Insurance Information

Insurance Claims Submission for Treatment Using ATRIDOX®

Indication for treatment: chronic adult periodontitis
Procedure code: D4381
CDT-2011/2012 description: Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report.
Use: to report treatment with ATRIDOX®
When: possibly on same visit as periodontal maintenance D4910

Initial/Definitive Treatment: Guidelines for New Patients

Treatment type: newly diagnosed chronic adult periodontitis patient

Procedure code: D4381

CDT descriptor: Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report.

When to use D4381:
1) Following evaluation after mechanical and surgical procedures (i.e. scaling and root planing, flap surgery, etc.); pockets > 5mm that demonstrate bleeding on gentle probing; scaling and root planing completed prior to ATRIDOX® administration
2) During routine periodontal maintenance visits
3) Uncommon situations (i.e. pre-existing medical condition) with detailed documentation

How to use:

Report each tooth or site separately on the claim form. For each tooth provide the tooth number, procedure code, date of treatment and fee per tooth.
Attach a detailed narrative report to support the claim.
Additional information that may be helpful in developing your report can be found in the ATRIDOX® package insert.

NOTE: the D4381 procedure code permits the filing of a separate charge for each tooth being treated with ATRIDOX®. The fee for ATRIDOX® therapy should be per tooth.
D4381 is a procedure code that by definition is covered on a “by report” basis. Review of the claim by a dental claims examiner is likely. Therefore, it is important to support the decision to treat the patient in this manner with sufficient and legible clinical information.

Maintenance Recall Treatment: Guidelines for Maintenance Patient

Treatment type: maintenance patient

Procedure codes: D4910 plus D4381

CDT descriptor:

D4910: Periodontal maintenance procedures following active therapy.
D4381: Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report.

When to use D4910 plus D4381:
1) During the maintenance appointment following scaling and root planing
2) After the completion of surgical or other definitive periodontal treatment therapies
3) During the same visit as periodontal maintenance

How to use:

Complete the periodontal maintenance procedure including: the removal of subgingival and supragingival plaque and calculus using an ultrasonic instrument, a periodontal evaluation, and a review of the patient’s plaque control efficiency. Treat new or recurring periodontal disease (sites > 5mm and BoP) with ATRIDOX®.
Report this procedure on the claim form using code D4910. Report each tooth separately on the claim form. For each tooth provide the tooth number, procedure code D4381, date of treatment and fee per tooth.
Attach a detailed narrative report (including pre- and post-therapy periodontal charting of the re-treated sites) to support the claim.

Disclaimer: The reimbursement information contained here is provided to help you understand the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for dental health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. The information contained here is provided for information purposes only and represents no statement, promise or guarantee by Zila, Inc., concerning reimbursement, payment or charge. Similarly, all CDT, CPT/HCPCS and ICD-9 codes are supplied for information purposes only and represent no statement, promise or guarantee by Zila that these codes will be appropriate or that reimbursement will be made.