in this family.
The code exists because a graft across three positions is not three independent surgeries. One donor harvest, one recipient bed preparation, one suturing session, but more coverage area than a single-position graft. The first-position/additional-position split is how CDT prices that difference.
The three-way pairing rule
Every soft tissue graft family with positional counting has its own add-on, and they do not cross:
| First position | Each additional contiguous position | Procedure |
|---|---|---|
| D4277 | D4278 | Free (epithelialized) soft tissue graft, patient’s own tissue |
| D4273 | D4283 | Autogenous subepithelial connective tissue graft |
| D4275 | D4285 | Non-autogenous connective tissue graft, donor material |
The parent decides the family; the add-on follows. The two codes without positional structure sit outside the table entirely: the pedicle graft D4270 has no add-on, and the combined connective tissue and double pedicle graft D4276 is reported per tooth on its own.
Counting positions correctly
Work through the operative note position by position:
- Identify the graft site’s span. Which teeth, implants, and edentulous tooth positions did the single continuous graft cover?
- First position → D4277. Any position in the span can be first; there is only one of it.
- Each remaining contiguous position → one D4278. A graft over #22, #23, and #24 is D4277 plus two D4278 lines.
- A break restarts the count. If the surgeon treated #22–#23 and separately #27, that is D4277 + D4278 for the first site and a second D4277 for #27. Billing #27 as a third add-on understates the second site’s independent work and misstates contiguity.
- Reconcile lines against the note. The number of positions named in the operative record should equal the D4277 and D4278 lines combined.
Common denials
- Orphaned add-on. D4278 submitted without D4277 on the same claim, often because the parent posted on a different date or claim. Resubmit with the pair together.
- Crossed family. D4278 attached to a D4273 or D4275 parent. The carrier reads two different procedures and pends for records.
- Contiguity challenged. Add-on positions that skip a tooth. The EOB reads as an overcount; the fix is recoding the second site as its own D4277, not appealing the add-on.
- Mucogingival criteria applied per position. Plans that review grafting against recession and attached-gingiva measurements may want the numbers at the additional positions too, not only the first. Charting that documents each grafted position defends each line.
- Frequency at the site. The additional positions share the graft site’s surgical history. A plan limiting perio surgery to one procedure per site per 36 or 60 months, where the contract has that structure, applies the window to the whole span.
Documentation that supports the claim
- The operative note naming every grafted position and describing one continuous epithelialized graft.
- Per-position mucogingival measurements, attached-gingiva width and recession, where the plan reviews against thresholds.
- The pairing made explicit: D4277 with the first position’s tooth number, each D4278 with its own position identifier.
- The pre-authorization reference when one was obtained, since add-on allowances are the part of the fee patients most often misestimate.
What to get right in your PMS
- Template D4278 to require a same-claim D4277. An edit that blocks the orphaned add-on saves the resubmission cycle.
- Attach a position identifier to every add-on line. “D4278 × 2” with no tooth numbers is the version reviewers pend.
- Do not let the fee schedule clone the parent fee onto the add-on. Patient estimates built on two full graft fees overstate the balance and start the fee conversation in the wrong place.
- Keep the three graft families’ add-ons visually distinct in the pick list, labeled by procedure instead of “graft, additional site” three times.
FAQs
- Can D4278 be billed by itself?
- No. D4278 reports each additional contiguous position in a free gingival graft whose first position was billed as D4277. A claim with D4278 and no D4277 describes an additional position with no first position, and carriers reject or pend it. If only one position was grafted, the entire procedure is a single D4277.
- What counts as a contiguous position for D4278?
- A tooth, implant, or edentulous tooth position directly adjacent to the previous grafted position within the same continuous graft site. The three categories count equally, so a graft running from a tooth across a neighboring edentulous ridge position takes a D4278 for that position. A gap of untreated positions breaks contiguity: the next area becomes a new graft site with its own D4277.
- What is the difference between D4278 and D4283?
- The parent procedure. D4278 is the add-on for the free soft tissue graft, an epithelialized graft placed on the surface, paired with D4277. D4283 is the add-on for the autogenous subepithelial connective tissue graft, paired with D4273. D4285 pairs with the non-autogenous connective tissue graft D4275. The three add-ons are not interchangeable, and a mixed pair, like D4277 with D4283, tells the carrier the claim was built from two different procedures.
- Does the carrier pay D4278 at the full graft fee?
- Generally no, and the payment logic is plan-dependent. Add-on positions share the parent graft's donor harvest and surgical setup, so contracted allowances for D4278 typically sit well below the D4277 allowance. Some contracts benefit graft procedures on a single-tooth basis, which can limit what additional positions pay at all. Verify the plan's stance in the pre-authorization rather than projecting the parent fee across every position.
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.