Perio chart dental codes: D0180, D4910 and a free PDF template

The perio chart dental code for a full periodontal exam is D0180, the CDT (Current Dental Terminology) code for a comprehensive periodontal evaluation. Charting has no billable code of its own. Instead, the probing depths, bleeding points, recession and furcation grades on the chart justify D0180, and later D4910 (periodontal maintenance) at recall visits.

Hygienists and billing staff tend to stumble on three calls: D0150 or D0180, periodontal maintenance or prophylaxis (D1110), and which findings back each code. This guide works through each one, with a free chart template you can print or fill in digitally.

It also covers how digital clinical records keep the completed chart attached to the claim, ready for an insurance audit.

Key takeaways

D0180 is the code for full-mouth six-point probing and charting, while D0150 covers a general exam without a periodontal focus.

Probing depths, bleeding on probing and recession on the chart decide whether a recall visit is billed as D4910 or routine prophylaxis (D1110).

D4341 (scaling and root planing) treats active disease first, and D4910 follows only once that prior active therapy is on record.

Practice management software like Pabau captures each required data point at the chair through digital forms, so claims don’t wait on missing notes.

What is periodontal charting and why does it matter for coding?

Periodontal charting is a clinical exam in which a hygienist or dentist probes six sites per tooth and records the findings. The sites are mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual and distolingual. Each chart records:

• Probing depth (PD): the distance from the gingival margin to the base of the sulcus or pocket, in millimeters
• Bleeding on probing (BOP): a yes/no marker of gingival inflammation at each site
• Gingival recession: how far the gingival margin has moved apical to the cementoenamel junction (CEJ)
• Furcation involvement: a Class I, II or III grade where a multi-rooted tooth’s roots divide
• Clinical attachment level (CAL): calculated as PD plus recession, showing how much periodontal support the tooth has lost

The threshold values on the chart justify the CDT code you select. Those values are pockets of 4mm or more, the BOP percentage, recession measurements and furcation grade. A chart showing pockets of 4mm or more with BOP supports a periodontitis diagnosis, and moves later recall visits to D4910.

Without those findings, the visit may need to be billed as D1110 instead, at a 30-50% lower reimbursement. Under HIPAA, the chart is protected health information and has to be stored securely. Digital records also log the exam date, clinician and findings alongside the submitted code.

How a structured chart supports coding accuracy

A perio chart template is a structured form that lays out six-point probing, BOP, recession and furcation fields. That layout matches the ADA’s definition of a comprehensive periodontal evaluation (D0180). With every field in a fixed place:

• Probing depths are recorded on every tooth, with no sites skipped
• BOP is captured as a percentage or count, supporting a gingivitis or periodontitis diagnosis
• Recession is noted separately from pocket depth, so CAL can be calculated
• Furcation involvement gets a documented grade (Class I-III)
• The completed form becomes the clinical evidence for D0180, or for D0150 where the exam had no perio focus

Payers audit dental claims by checking the charting against the billed code. A D0180 claim without documented six-point probing will be denied. So will a D4910 claim without evidence of prior active periodontal therapy. A template confirms the exam is complete before the patient leaves, rather than months later when the denial arrives.

How to fill out the chart, step by step

The template is a one-page PDF that works alongside your intake forms or as a standalone sheet during the hygiene appointment. Six steps take you from probing to a billable code:

1. Choose print or tablet: Print the template and clip it to the patient chart, or load the PDF into your tablet charting app. Practice management software like Pabau builds perio templates into the patient record through its chair-side digital forms. Assign the form to the hygiene appointment so it’s ready at the chair.
2. Record probing depths per tooth: Use a calibrated periodontal probe, typically color-coded at 3mm, 6mm and 9mm. The grid gives each tooth six columns, covering the three buccal sites and the three lingual sites. Enter each measurement as a number, such as 2, 3, 4, 2, 2, 3 for tooth #1.
3. Mark bleeding on probing: Check the BOP column for each site that bleeds on gentle probing. At the end of the exam, divide the bleeding sites by the total sites probed. For example, 12 bleeding sites out of 168 gives a BOP of 7%. A BOP above 10% signals inflammation and, with pockets of 4mm or more, supports a periodontitis diagnosis.
4. Measure and record gingival recession: Note recession in millimeters wherever the gingival margin sits apical to the CEJ. Recession plus probing depth equals clinical attachment level, which sets disease severity.
5. Document furcation involvement: At multi-rooted teeth, probe the furcation area and grade what you find. Class I means the probe enters the furcation but doesn’t penetrate it. Class II means it penetrates but doesn’t exit the opposite side. Class III means it passes all the way through.
6. Link the completed chart to the CDT code in your billing software: Billing staff attach the chart to the claim before it goes out. A scanned copy works as well as a digital one. The chart supports D0180 for a comprehensive perio exam, or D4910 where the patient has a prior periodontal diagnosis. It supports D1110 when findings are normal and no perio diagnosis exists. Keeping it linked in your EMR speeds up any audit response.

A CDT code reference at the bottom of the template lists when to use D0180, D0150, D4910, D4341 and D1110. Check your code choice against it before the claim goes out. On paper claims, the ADA dental claim form is where that code travels to the payer, with the chart attached.

CDT codes used with periodontal charting

Several CDT codes can follow a completed perio chart, depending on the patient’s history and current findings. Knowing the sequencing and bundling rules keeps claims from being denied or downcoded:

Key billing rule: D1110 (prophylaxis) and D4910 (periodontal maintenance) can’t be billed on the same date. If the chart shows periodontitis, only D4910 is billable. If it shows healthy status, only D1110 applies. Mixing the two up is one of the most common causes of dental claim denials.

The map below turns those rules into two questions, one for evaluation visits and one for cleaning visits.

D0150 vs D0180: Choosing the right exam code

Mixing up D0150 (comprehensive oral evaluation) and D0180 (comprehensive periodontal evaluation) leads to denied and downcoded claims. The deciding factors are the scope of the exam and what the chart documents:

If the chart contains six-point probing measurements, bill D0180. If only a visual screening or spot-check probing was done, use D0150. Payers compare the claim code against the chart, so the documentation decides. The ADA’s CDT code descriptors are the authoritative source for this distinction.

The perio chart covers the gums only. Pair it with a dental examination form for the rest of the oral evaluation.

How chart findings drive periodontal maintenance coding

Once a D0180 exam confirms periodontitis, recall visits shift from D1110 to D4910. The diagnosis rests on pockets of 4mm or more, BOP and/or clinical attachment loss. At each recall, the chart has to keep justifying D4910:

• Probing depths of 4mm or more: indicate ongoing periodontal disease, so D4910 is appropriate
• Bleeding on probing above 10%: signals inflammation and, with those pockets, supports the periodontitis diagnosis and the medical necessity of D4910
• Clinical attachment loss: calculated as PD plus recession, with loss of 3mm or more confirming established disease
• History of prior active therapy (D4341 or periodontal surgery): required before D4910 can be billed, because maintenance only follows treatment

When payers audit D4910 claims, they ask for the supporting perio chart, the prior D4341 billing history and proof the patient meets the periodontitis criteria. A complete chart has that evidence ready, which protects the practice from overpayment recovery demands.

Who the template is for

The template suits dental teams across several practice types:

• General dental practices offering perio exams and maintenance: complete charting supports the billing split between D1110 and D4910
• Periodontal specialty practices treating active periodontitis: the chart documents D4341 (scaling and root planing) outcomes and a baseline for future maintenance billing
• Dental hygienists and registered dental therapists: using the template at the chair means all six sites per tooth get recorded
• Front-office and billing staff: the built-in CDT code reference guides code selection from the chart findings, reducing posting errors
• Dental schools and hygiene programs: the template teaches the standard structure of a comprehensive perio exam, in line with the ADA’s D0180 definition

Any practice billing for periodontal services benefits from a structured perio chart. If your team relies on free-text notes, switching to the template gives every claim the same complete evidence.

Fitting perio charting into your practice workflow

Build the chart into the clinical and billing steps your team already follows:

• Before the appointment: Label the appointment type “Perio exam” or “Perio maintenance recall” in your scheduling system. That tells the hygienist to prepare the perio chart at check-in.
• At the chair: Use the template during the clinical exam. Attach a printed or tablet copy to the appointment so it’s on hand from the start.
• After the exam: The hygienist or dentist checks the chart for completeness before the patient leaves. Missing sites or unclear entries get filled in there and then.
• Billing preparation: Scan or photograph the completed chart and attach it to the patient’s EMR record. Flag it with the CDT code the findings support.
• Claim submission: Include the chart as a supporting attachment with electronic claims. For paper claims, send a copy with each claim batch.
• Audit readiness: Keep the chart in the patient’s permanent record for at least seven years. When a payer requests documentation, you can respond the same day.

How Pabau keeps perio charts and claims together

Many dental practices still chart on paper, scan the sheet and attach it to the claim by hand. Each handoff is a chance for a skipped site or a lost page, and the denial only shows up weeks later.

With Pabau, the perio chart is a digital form attached to the hygiene appointment. The hygienist fills it in at the chair, and it saves straight to the patient’s Client records file with the date and clinician.

Your billing team then works from the same record when they choose the CDT code and submit the claim. When a payer asks for documentation, the chart is already filed against the visit.

Keep perio charts and CDT claims in step

Pabau’s digital forms capture the full perio chart at the chair and file it against the patient record. Your billing team codes and submits from the same file.

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Conclusion

The CDT code on a perio claim is only as defensible as the chart behind it. If your team changes one habit after reading this, make it recording BOP as a percentage at every exam. That single figure settles most D4910 versus D1110 questions before they reach a payer.

The trade-off is a few extra minutes per hygiene visit. That’s far less time than reworking a denied D0180 claim or answering an overpayment audit months later.

Book a demo to see how Pabau files each perio chart against the visit, so your team codes periodontal claims from complete evidence.

Continue your research

Writing up the hygiene visit itself? Our dental note template shows what to include so the clinical note backs up the codes on the claim.

Setting recall intervals for perio patients? The dental cleaning schedule template sets recall intervals by risk level, which lines up with D4910 maintenance timing.

Need the full picture at a new-patient visit? A dental medical history form captures the risk factors that often justify a D0180 exam.

Frequently asked questions