SRP 4+ teeth: recent charting, radiographs, diagnosis
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D4341 periodontal scaling and root planing, four or more teeth per quadrant · the upper left quadrant · 04/24/2026
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Diagnosis: generalized Stage III Grade B periodontitis. Upper left quadrant on the 03/28/2026 charting: 4 teeth with probing depths of 4 mm or more (#12: 6 mm, #13: 7 mm, #14: 6 mm, #15: 7 mm). Bleeding on probing at 8 sites. Full-mouth periodontal charting was recorded 03/28/2026. Generalized horizontal bone loss noted on FMX. Heavy subgingival calculus UL. Bitewing radiographs taken 03/06/2026. Treatment: D4341 periodontal scaling and root planing, four or more teeth per quadrant on the upper left quadrant, date of service 04/24/2026.
Claim note
SRP UL: perio chart, radiographs, narrative attached
Attachments
| Item | Status | Detail |
|---|---|---|
| Periodontal chart | In Open Dental | Full-mouth periodontal charting was recorded 03/28/2026. Source: Perio Chart exam dated 03/28/2026 (PerioExamNum 19301). |
| Radiograph | In Open Dental | Bitewing radiographs taken 03/06/2026. Source: Open Dental Imaging: "4BWX" (X-Rays), DocNum 19201. |
Documentation checks
| Check | Status | Detail |
|---|---|---|
| Periodontal charting within 12 months | Met | Full-mouth periodontal charting was recorded 03/28/2026. |
| 4+ teeth in the quadrant with pockets of 4 mm or more | Met | Upper left quadrant on the 03/28/2026 charting: 4 teeth with probing depths of 4 mm or more (#12: 6 mm, #13: 7 mm, #14: 6 mm, #15: 7 mm). Bleeding on probing at 8 sites. |
| Radiograph of the upper left quadrant within 24 months | Met | Bitewing radiographs taken 03/06/2026 (1.6 months before the date of service). |
| Periodontal diagnosis documented | Met | Diagnosis: generalized Stage III Grade B periodontitis. |
| Radiographic bone loss documented | Met | Generalized horizontal bone loss noted on FMX. |
Evidence used (7 facts)
| ID | Fact | Where it comes from |
|---|---|---|
| C1 | D4341 periodontal scaling and root planing, four or more teeth per quadrant on the upper left quadrant, date of service 04/24/2026. | Procedure D4341 (ProcNum 19001) |
| C2 | Bitewing radiographs taken 03/06/2026. | Open Dental Imaging: "4BWX" (X-Rays), DocNum 19201 |
| C3 | Full-mouth periodontal charting was recorded 03/28/2026. | Perio Chart exam dated 03/28/2026 (PerioExamNum 19301) |
| C4 | Upper left quadrant on the 03/28/2026 charting: 4 teeth with probing depths of 4 mm or more (#12: 6 mm, #13: 7 mm, #14: 6 mm, #15: 7 mm). Bleeding on probing at 8 sites. | Perio Chart exam dated 03/28/2026, UL quadrant |
| N1 | Diagnosis: generalized Stage III Grade B periodontitis."Dx: generalized Stage III Grade B periodontitis" | Clinical note: D4341 UL on 04/24/2026 (this procedure) |
| N2 | Generalized horizontal bone loss noted on FMX."Generalized horizontal bone loss noted on FMX" | Clinical note: D4341 UL on 04/24/2026 (this procedure) |
| N3 | Heavy subgingival calculus UL."Heavy subgingival calculus UL" | Clinical note: D4341 UL on 04/24/2026 (this procedure) |
Draft → check → revise loop (1 iteration)
Iteration 1: no issues
Clinical notes read (1, names redacted)
D4341 UL on 04/24/2026 (this procedure)
Dx: generalized Stage III Grade B periodontitis. Generalized horizontal bone loss noted on FMX. Heavy subgingival calculus UL. SRP UL completed under local anesthesia. OHI given.