SRP narrative example - generalized Stage II periodontitis, D4341 + D4342
Two quadrants treated on one date, one with four teeth and one with three, so the same claim carries both codes.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - SCALING AND ROOT PLANING
D4341 (upper right, 4 teeth) / D4342 (lower right, 3 teeth)
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Diagnosis: generalized periodontitis, Stage II, Grade B.
Six-point full-mouth periodontal charting completed within the past 12 months records probing depths of 4-6 mm at the qualifying sites, with bleeding on probing recorded. Full-mouth radiographs taken within the past 12 months show generalized horizontal bone loss, with calculus visible on the root surfaces.
Scaling and root planing was performed on teeth #2, #3, #4, and #5 (upper right quadrant, 4 teeth - D4341) and on teeth #29, #30, and #31 (lower right quadrant, 3 teeth - D4342). Local anesthetic: 2% lidocaine with 1:100,000 epinephrine, 2 carpules. Appointment duration: 60 minutes, documented in the chart notes. No scaling and root planing has been performed in these quadrants within the past 24 months.
Attachments: six-point periodontal charting (dated); full-mouth radiographs (unannotated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 241 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D4341 UR (#2-5) + D4342 LR (#29-31); gen periodontitis St II/Gr B; 6-pt charting <12mo, PD 4-6mm w/ BOP; FMX <12mo: gen horizontal bone loss + root calculus; no SRP these quads <24mo. Charting + FMX attached.
Before you use this, your chart must show:
- •the teeth treated in each quadrant, by Universal tooth number
- •whether these quadrants were scaled and root planed before, and when
- •periodontal charting, with the method recorded
- •the date the charting was completed
- •the probing depths recorded at the qualifying sites
- •bleeding on probing recorded at the charted sites
- •the periodontal diagnosis recorded in the chart notes
- •diagnostic radiographs of the treated quadrants
- •the date the radiographs were taken
- •radiographic evidence of bone loss
- •radiographic root-surface calculus, where the payer accepts it
- •the type and amount of local anesthetic in the chart notes
- •the appointment duration in the chart notes
Satisfies the published criteria of:
- Aetna
- Delta Dental (Delta Dental Ins. enterprise)
- United Concordia
- Guardian
Criteria met is not coverage; the plan contract controls.
SRP narrative example - four quadrants, Stage III periodontitis with vertical defects
Full-mouth treatment with deeper pockets and vertical bony defects, all four quadrants coded D4341.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - SCALING AND ROOT PLANING
D4341 (upper right, 4 teeth) / D4341 (upper left, 4 teeth) / D4341 (lower left, 4 teeth) / D4341 (lower right, 4 teeth)
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Diagnosis: generalized periodontitis, Stage III, Grade B.
Six-point full-mouth periodontal charting completed within the past 12 months records probing depths of 5-8 mm at the qualifying sites, with bleeding on probing recorded. Full-mouth radiographs taken within the past 12 months show generalized horizontal bone loss with vertical defects, with calculus visible on the root surfaces.
Scaling and root planing was performed on teeth #2, #3, #4, and #5 (upper right quadrant, 4 teeth - D4341), on teeth #12, #13, #14, and #15 (upper left quadrant, 4 teeth - D4341), on teeth #18, #19, #20, and #21 (lower left quadrant, 4 teeth - D4341), and on teeth #28, #29, #30, and #31 (lower right quadrant, 4 teeth - D4341). Local anesthetic: 2% lidocaine with 1:100,000 epinephrine, 4 carpules. Appointment duration: 90 minutes, documented in the chart notes. No scaling and root planing has been performed in these quadrants within the past 24 months.
Attachments: six-point periodontal charting (dated); full-mouth radiographs (unannotated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 289 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D4341 UR (#2-5) + D4341 UL (#12-15) + D4341 LL (#18-21) + D4341 LR (#28-31); gen periodontitis St III/Gr B; 6-pt charting <12mo, PD 5-8mm w/ BOP; FMX <12mo: horizontal + vertical bone loss + root calculus; no SRP these quads <24mo. Charting + FMX attached.
Before you use this, your chart must show:
- •the teeth treated in each quadrant, by Universal tooth number
- •whether these quadrants were scaled and root planed before, and when
- •periodontal charting, with the method recorded
- •the date the charting was completed
- •the probing depths recorded at the qualifying sites
- •bleeding on probing recorded at the charted sites
- •the periodontal diagnosis recorded in the chart notes
- •diagnostic radiographs of the treated quadrants
- •the date the radiographs were taken
- •radiographic evidence of bone loss
- •radiographic root-surface calculus, where the payer accepts it
- •the type and amount of local anesthetic in the chart notes
- •the appointment duration in the chart notes
Satisfies the published criteria of:
- Aetna
- Delta Dental (Delta Dental Ins. enterprise)
- United Concordia
- Guardian
Criteria met is not coverage; the plan contract controls.
D4342 narrative example - two teeth in one quadrant, listed by tooth number
A partial quadrant, where United Concordia asks for individual tooth numbers rather than a quadrant indicator.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - SCALING AND ROOT PLANING
D4342 (lower left, 2 teeth)
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Diagnosis: localized periodontitis, Stage II, Grade A.
Six-point full-mouth periodontal charting completed within the past 12 months records probing depths of 4-5 mm at the qualifying sites, with bleeding on probing recorded. Bitewing and periapical radiographs taken within the past 12 months show localized horizontal bone loss, with calculus visible on the root surfaces.
Scaling and root planing was performed on teeth #18 and #19 (lower left quadrant, 2 teeth - D4342). Local anesthetic: 4% articaine with 1:100,000 epinephrine, 1 carpule. Appointment duration: 45 minutes, documented in the chart notes. No scaling and root planing has been performed in these quadrants within the past 24 months.
Attachments: six-point periodontal charting (dated); bitewing and periapical radiographs (unannotated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 227 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D4342 LL (#18-19); loc periodontitis St II/Gr A; 6-pt charting <12mo, PD 4-5mm w/ BOP; BW+PA <12mo: loc horizontal bone loss + root calculus; no SRP these quads <24mo. Charting + BW+PA attached.
Before you use this, your chart must show:
- •the teeth treated in each quadrant, by Universal tooth number
- •whether these quadrants were scaled and root planed before, and when
- •periodontal charting, with the method recorded
- •the date the charting was completed
- •the probing depths recorded at the qualifying sites
- •bleeding on probing recorded at the charted sites
- •the periodontal diagnosis recorded in the chart notes
- •diagnostic radiographs of the treated quadrants
- •the date the radiographs were taken
- •radiographic evidence of bone loss
- •radiographic root-surface calculus, where the payer accepts it
- •the type and amount of local anesthetic in the chart notes
- •the appointment duration in the chart notes
Satisfies the published criteria of:
- Delta Dental (Delta Dental Ins. enterprise)
- Guardian
Not fully met for Aetna (3 of 4), United Concordia (2 of 3).
Criteria met is not coverage; the plan contract controls.
Medicaid SRP narrative example - full charting, AAP case type, radiographic findings
The fuller documentation profile a Medicaid manual tends to want: complete six-point charting rather than a screening, the AAP case type where the chart records one, and the radiographic findings named.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - SCALING AND ROOT PLANING
D4341 (upper right, 4 teeth) / D4341 (upper left, 4 teeth)
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Diagnosis: generalized periodontitis, Stage III, Grade B. AAP case type III is documented in the periodontal charting.
Six-point full-mouth periodontal charting completed within the past 12 months records probing depths of 5-7 mm at the qualifying sites, with bleeding on probing recorded. Full-mouth radiographs taken within the past 12 months show generalized horizontal bone loss, with calculus visible on the root surfaces.
Scaling and root planing was performed on teeth #2, #3, #4, and #5 (upper right quadrant, 4 teeth - D4341) and on teeth #12, #13, #14, and #15 (upper left quadrant, 4 teeth - D4341). Local anesthetic: 2% lidocaine with 1:100,000 epinephrine, 2 carpules. Appointment duration: 60 minutes, documented in the chart notes. No scaling and root planing has been performed in these quadrants within the past 24 months.
Attachments: six-point periodontal charting (dated); full-mouth radiographs (unannotated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 242 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D4341 UR (#2-5) + D4341 UL (#12-15); gen periodontitis St III/Gr B; 6-pt charting <12mo, PD 5-7mm w/ BOP; FMX <12mo: gen horizontal bone loss + root calculus; no SRP these quads <24mo. Charting + FMX attached.
Before you use this, your chart must show:
- •the teeth treated in each quadrant, by Universal tooth number
- •whether these quadrants were scaled and root planed before, and when
- •periodontal charting, with the method recorded
- •the date the charting was completed
- •the probing depths recorded at the qualifying sites
- •bleeding on probing recorded at the charted sites
- •the periodontal diagnosis recorded in the chart notes
- •the AAP case type, where the payer requires it
- •diagnostic radiographs of the treated quadrants
- •the date the radiographs were taken
- •radiographic evidence of bone loss
- •radiographic root-surface calculus, where the payer accepts it
- •the type and amount of local anesthetic in the chart notes
- •the appointment duration in the chart notes
Satisfies the published criteria of:
- Aetna
- Delta Dental (Delta Dental Ins. enterprise)
- United Concordia
- Guardian
Criteria met is not coverage; the plan contract controls.
SRP retreatment narrative example - same quadrant, more than 24 months later
A quadrant treated before, with the interval stated so the frequency rule can be read off the narrative.
Example — replace every finding with what your chart documents
EXAMPLE - NOT A PATIENT RECORD. The findings below are a Dentovio sample written to show the shape of a narrative. No clinician charted them and no patient was examined. Do not submit this document; build your own from what your chart documents.
EXAMPLE - NOT A PATIENT RECORD - CLAIM NARRATIVE - SCALING AND ROOT PLANING
D4341 (lower right, 4 teeth)
Patient: [PATIENT NAME] - DOB: [DATE OF BIRTH] - Member ID: [MEMBER ID]
Date of service: [DATE OF SERVICE]
Treating provider: [PROVIDER NAME, CREDENTIALS] - NPI: [NPI]
Diagnosis: localized periodontitis, Stage III, Grade C.
Six-point full-mouth periodontal charting completed within the past 12 months records probing depths of 5-7 mm at the qualifying sites, with bleeding on probing recorded. Full-mouth radiographs taken within the past 12 months show vertical bony defects, with calculus visible on the root surfaces.
Scaling and root planing was performed on teeth #28, #29, #30, and #31 (lower right quadrant, 4 teeth - D4341). Local anesthetic: 2% lidocaine with 1:100,000 epinephrine, 3 carpules. Appointment duration: 75 minutes, documented in the chart notes. No scaling and root planing has been performed in these quadrants within the past 24 months.
Attachments: six-point periodontal charting (dated); full-mouth radiographs (unannotated).
EXAMPLE - NOT A PATIENT RECORD. No clinician charted the findings above. Replace every one of them with what your own chart documents before anything goes to a payer.
Remarks-line variant — 216 characters, including the EXAMPLE marker
EXAMPLE - NOT A PATIENT RECORD - D4341 LR (#28-31); loc periodontitis St III/Gr C; 6-pt charting <12mo, PD 5-7mm w/ BOP; FMX <12mo: vertical defects + root calculus; no SRP these quads <24mo. Charting + FMX attached.
Before you use this, your chart must show:
- •the teeth treated in each quadrant, by Universal tooth number
- •whether these quadrants were scaled and root planed before, and when
- •periodontal charting, with the method recorded
- •the date the charting was completed
- •the probing depths recorded at the qualifying sites
- •bleeding on probing recorded at the charted sites
- •the periodontal diagnosis recorded in the chart notes
- •diagnostic radiographs of the treated quadrants
- •the date the radiographs were taken
- •radiographic evidence of bone loss
- •radiographic root-surface calculus, where the payer accepts it
- •the type and amount of local anesthetic in the chart notes
- •the appointment duration in the chart notes
Satisfies the published criteria of:
- Aetna
- Delta Dental (Delta Dental Ins. enterprise)
- United Concordia
- Guardian
Criteria met is not coverage; the plan contract controls.
