SRP 1-3 teeth with 2 qualifying teeth

Claim 21000 · Summit Smile Insurance · Date of service 08/10/2026 · Source: synthetic case srp-03-d4342 · Generated 2026-10-12 07:08 UTC

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D4342 periodontal scaling and root planing, one to three teeth per quadrant · the lower right quadrant · 08/10/2026

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Perio diagnosis: localized Stage II periodontitis. Lower right quadrant on the 07/13/2026 charting: 2 teeth with probing depths of 4 mm or more (#28: 5 mm, #29: 5 mm). Bleeding on probing at 4 sites. Full-mouth periodontal charting was recorded 07/13/2026. Moderate calculus and bleeding on probing throughout LR quadrant. Full-mouth series of radiographs taken 04/23/2026. Treatment: D4342 periodontal scaling and root planing, one to three teeth per quadrant on the lower right quadrant, date of service 08/10/2026.

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Claim note

SRP LR: perio chart, radiographs, narrative attached

Would strengthen the claim

Document the radiographic bone loss findings for the quadrant.

Attachments

Item	Status	Detail
Periodontal chart	In Open Dental	Full-mouth periodontal charting was recorded 07/13/2026. Source: Perio Chart exam dated 07/13/2026 (PerioExamNum 21301).
Radiograph	In Open Dental	Full-mouth series of radiographs taken 04/23/2026. Source: Open Dental Imaging: "FMX" (X-Rays), DocNum 21201.

Documentation checks (Default (common plan guidelines - verify per carrier))

Check	Status	Detail
Periodontal charting within 12 months	Met	Full-mouth periodontal charting was recorded 07/13/2026.
1-3 teeth in the quadrant with pockets of 4 mm or more	Met	Lower right quadrant on the 07/13/2026 charting: 2 teeth with probing depths of 4 mm or more (#28: 5 mm, #29: 5 mm). Bleeding on probing at 4 sites.
Radiograph of the lower right quadrant within 24 months	Met	Full-mouth series of radiographs taken 04/23/2026 (3.6 months before the date of service).
Periodontal diagnosis documented (recommended)	Met	Perio diagnosis: localized Stage II periodontitis.
Radiographic bone loss documented (recommended)	Not documented	No note describes radiographic bone loss.

Evidence used (7 facts)

ID	Fact	Where it comes from
C1	D4342 periodontal scaling and root planing, one to three teeth per quadrant on the lower right quadrant, date of service 08/10/2026.	Procedure D4342 (ProcNum 21001)
C2	Full-mouth series of radiographs taken 04/23/2026.	Open Dental Imaging: "FMX" (X-Rays), DocNum 21201
C3	Full-mouth periodontal charting was recorded 07/13/2026.	Perio Chart exam dated 07/13/2026 (PerioExamNum 21301)
C4	Lower right quadrant on the 07/13/2026 charting: 2 teeth with probing depths of 4 mm or more (#28: 5 mm, #29: 5 mm). Bleeding on probing at 4 sites.	Perio Chart exam dated 07/13/2026, LR quadrant
N1	Perio diagnosis: localized Stage II periodontitis. "Perio dx: localized Stage II periodontitis"	Clinical note: D4342 LR on 08/10/2026 (this procedure)
N2	Moderate calculus and bleeding on probing throughout LR quadrant. "Moderate calculus and BOP throughout LR quadrant"	Clinical note: D4342 LR on 08/10/2026 (this procedure)
N3	Moderate calculus and bleeding on probing throughout LR quadrant. "Moderate calculus and BOP throughout LR quadrant"	Clinical note: D4342 LR on 08/10/2026 (this procedure)

Draft → check → revise loop (1 iteration)

Iteration 1: no issues

Clinical notes read (1, names redacted)

D4342 LR on 08/10/2026 (this procedure)

Perio dx: localized Stage II periodontitis. Moderate calculus and BOP throughout LR quadrant. SRP LR completed under local anesthesia. OHI given.

Engine: extractor heuristic, narrator template, reviewer none.