SRP Insurance Narrative Template for Dental Office Managers – Streamline Claims

An SRP narrative is the short letter that tells the insurance company why the patient needed scaling and root planing instead of a regular cleaning. The reviewer never sees the patient. The narrative, the perio chart and the X-rays have to make the case for you.

Get the free SRP narrative templates

The one-page sample below comes from Coding with Kyle, the coding series by DOMA founder Kyle, who has 25 years in dental office management. It has:

• Office details, insurance company, patient name and claim number
• A diagnosis line
• A checklist of periodontal risk factors, such as tobacco use, probe depths over 3 mm, bleeding sites and radiographic bone loss
• A findings paragraph and a treatment paragraph you can edit

What an SRP narrative has to show

The reviewer is looking for proof of active periodontal disease. Every SRP narrative should cover:

• The periodontal diagnosis the doctor recorded at the exam
• Pocket depths from a full perio chart, with the deepest sites called out by tooth
• Bleeding on probing: where it showed up and whether it is generalized or localized
• Bone loss on current radiographs, with the date they were taken
• Attachment loss and recession, if they were charted
• Calculus and biofilm above and below the gumline
• Which quadrants are being treated and how many teeth in each
• Risk factors from the medical history, such as diabetes, tobacco use or a history of periodontal disease

The narrative has to match the chart. If the letter says 5 to 6 mm pockets and the chart shows mostly 3s, the claim can come back with a denial or a request for more records.

Pick the right CDT code

SRP is billed by quadrant, and the code depends on how many teeth in that quadrant are being treated:

• D4341: periodontal scaling and root planing, four or more teeth per quadrant
• D4342: periodontal scaling and root planing, one to three teeth per quadrant

Two other codes get mixed up with SRP. D4346 is scaling for generalized gingival inflammation when the patient is not a candidate for SRP, and as Kyle explains in his D4346 breakdown, it is not reported together with SRP. After SRP, the patient moves to periodontal maintenance (D4910), which needs its own perio maintenance narrative.

Frequency limits and pocket depth requirements vary by plan. Check the patient’s benefits before the appointment.

What to send with the claim

• The narrative, reviewed by the treating provider
• A complete, dated perio chart (our periodontal charting form works if your software doesn’t print one cleanly)
• Current radiographs that show bone levels
• Intraoral photos, if you have them

Sending the chart and X-rays with the first submission saves a round of back and forth with the carrier.

Sample SRP narrative

This is the template’s wording with brackets where your details go. Keep only what the chart and X-rays support.

RE: [Patient name], DOB [date], Claim # [number]

Diagnosis: [periodontal diagnosis recorded by the doctor]

Full-mouth periodontal charting on [date] shows probing depths of [x to y] mm in [quadrants or teeth], with bleeding on probing at [number] sites. Radiographs taken [date] show [horizontal or vertical] bone loss in [areas]. Supragingival and subgingival calculus and biofilm are present. Risk factors: [for example, type 2 diabetes, tobacco use].

Treatment: scaling and root planing, [UR, UL, LR, LL], [D4341 or D4342] per quadrant, under local anesthesia ([agent]). According to the AAP, ADA and ADHA, non-surgical scaling and root planing is the primary treatment for active periodontal disease. Home care instructions were given, and the patient will be re-evaluated in [number] weeks to decide on periodontal maintenance or further treatment.

Sincerely, [provider name]

Details to add on treatment day

• Quadrants treated and the date of each visit
• Local anesthetic used
• Appointment length
• Any adjunct the doctor placed, like a local antimicrobial (see the Arestin narrative)
• Home care instructions and when the patient comes back for re-evaluation

Front desk checklist before you submit

• Diagnosis matches the chart and the narrative
• Each quadrant has the right code for its tooth count
• Chart and X-rays are attached and dated
• No D4346 on the same claim as SRP
• Benefits checked for frequency limits

Send this checklist to whoever submits your perio claims. If an SRP claim keeps coming back, post it in the DOMA community and ask the 26,700+ members how they would handle it.

SRP narrative FAQ

What is an SRP narrative?

A short letter to the insurance company that explains why the patient needed scaling and root planing instead of a regular cleaning. It goes with the perio chart and X-rays, because the reviewer never sees the patient.

What CDT code is used for scaling and root planing?

SRP is billed by quadrant. Use D4341 when four or more teeth in the quadrant are treated and D4342 for one to three teeth.

What should I send with an SRP claim?

The narrative reviewed by the treating provider, a complete dated perio chart and current radiographs that show bone levels. Add intraoral photos if you have them.

Can D4346 be billed with SRP?

No. D4346 is for generalized gingival inflammation when the patient is not a candidate for SRP, and it is not reported together with SRP on the same claim.

Related DOMA Resources

More on dental insurance, coding and claims.

• Dental insurance and billing: a manager’s revenue cycle guide
• Dental insurance and billing resources
• Master dental coding and stop insurance denials
• Dental insurance narrative for osseous surgery
• Forms, SOPs and templates for dental offices