Autogenous connective tissue graft

An insurance narrative for autogenous connective tissue grafts, using codes D4273 for the first tooth and D4283 for each additional tooth. Addressed to the dental claims consultant, it has blanks for patient details and teeth, and a numbered list of findings: recession, inflammation, keratinized, attached, and unattached gingiva in millimeters, root sensitivity, and root caries. It notes attached charting and x-rays and states the procedure is not cosmetic.

The insurance coordinator completes it from the periodontal chart and the doctor’s notes, then attaches it to the graft claim with the records it lists. Have the doctor check the measurements before it is submitted.