D4278 is the CDT code for each additional contiguous tooth, implant, or edentulous position covered by the same free gingival graft.
- When to use: One continuous free graft covers more than one touching position, so the first is D4277 and each position after it gets one D4278.
- When not to use: The add-on for a patient's own connective tissue graft is D4283, for a donor material graft is D4285, and a separate graft site is a new D4277.
- Billing note: Carriers reject D4278 without D4277 on the same claim, so submit the pair together with a tooth or position number on every line.
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 graft site is one D4278 line. As with the parent, the donor and recipient surgical work is already in the fee, and there is no separate harvest line anywhere in this family.
A graft across three positions is not three independent surgeries. It is one donor harvest, one recipient bed preparation, and one suturing session covering more area than a single-position graft. The first-position and 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. Two graft codes have no positional structure: 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.
- 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 read 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 each grafted position defends each line.
- Frequency at the site. The additional positions share the graft site’s surgical history. Where a contract limits perio surgery to one procedure per site per 36 or 60 months, the window applies 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.
- D4277 with the first position’s tooth number and each D4278 with its own position identifier. “D4278 × 2” with no tooth numbers is the version reviewers pend.
- The pre-authorization reference when one was obtained. Add-on allowances are the part of the fee patients most often misestimate, and an estimate that clones the parent fee onto each add-on overstates the balance.
FAQs
- Can D4278 be billed by itself?
- No. D4278 reports each additional contiguous position in a free gingival graft whose first position is billed as D4277. Without D4277 on the claim, carriers reject or pend it. If only one position was grafted, the whole 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. All three 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, and the next area is 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 D4277, an epithelialized graft placed on the surface. D4283 is the add-on for the autogenous subepithelial connective tissue graft D4273, and D4285 pairs with the non-autogenous connective tissue graft D4275. The add-ons are not interchangeable, and a mixed pair such as 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 D4278 allowances 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.