After the last quadrant of scaling and root planing, the patient comes back in about 4–8 weeks for a periodontal re-evaluation. The tissue has had time to heal, and you re-probe to see how it responded. The note from this visit links SRP to what follows: periodontal maintenance (D4910), retreatment, or a referral. If the re-evaluation is missing or vague, that link is broken, and the D4910 claims that follow are harder to defend.
What a re-evaluation note needs
- When SRP was completed and the baseline diagnosis. The re-evaluation only makes sense in reference to what came before.
- Re-probing compared to baseline. Not just today's numbers, but the change: generalized reduction of 1–2mm, minimal change, or sites that got worse.
- Residual pockets, by site. Any site 5mm or deeper, listed by tooth and surface, especially if it still bleeds.
- Bleeding on probing, before and after. A drop in BOP percentage is one of the clearest signs of response.
- Home care and plaque control. A poor response with poor home care calls for a different plan than a poor response with excellent home care.
- The decision and the interval. Maintenance, retreatment, or referral, and how often you'll see them.
Why this visit gets skipped
Re-evaluations are often folded into the first maintenance visit or done without full charting, and the note just says "tissue improved, begin perio maintenance." Clinically that might be right, but the chart doesn't show it. Payers reviewing D4910 look for a history of active periodontal therapy and evidence that the patient is in maintenance for a reason. The re-evaluation note with its before-and-after numbers is that evidence.
It also protects the patient. Residual pockets that are recorded get treated or referred. Residual pockets that only lived in the hygienist's memory get missed at the next visit.
Example: 6-week re-evaluation
Patient seen for periodontal re-evaluation, 6 weeks after scaling and root planing, all four quadrants. Baseline diagnosis: generalized Stage III, Grade B periodontitis. Medical history reviewed, no changes. Patient reports sensitivity resolved, gums feel tighter. Home care compliance good; plaque minimal. Full-mouth 6-point probing completed. Compared to baseline: generalized reduction of 1–2mm. Residual pockets localized: #3 MB 6mm with bleeding, #14 DL 5mm. Bleeding on probing reduced from baseline, 12% (baseline 45%). Tissue improved, mild residual inflammation at #3. Treatment today: re-instrumentation of #3 MB and #14 DL; home care instruction reinforced with interdental brushes. Response favorable overall. Next phase: begin periodontal maintenance (D4910) at 3 months; re-check #3 MB at that visit and refer to periodontist if it remains 6mm or deeper. Findings reviewed with dentist.
Billing the re-evaluation
Practices handle this visit differently. Some bill it as a re-evaluation (D0171, where the payer recognizes it) and some don't bill it separately. Whatever your office does, the clinical note should be the same: the numbers, the comparison, and the decision. For the visits that come before and after, see our guides on documenting SRP and periodontal maintenance notes.
Re-probe out loud, get the comparison in the note
ProphyNotes turns spoken pocket depths into structured perio data, so re-evaluation numbers land in the note next to the baseline without anyone typing them.
Need a note template now? Use our free periodontal re-evaluation template → No signup required.
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