D4263 is the CDT code for a bone replacement graft placed around a retained natural tooth, for the first site in a quadrant. It is a periodontal regenerative procedure that adds graft material to a bony defect next to a tooth you are keeping. D4264 covers each additional site in the same quadrant.
Last updated June 2026 · Reviewed by the PracticeAlpha billing team
Use D4263 for the first bone replacement graft site in a quadrant placed around a retained natural tooth. The graft material (autograft, allograft, xenograft, or alloplast) is placed into a periodontal osseous defect next to a tooth the patient is keeping. The tooth stays. This is regenerative periodontal therapy, not extraction or implant site preparation.
Common clinical scenarios: An infrabony defect found during osseous surgery on a tooth with deep pocketing. A furcation defect on a molar being treated to retain the tooth. Vertical bone loss next to a tooth where the goal is to regenerate lost attachment. The first such grafted site in a given quadrant is billed as D4263.
Do NOT use D4263 for: Additional graft sites in the same quadrant (use D4264 for each). Grafts into an extraction socket or edentulous ridge (use D7953). A graft placed at the same time as implant placement (use the relevant D6000-series code). Guided tissue regeneration membranes (those are D4266 or D4267, billed separately).
Click any code to see the difference.
The first bone replacement graft site around a retained natural tooth in a given quadrant. Billed once per quadrant per date of service. Includes the graft material and placement at that first site.
Each additional bone graft site in the same quadrant after the first. If you graft three tooth sites in one quadrant, that is one D4263 plus two D4264 line items, all on the same date.
Billing tip: The pairing is per quadrant, not per arch or per mouth. Two grafted teeth in different quadrants are two D4263 line items, not D4263 plus D4264. Mapping each grafted site to the right quadrant is what gets the additional sites paid.
Without charting that proves a bony defect, the graft looks unnecessary to the payer. Submit full-mouth or quadrant periodontal charting with pocket depths, plus a pre-operative radiograph showing the vertical or furcation defect. "Bone loss present" is not enough. The note needs measured pocket depths and a radiographic image of the defect at the grafted tooth.
D4263 is the first site in a quadrant, with D4264 for each additional site in that same quadrant. Billing D4263 multiple times in one quadrant triggers a denial of the duplicate lines. Map each grafted tooth to its quadrant, report one D4263 per quadrant, and use D4264 for the rest.
Some plans consider the bone graft part of the osseous surgery fee. When D4263 is billed alongside D4260 or D4261, the payer may bundle the graft and pay only the surgery. Check the plan policy first. If the plan allows both, document them as separate procedures with distinct narratives.
The operative note must state that graft material was actually placed. If the note only describes flap access and debridement, there is nothing supporting a regenerative graft code. Record the type of graft material used (autograft, allograft, xenograft, or alloplast) and the site it was placed.
A graft already billed at the same site within the plan window can trigger a denial. If the tooth was grafted before, expect scrutiny. Submit a narrative explaining the new defect or why retreatment is indicated, and confirm the plan history before scheduling.
Periapical or bitewing showing the bony defect at the grafted tooth. Vertical bone loss, an infrabony pocket, or furcation involvement. The image is the primary justification for a regenerative graft.
Pocket depths, clinical attachment levels, and furcation grades for the involved teeth. The charting connects the diagnosis to the specific site being grafted.
Describe the flap, the defect found, the type of graft material placed (autograft, allograft, xenograft, or alloplast), and the exact tooth and quadrant. This supports the regenerative code.
Identify which quadrant each grafted tooth belongs to. One D4263 per quadrant, D4264 for each additional site. Clear mapping prevents duplicate-line denials.
Many plans require pre-auth for regenerative periodontal procedures. Submit charting and a diagnostic radiograph, wait for approval, and record the pre-auth number on the claim.
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Learn about our billing servicesD4263 is the CDT code for a bone replacement graft placed around a retained natural tooth, for the first site in a quadrant. It is a periodontal regenerative procedure that adds graft material to a bony defect next to a tooth you are keeping, not an implant or extraction site.
D4263 is the first bone graft site in a quadrant. D4264 is each additional site in that same quadrant. You bill D4263 once per quadrant and add D4264 for every extra tooth site grafted in that quadrant on the same date.
D4263 is a bone graft around a retained natural tooth to treat a periodontal defect. D7953 is a bone graft into an extraction socket or edentulous ridge for future implant or denture support. The presence of a natural tooth at the graft site determines which code applies.
Common reasons: missing periodontal charting that documents the bony defect, no pre-operative radiograph, billing D4263 per tooth instead of per quadrant, plans that bundle the graft with osseous surgery, and graft material not documented in the operative note.
Many dental plans require pre-auth for periodontal regenerative procedures. Submit pre-auth with full periodontal charting, pocket depths, and a diagnostic radiograph showing the defect before treatment to reduce the chance of denial.
Some plans allow D4263 in addition to osseous surgery (D4260 or D4261) when both are performed, while others bundle the graft into the surgical fee. Check the plan policy and document each procedure separately in the operative note.
Search all 206 CDT codes in our dental coding guide.