If you have ever stood in front of your computer, wondering whether you should bill D0272, D0273, or D0274 for a set of four bitewings, you are not alone.
Dental coding can feel like a maze. And when you add the word “vertical” into the mix, things get even more confusing.
But here is the good news: the correct ADA code for four vertical bitewings is clear once you understand a few simple rules.
In this guide, we will walk through everything you need to know. You will learn the exact code to use, how vertical bitewings differ from horizontal ones, when to choose one over the other, and how to document your work to avoid claim denials.
What Exactly Are Vertical Bitewings?
Before we talk about codes, we need to talk about the images themselves.
Bitewings are a type of dental X-ray that shows the crowns of your upper and lower teeth in one single view. They are called “bitewings” because you bite down on a small tab or wing-shaped sensor holder.
Traditional bitewings are horizontal. That means the long side of the image runs left to right. These are perfect for looking at cavities between teeth and checking the height of bone crests in patients with healthy gum levels.
Vertical bitewings, however, are rotated 90 degrees. The long side of the image runs up and down.
Why does that matter?
Because vertical bitewings show more bone. They allow you to see the crestal bone level and a deeper portion of the root. This makes them especially useful for patients with moderate to advanced periodontal disease.
Key Features of Vertical Bitewings
| Feature | Horizontal Bitewings | Vertical Bitewings |
|---|---|---|
| Orientation | Landscape (wider than tall) | Portrait (taller than wide) |
| Best for | Caries detection, routine recall | Periodontal evaluation, bone loss monitoring |
| Bone visibility | Limited crestal bone | Deeper bone levels |
| Common patient type | Healthy gums or mild gingivitis | Moderate to severe periodontitis |
So when you take four vertical bitewings, you are typically covering the premolar and molar regions on both the left and right sides, using the taller orientation to capture more vertical information.
The Correct ADA Code for 4 Vertical Bitewings
Now for the answer you came here for.
The ADA code for four vertical bitewings is D0274.
Let me repeat that for clarity: D0274 is the code you should use when you take four bitewing radiographic images in the vertical orientation.
Here is how the ADA defines D0274:
Four bitewing radiographic images – vertical
That is the official description from the Current Dental Terminology (CDT) code book.
How D0274 Compares to Other Bitewing Codes
To make sure you never confuse these codes again, here is a simple comparison table.
| ADA Code | Description | Number of Images | Orientation |
|---|---|---|---|
| D0270 | Single bitewing image | 1 | Either (usually horizontal) |
| D0272 | Two bitewing images | 2 | Either (usually horizontal) |
| D0273 | Three bitewing images | 3 | Either |
| D0274 | Four bitewing images – vertical | 4 | Vertical only |
| D0277 | Vertical bitewings – 7 to 8 images | 7-8 | Vertical |
Notice that D0274 specifically says “vertical.” That is important. Some offices mistakenly use D0272 (two bitewings) and then add a modifier. Do not do that. Use the correct code from the start.
Important note: There is no ADA code called “four horizontal bitewings.” If you take four images in the horizontal orientation, you would typically use D0272 twice (two bitewings on the right, two on the left) but that is not technically correct. Most payers expect D0272 for two images or D0274 for four vertical images. For four horizontals, check your specific insurance plan. Some accept D0272 billed twice. Others prefer D0270 four times. This is a gray area, so verify first.
When Should You Use D0274? Clinical Indications
You should not use D0274 for every patient. That would be like using a sledgehammer to hang a picture. It works, but it is overkill.
D0274 is clinically indicated in specific situations.
1. Known or Suspected Periodontal Disease
If a patient has pocket depths of 5mm or more, you need to see the bone levels clearly. Horizontal bitewings cut off the bottom of the bone image. Vertical bitewings show the full story.
2. Monitoring Progressive Bone Loss
For patients in active periodontal treatment, you will want to compare bone levels over time. Vertical bitewings give you a consistent, reproducible view year after year.
3. Post-Operative Evaluation Following Periodontal Surgery
After flap surgery, bone grafting, or other periodontal procedures, you need to assess healing. D0274 gives you the depth required to evaluate bone regeneration.
4. Patients with High Caries Risk Who Also Have Periodontal Concerns
Sometimes a patient has both problems: cavities and bone loss. In that case, vertical bitewings still show the crowns well enough for caries detection while also giving you the bone information you need.
5. Legal Documentation for Malpractice Protection
If a patient has progressive periodontal disease and you fail to document it, you could face legal exposure. Vertical bitewings provide a permanent record of bone levels at a specific point in time.
When NOT to Use D0274
| Situation | Better Choice |
|---|---|
| Routine recall with healthy gums | D0272 (two horizontal bitewings) |
| Child patient with primary dentition | D0272 or panoramic |
| Asymptomatic patient with no bone loss | D0272 |
| Patient with severe gag reflex | Horizontal bitewings (faster, easier) |
How to Document D0274 Correctly in the Patient Chart
Documentation is where many claims fail. You can take beautiful vertical bitewings, but if your notes do not support medical necessity, the insurance company will deny payment.
Here is a documentation checklist you can use.
Required Elements for D0274
- Clinical indication. Write one sentence explaining why vertical bitewings were needed. Example: “Generalized 5-6mm probing depths noted on posterior teeth. Vertical bitewings ordered to assess crestal bone levels.”
- Number of images. State clearly: “Four vertical bitewing images were obtained.”
- Regions captured. Specify which teeth or areas. Example: “Right premolar/molar and left premolar/molar.”
- Image quality. Note if images are diagnostic or if any retakes were needed.
- Comparison to prior films. If available, note changes. Example: “Compared to 04/15/2024 films, there is evidence of progressive bone loss of approximately 1-2mm in the mandibular right molar region.”
Sample Documentation Note
*“Patient presents for periodontal reevaluation. Probing depths range from 4-7mm in all posterior segments. Four vertical bitewing images (D0274) were taken of the right and left premolar/molar regions to evaluate crestal bone height and rule out furcation involvement. Images are of diagnostic quality. Moderate horizontal bone loss (30-50%) noted in mandibular posterior regions compared to prior films from 01/10/2025.”*
That note is clear, complete, and supports medical necessity.
Insurance and Reimbursement for D0274
Let us talk about money. Because at the end of the day, you need to get paid for the work you do.
Is D0274 Typically Covered?
Most dental insurance plans cover D0274, but with a few conditions.
Frequency limitations. Many plans allow bitewings once per six or twelve months. Some plans treat vertical bitewings as a separate benefit with its own frequency. For example, a plan might cover D0272 (horizontal) twice per year but D0274 only once per year for periodontal patients.
Medical necessity requirement. Unlike routine horizontal bitewings, vertical bitewings often require a documented diagnosis of periodontal disease. Without that diagnosis, the claim may be denied.
Reimbursement Amounts
Reimbursement varies widely by region and insurance carrier. As a rough guide:
| Payer Type | Typical Reimbursement for D0274 |
|---|---|
| PPO dental plans | $30 – $60 |
| Medicaid (adult) | $15 – $35 |
| Fee-for-service (patient pay) | $60 – $120 |
Note: These are estimates. Your actual fees will depend on your geographic location, fee schedule, and contract negotiations.
Common Denial Reasons for D0274
| Denial Code | Meaning | How to Fix |
|---|---|---|
| No medical necessity | No documented bone loss or perio disease | Add probing depths and diagnosis to chart note |
| Frequency limitation | Patient had bitewings too recently | Check last X-ray date before ordering |
| Code not valid for this patient age | Pediatric patient rarely needs vertical bitewings | Use D0272 instead |
| Missing documentation | No narrative or images attached | Submit perio charting with claim |
Pro Tip: Pre-authorization
If you are unsure whether a specific plan covers D0274, send a pre-authorization request. It takes a few extra minutes but saves you from writing off a denied claim later.
Step-by-Step: Taking 4 Vertical Bitewings in Your Office
You already know how to take X-rays. But vertical bitewings require a slightly different technique. Here is a quick refresher.
Equipment Needed
- Digital sensor or film
- Vertical bitewing holder (most holders can rotate 90 degrees)
- Beam alignment device (Rinn holder or similar)
- Lead apron with thyroid collar
Positioning Steps
- Rotate your holder. If you use a Rinn-type holder, rotate the bite block so the sensor sits vertically.
- Place the sensor. Position it so the top of the sensor is aligned with the occlusal plane. The sensor should extend equally above and below the biting surface.
- Angle the tube head. Use a +5 to +10 degree vertical angle for maxillary and mandibular views. The central ray should be directed slightly downward.
- First exposure: Right premolars. Aim between the canine and first premolar.
- Second exposure: Right molars. Aim between the first and second molars.
- Third exposure: Left premolars. Same positioning as the right side.
- Fourth exposure: Left molars. Same positioning as the right side.
Common Errors to Avoid
- Sensor too high or too low. The occlusal plane should be centered vertically on the image.
- Overlapping contacts. If contacts overlap, adjust your horizontal angle.
- Cone cuts. Make sure the entire sensor is covered by the X-ray beam.
- Patient movement. Use a countdown before exposing.
D0274 vs. D0277: What Is the Difference?
You might see D0277 in the code book and wonder: when do I use that?
D0277 is for seven to eight vertical bitewing images. That is a full-mouth series of vertical bitewings, typically covering from canines through molars on both sides, plus sometimes premolar views.
Use D0274 when you want four images.
Use D0277 when you want a more complete vertical survey.
Most general dentists use D0274. Periodontists use D0277 more often because they need to see every interproximal space in detail.
| Feature | D0274 | D0277 |
|---|---|---|
| Number of images | 4 | 7-8 |
| Regions covered | Premolars and molars (both sides) | Canine through molars (both sides) |
| Typical provider | General dentist | Periodontist |
| Typical insurance coverage | Moderate | Lower (often denied as duplicate of FMX) |
Digital vs. Film: Does the Code Change?
No. The ADA code D0274 is the same whether you use digital sensors or traditional film.
However, some offices add a separate code for digital capture. That is usually D0391 (interpretation of digital images) or similar. But that is an add-on, not a replacement for D0274.
Always bill D0274 for the images themselves. Bill the interpretation code separately if your payer allows it.
How D0274 Fits Into a Full Periodontal Evaluation
A complete periodontal evaluation includes several components:
- Medical and dental history review
- Extraoral and intraoral soft tissue exam
- Periodontal probing (six sites per tooth)
- Mobility and furcation assessment
- Radiographic evaluation (often D0274)
- Treatment planning
Without D0274, your perio evaluation is incomplete. You cannot see bone loss on a clinical exam alone. The radiographs provide the objective evidence you need to diagnose, stage, and treat periodontal disease.
Staging Periodontitis Using Vertical Bitewings
The 2017 AAP/EFP classification system uses radiographic bone loss as a key criterion.
| Stage | Typical Bone Loss on Vertical Bitewings |
|---|---|
| Stage I (Mild) | <15% bone loss |
| Stage II (Moderate) | 15-30% bone loss |
| Stage III (Severe) | >30% bone loss with potential tooth loss |
| Stage IV (Very Severe) | >30% bone loss with masticatory dysfunction |
You cannot determine these percentages accurately without vertical bitewings. Horizontal bitewings cut off the apex of the bone image, making measurement unreliable.
Common Questions About D0274 (FAQ)
Here are answers to the questions dental professionals ask most often.
Can I bill D0274 if I take three vertical bitewings?
No. Three vertical bitewings should be billed as D0273. The code specifically says “three bitewing images – vertical.” Do not use D0274 for three images. That is inaccurate coding and could be considered fraud.
What if I take four horizontal bitewings instead?
This is a tricky area. There is no ADA code for four horizontal bitewings. Some offices bill D0272 twice (two bitewings, two times). Others bill D0270 four times. The safest approach is to check with each insurance carrier. Better yet, if you need four images, consider using vertical orientation so you can use D0274 correctly.
Do vertical bitewings show more radiation?
No. The radiation exposure is nearly identical to horizontal bitewings for the same number of images. The orientation does not change the dose. The only difference is the shape of the image.
Can I use D0274 for a child?
Rarely. Children rarely need vertical bitewings because they do not typically have significant bone loss. Use D0272 (two horizontal bitewings) for routine pediatric recall exams. For a child with known periodontal disease (very rare), D0274 might be appropriate, but document thoroughly.
My software lists D0274 as “four bitewings – vertical.” Is that correct?
Yes. That is the standard ADA description.
How often can I bill D0274 for the same patient?
That depends on your insurance contracts. Most plans allow once every 12 months for patients with active periodontal disease. Some allow every 6 months. A few never allow vertical bitewings for non-perio patients. Always check the specific plan.
Documentation Template for D0274
You can copy and paste this template into your dental software. Fill in the blanks for each patient.
Date of service: [DATE]
Procedure: D0274 – Four vertical bitewing radiographic images
Clinical indication: [Example: Generalized probing depths of 5-7mm in posterior teeth. Need to assess crestal bone levels and rule out furcation involvement.]
Images obtained: Four vertical bitewings – right premolars, right molars, left premolars, left molars.
Image quality: All images diagnostic. No retakes required. [Or: One retake of left molars due to patient movement. Second image diagnostic.]
Comparison to prior films: [Example: Compared to films from [PRIOR DATE], there is [no change / evidence of progressive bone loss of approximately X mm in region X].]
Findings summary: [Example: Moderate horizontal bone loss (30-50%) noted in mandibular posterior regions. Furcation involvement noted on tooth #19 (Grade II). No apical pathology noted.]
Ordering provider: [NAME, DDS]
Technician: [NAME, RDA]
Keep this template in a quick-reference location. It will save you time and protect you from denials.
A Note on Teledentistry and Remote Coding
Teledentistry is growing quickly. But can you bill D0274 for images taken at a remote site?
Yes, in many cases. But there are rules.
The images must be taken under the supervision of a licensed dental professional, even if that supervision is virtual. The supervising dentist must review the images and document their interpretation.
Some states have specific teledentistry codes. For example, D9995 (teledentistry synchronous) or D9996 (teledentistry asynchronous) might be billed alongside D0274.
Check your state dental board regulations before billing D0274 for remote services.
How to Train Your Staff on D0274
Your dental assistants and hygienists take the X-rays. They need to understand why vertical bitewings matter.
Hold a 15-minute training session. Cover these three points:
- When to use vertical. Any patient with probing depths >4mm in posterior teeth.
- How to position. Rotate the holder, center the occlusal plane, use correct vertical angulation.
- How to document. Write “vertical bitewings” on the routing slip so the dentist knows which code to bill.
A well-trained team means fewer retakes, better documentation, and fewer denied claims.
What the ADA Says About D0274
The American Dental Association publishes the CDT code book every year. The description for D0274 has remained stable for many years.
According to the ADA:
- D0274 is a diagnostic code. It describes the act of capturing the images, not interpreting them.
- The code implies four separate exposures on a single patient on the same date of service.
- “Vertical” means the long axis of the image is perpendicular to the occlusal plane.
The ADA does not specify which teeth must be included. That is left to clinical judgment. Most dentists include the premolar and molar regions on both sides, but you could theoretically take four vertical bitewings of the anterior teeth. That would be unusual, but the code would still apply.
Billing D0274 with Other Codes
You often take vertical bitewings as part of a larger appointment. Here is how to bill D0274 alongside other common codes.
| Service Provided on Same Day | Bill Together? | Notes |
|---|---|---|
| D0150 (Comprehensive exam) | Yes | Both codes are fully payable if medically necessary |
| D0120 (Periodic exam) | Yes | Routine combination |
| D0180 (Periodic perio exam) | Yes | Ideal combination for perio patients |
| D1110 (Prophylaxis) | Yes | Common and covered |
| D4341 (Scaling and root planing – per quadrant) | Yes | D0274 supports medical necessity for SRP |
| D4910 (Periodontal maintenance) | Yes | Standard of care for perio patients |
| D0210 (Full mouth X-rays) | No | Do not bill both on the same day unless one is a retake |
Never bill D0274 and D0210 on the same date for the same patient without a very good reason (like a retake of poor images). That looks like double-billing and will trigger an audit.
Real-Life Case Studies Using D0274
Sometimes examples help more than rules. Here are three real-world scenarios.
Case Study 1: New Patient with Unknown Perio History
Patient: 52-year-old male, no X-rays for 3 years. Probing depths range from 2-6mm.
Action: You take four vertical bitewings (D0274) plus a panoramic image.
Result: Vertical bitewings reveal 4-5mm of bone loss on mandibular molars. You diagnose Stage II periodontitis. Insurance pays D0274 in full because you documented probing depths and bone loss.
Case Study 2: Routine Recall, Healthy Patient
Patient: 34-year-old female, non-smoker, 2-3mm probing depths everywhere. No history of perio disease.
Action: You consider D0274 but decide on D0272 (two horizontal bitewings) instead.
Result: Insurance pays D0272. No denial. Patient happy. You saved time and avoided an unnecessary code.
Case Study 3: Denial Overturned
Patient: 68-year-old male, history of periodontitis. You take D0274 as part of perio maintenance visit. Insurance denies for “no medical necessity.”
Action: You submit an appeal with probing depths (5-7mm), prior X-rays showing bone loss, and a narrative explaining why vertical orientation is needed.
Result: Insurance reverses denial and pays the claim within 30 days.
The lesson? Document, document, document.
The Future of Bitewing Coding
Dental coding changes slowly. The ADA updates the CDT manual every year, but major changes are rare.
That said, two trends may affect D0274 in the coming years.
1. AI in radiology interpretation. As AI tools become common for reading X-rays, we may see new codes for AI-assisted interpretation. But the capture code (D0274) will likely remain unchanged.
2. Value-based care. Some insurance plans are moving toward value-based reimbursement. In that model, you might be paid for outcomes rather than procedures. D0274 could become part of a bundled payment for periodontal care rather than a standalone code.
For now, D0274 remains the standard code for four vertical bitewings. That is unlikely to change anytime soon.
Summary Table: Quick Reference for D0274
| Question | Answer |
|---|---|
| What is the ADA code for 4 vertical bitewings? | D0274 |
| How many images? | Exactly 4 |
| Orientation required? | Vertical (portrait orientation) |
| When to use? | Periodontal disease, bone loss monitoring, furcation assessment |
| Typical reimbursement? | $30 – $60 (PPO), $60 – $120 (FFS) |
| Frequency limit? | Usually once per 12 months |
| Documentation needed? | Probing depths, bone loss measurement, clinical indication |
| Can I use for children? | Rarely – only with documented perio disease |
| What code for 7-8 vertical bitewings? | D0277 |
Final Checklist Before Billing D0274
Use this checklist before you submit every D0274 claim.
- Did the patient have a diagnosis of periodontal disease or suspected bone loss?
- Did you document probing depths of 4mm or more in the posterior regions?
- Did you note the number of images taken (four)?
- Did you specify “vertical” in your chart note?
- Did you check the patient’s last bitewing date to avoid frequency denial?
- Did you obtain a signed treatment plan (if required by the payer)?
- Did you attach any required supporting documentation (perio charting, narrative)?
If you checked every box, submit with confidence.
Conclusion
To summarize this guide in three lines:
The correct ADA code for four vertical bitewings is D0274. Use this code for patients with documented periodontal disease or suspected bone loss to capture deeper bone levels than horizontal bitewings allow. Always support your claim with probing depths, a clear clinical indication, and prior X-ray comparison to avoid denials.
Additional Resource
For the most current ADA CDT codes, including official definitions and yearly updates, visit the American Dental Association’s official Coding Resource page:
🔗 www.ada.org/en/publications/cdt
(Copy and paste this link into your browser. The ADA updates this page annually with new codes and revisions.)
FAQ (Frequently Asked Questions)
Q1: Can I bill D0274 if I only take three vertical bitewings?
A: No. Use D0273 for three vertical bitewings. Billing D0274 for fewer than four images is inaccurate and could be considered upcoding.
Q2: What is the difference between D0272 and D0274?
A: D0272 is for two bitewing images (any orientation, but typically horizontal). D0274 is specifically for four images taken in the vertical orientation.
Q3: Will insurance always pay for D0274?
A: No. Most plans pay when there is documented medical necessity (periodontal disease, bone loss). For healthy patients without perio disease, D0274 is often denied.
Q4: How do I explain D0274 to a patient?
A: Say: “These X-rays are taller than usual. They help me see the bone levels around your teeth more clearly. This is important because your gum probing depths show some concerns we need to monitor.”
Q5: Can I use D0274 for a panoramic X-ray?
A: Absolutely not. Panoramic X-rays have their own codes (D0330 for panoramic image). D0274 is strictly for four intraoral bitewing images.
Q6: What if my patient has no posterior teeth?
A: D0274 is designed for posterior regions. If your patient has no posterior teeth, you would not take posterior bitewings. Consider periapical images (D0220, D0230) instead.
Q7: Is there a code for four vertical bitewings plus interpretation?
A: The capture and interpretation are usually bundled into D0274. Some payers allow an additional code for interpretation (D0391 for digital image interpretation), but this is rare. Check your specific contract.
Q8: How long should I keep D0274 images?
A: Follow your state dental board’s record retention laws. Most states require 5-7 years for adult records. For minors, keep until the patient turns 21 or 23 (depending on the state).
Q9: Can a hygienist or assistant bill D0274 under their own name?
A: No. The billing provider must be the dentist who ordered and interpreted the images. The hygienist or assistant can take the X-rays, but the claim goes under the supervising dentist’s NPI number.
Q10: What happens if I accidentally bill D0274 but took horizontal bitewings?
A: If the payer audits you, they could demand a refund and possibly fine you for inaccurate coding. If you realize the error, submit a corrected claim as soon as possible.
Author: Technical Dental Writer
Date: APRIL 15, 2026
Disclaimer: This article is for informational and educational purposes only. Dental coding guidelines vary by payer and region. Always verify requirements with your local dental society or insurance carrier before submitting claims.
