Free Scaling & Root Planing (SRP) Note Template (D4341/D4342)
SRP is the most insurance-scrutinized note in general dentistry. This scaling and root planing template documents the perio diagnosis, qualifying pocket depths, quadrants treated, anesthesia, and instrumentation — the exact items claims reviewers look for before paying D4341.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Scaling and root planing, quadrants: [UR, LR] — [4+] teeth per quadrant with pocket depths [4-6]mm (D4341). Diagnosis: [generalized Stage II, Grade B periodontitis]. Perio charting reviewed: [4-6]mm pockets with bleeding on probing; radiographic bone loss noted on current radiographs. Local anesthesia: [1] carpule(s) of [2% Lidocaine 1:100k epi] via [IANB]. Adequate anesthesia confirmed. Ultrasonic scaler used for supra- and subgingival calculus removal. Hand scalers and curettes used to refine and plane all root surfaces. Checked with perio probe to ensure smooth. Oral hygiene instructions given. [Chlorhexidine 0.12% rinse prescribed.] Patient tolerated procedure well. Periodontal re-evaluation scheduled in [4-6] weeks.
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When to use this template
Use this SRP note template for periodontal scaling and root planing, whether a full quadrant (D4341, four or more qualifying teeth) or a limited area (D4342, one to three teeth). The distinction is where most denials happen: D4341 requires four or more teeth in the quadrant with qualifying pocket depths of 4mm or greater. If only one to three teeth qualify, the correct code is D4342 — billing D4341 anyway is the most common SRP coding error and a reliable trigger for downgrades.
The note must establish medical necessity on its own: a periodontal diagnosis, pocket depths with bleeding on probing, and radiographic bone loss. Submit or reference current perio charting (payers generally want it under 12 months old). Treating more than two quadrants in a single visit usually triggers a request for full-mouth charting, radiographs, and the treatment plan — if you do it, document why the patient needed it in one visit.
Two details separate SRP documentation from a prophy note, and reviewers look for both. First, anesthesia: root planing to the depth of the pockets generally requires it, and its absence reads like a prophy billed as SRP. Second, the re-evaluation: SRP is phase-one periodontal therapy, so the note should close with the 4–6 week perio re-eval at which you measure response and decide on maintenance or referral. Most payers limit SRP to once per quadrant every 24–36 months, tracked per quadrant.
Step by step: how to document this scaling and root planing
- 1
Establish medical necessity
Periodontal diagnosis recorded with current perio charting: pocket depths ≥4mm, bleeding on probing, and radiographic bone loss.
- 2
Select the code by tooth count
Four or more qualifying teeth in the quadrant → D4341; one to three → D4342.
- 3
Anesthetize
Local anesthesia delivered per quadrant and confirmed — root planing to pocket depth requires it.
- 4
Debride ultrasonically
Ultrasonic scaler removes supra- and subgingival calculus.
- 5
Hand-instrument the roots
Scalers and curettes refine and plane all root surfaces; smoothness verified with the perio probe.
- 6
Educate and re-evaluate
Oral hygiene instruction delivered; periodontal re-evaluation scheduled at 4–6 weeks to assess response.
Tips for using this template
- check_circleCount the qualifying teeth before you pick the code: D4341 needs 4+ teeth in the quadrant with ≥4mm pockets; 1–3 qualifying teeth is D4342. Billing D4341 for a D4342 quadrant is the classic SRP denial.
- check_circleState the periodontal diagnosis (e.g., Stage/Grade per the AAP classification) in the note itself — "deep cleaning" is not a diagnosis.
- check_circleReference the perio charting and its date. Payers generally want complete charting less than 12 months old, and for younger patients some require it submitted with the claim.
- check_circleDocument radiographic bone loss explicitly — pocket depths alone without bone loss reads as gingivitis, which does not support SRP.
- check_circleDocument anesthesia. Root planing to pocket depth generally requires it, and its absence makes the note read like a prophy billed as SRP.
- check_circleLimit to two quadrants per visit unless there is a documented reason — three or four quadrants in one sitting routinely triggers a records request.
- check_circleClose with the 4–6 week re-evaluation. SRP is phase-one therapy; the re-eval documents response and supports the perio-maintenance (D4910) claims that follow.
- check_circleNever mix prophy language into an SRP note — "polished" and "cleaning" undermine the medical-necessity story the rest of the note is telling.
Standards & references
- ADA — D4341/D4342 Coding for Periodontal Scaling and Root Planing — ADA guidance on the 4+ teeth vs 1–3 teeth distinction and SRP claim documentation.
- ADA Code on Dental Procedures (CDT) — D4341 (four or more teeth per quadrant) and D4342 (one to three teeth) definitions.
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