Don’t Fail Your Next Exam

A complete comprehensive evaluation leads to complete comprehensive treatment.

Without the necessary information, conditions and situations may exist that, if missed, may lead to misdiagnosis, maltreatment, and negative outcomes. Without a basic understanding of the coding nomenclature and the components of each of the evaluation codes, errors are likely. The purpose of this article is to help your team understand the different codes and what is required of each.

Let’s deal at the onset with one of the most widely held misconceptions. Codes DO120 through DO180 are being applied as exam codes. In actuality, they are evaluation codes with the exam being one aspect of the evaluation. The definitions below spell this out:

Exam: n. An examination; a test.
e·val·u·at·ed, e·val·u·at·ing, e·val·u·ates
1. To ascertain or fix the value or worth of.
2. To examine and judge carefully; appraise.

The exam is a part of the evaluation process, but an exam is not an evaluation. An evaluation has been completed when the doctor uses the information gathered during the exam process to arrive at a comprehensive assessment of that information. An examination and/or tests are done as part of the process, but an evaluation is not complete until an appraisal of the information is complete. Doing an exam does not meet the criteria established for application of the billing codes D0120 – D0180. Unless an evaluation of the exam information is done (and recorded in the chart) the components of the evaluation have not been completed and should not be coded and billed.

This discussion leads to another very important component of the exam process, record keeping. If it’s not in your treatment record, you didn’t see it, you didn’t say it, you didn’t do it, it didn’t need to be done, and it doesn’t exist from a legal perspective. In other words, if you’ve completed a thorough exam, made a definitive diagnosis, devised a comprehensive treatment plan that addresses any pathology, obtained informed consent, but then failed to record this information in the clinical record, you didn’t do an evaluation from a legal perspective. Simply listing “exam” in the patient record does not meet the standard of care if you are ever challenged in the courts or by the regulatory boards. Be thorough, complete, and diligent in your record keeping in every area of your practice but especially as it relates to patient evaluations. The evaluation is the foundation from which your treatment is built and upon which your defense ultimately rests.

What’s the big deal?
The health care culture is changing as we move toward a more global health care community. With the ADA Code Advisory Committee and insurance carriers moving toward a more diagnosis/evaluation-driven treatment foundation, evaluations become increasingly important. We have observed over the last few years that overall health conditions and mitigating levels of health/risk have become more important as justification for treatment. The evaluations provided would become the foundation upon which sound treatment models are developed and will be viewed as justification for repayment by third-party payers in this new global environment.

(Take code D1206—fluoride varnish—for example. This code requires a caries risk assessment of moderate/severe caries risk level, a case where the diagnosis justifies the treatment.) Keep this future model in mind as we discuss the many evaluation code/descriptors presently in use and their proper documentation and usage associated.
Let’s look at clinical scenarios that may help to differentiate the evaluation codes:

D0150 from D0180
Mrs. Allan comes to the office as a new patient and has completed her health history form. Upon review of the health history, the doctor notices that Mrs. Allan is a smoker. The American Academy of Periodontology states that “recent studies have shown that tobacco use may be one of the most significant risk factors in the development and progression of periodontal disease. In addition, following periodontal treatment or any type of oral surgery, the chemicals in tobacco can slow down the healing process and make the treatment results less predictable.”

A smoker is more likely than a nonsmoker to have the following problems:

  • Calculus
  • Deep pockets
  • Loss of the bone and tissue that support teeth

Because smoking is a risk factor for periodontal disease, Dr. Smith (a general dentist) determines that a D0180, comprehensive periodontal evaluation is indicated. This is an appropriate application of code D0180 as described in this scenario. Other factors that could justify the application of code D0180 might be signs or symptoms of periodontal disease, history of periodontal disease, or other risk factors such as diabetes. Note: in this scenario, D0150 could also be used to describe the evaluation provided; however, this alternative does not emphasize the concern for and attention to the potential for periodontal disease. Note: a comprehensive periodontal charting is a required component of D0180, while D0150 mandates a periodontal screening and/or charting as indicated. In some cases, the reimbursement for D0180 is higher than D0150.

D0160 from D0150
During the D0180 evaluation in the scenario outlined above, Dr. Smith understands that Mrs. Allan is not able to comfortably chew everything she is eating.  She complains that she has periodic pain on the left TMJ area when chewing “hard” food. Dr. Smith observes that there is significant clicking and crepitis on the left side and the jaw deviates to the left upon opening. Dr. Smith determines that Mrs. Allan should return at a subsequent appointment for further evaluation for potential TMD. Mrs. Allan returns and undergoes a detailed and extensive oral evaluation and workup evaluation for comprehensive TMD treatment. Dr. Smith determines that D0160 should be billed for this second, detailed, and extensive oral evaluation, focusing on the possible TMD, and that would be appropriate. D0160 follows either a D0150 or D0180 evaluation as indicated in those evaluations. D0160 may also be applicable in instances where treatment expands to involve more complex, multidisciplinary treatments including orthodontics, TMD, perio-prosthetic reconstruction, and/or oral cancer treatment cases.

D0150 and D0180 from D0120
D0120 describes a periodic oral evaluation provided to an established patient, but may not be used with a new patient. Codes D0150 and D0180 may be used to describe an evaluation provided to a new or established patient when the patient is evaluated comprehensively. D0150 is indicated only for established patients who have been absent from active treatment for three or more years or those who have had a significant change in health. D0150 or D0180 evaluations are typically provided for new patients who are 3 years old or older.

Mrs. Williams’ husband, John, transfers from Dr. Jones’ office to Dr. Smith’s office. John has been receiving regular care and is current with his 6 month recare regime. Even though John’s visit is a routine oral examination, he is not a patient of record in Dr. Smith’s office. It would be appropriate to code a D0150 for this initial visit in Dr. Smith’s office or D0180 if John has signs, symptoms, or risk factors of periodontal disease, but not a D0120. Think of D0120 as an updated evaluation of conditions that have been previously evaluated.

D0140 from D9110
D0140 is a limited oral evaluation that is problem focused and does not include definitive treatment. Mrs. Williams was in a car accident and struck her mouth on the steering wheel. Her mouth and teeth are sore. The area was evaluated but no treatment was deemed necessary. D0140 describes this type of evaluation.  D9110, on the other hand, is used to describe a minor procedure (treatment) to alleviate dental pain. Mrs. Williams was in a car accident and fractured off the palatal cusp of tooth #4, exposing the pulp horn. The edges of the fracture are smoothed and zinc phosphate/eugenol is placed over the exposure and the area is sealed with IRM until she can receive more definitive treatment. D9110 would be used to describe the treatment provided in this accident scenario.

D9110 is not used to describe a situation where only a prescription is provided and no treatment is performed to alleviate pain. Use D9110 when a minor procedure is performed to relieve pain, e.g., when the dentist uses a curette to remove a popcorn kernel from under gum tissue, uses a handpiece and finishing bur to smooth a rough edge, or places wax over an ortho bracket that is lacerating gum tissue. Use D0140 when a specific problem is evaluated. Procedures provided to treat the complaint once the evaluation is completed are coded and billed separately.

D9310 from D0140
D9310 describes a consultation evaluation provided because of a request made by another dentist or physician. There must be a formal referral from another practitioner or appropriate source to report code D9310. (Note: patients are not considered an appropriate source per the American Dental Association’s Code Advisory Committee.) D0140 is used to describe an evaluation where the patient presents with a specific problem, emergency, trauma, and/or acute infection without being referred by another practitioner or appropriate source.

Things to remember:
Evaluations must be completed by the dentist except for hygienists who are specifically licensed to diagnose in Oregon and Colorado. Staff may help in the process by gathering and collating information, conduct tests, and exposing X-rays. The doctor must assess the information and complete the evaluation.

Evaluations D0120, D0150, and D0180 include a basic oral cancer screening, where indicated. The screening should be recorded in the patient’s clinical record to meet the standard of care and to justify reimbursement. The type of oral cancer screening may vary depending on the patient’s age and risk factors. A separate adjunctive pre-diagnostic test such as the use of VELscope would be separately reported as D0431.

Again it’s important to remember a notation of “exam” listed in the treatment record is not enough to justify the submission of codes D0120 through D0180. Submission of these codes must include the evaluation of the information gathered during the exam and the conclusions determined in the evaluation should those determinations be recorded in the treatment record.

Miscoding occurs when offices have the following misconceptions:

Misconception: D0180 is a hygienist’s/hygiene exam code.
Truth: D0180 is a comprehensive evaluation code used to describe evaluations performed for patients that have signs, symptoms, and/or risk factors for periodontal disease. This evaluation is provided by the dentist to the target patient group with special focus on the patient’s periodontal status and needs.

Misconception: D0180 can only be used by a periodontist.
Truth: D0180 is a comprehensive evaluation code used to describe evaluations done for patients who have signs, symptoms, and/or risk factors for periodontal disease and may be provided by any licensed dentist.

Misconception: D0150 can be billed every three years.
Truth: D0150 may be reported for an extensive evaluation of an established patient in very limited circumstances. Generally, this requires a significant change in health status (diabetes, etc.) or absence from active treatment for three or more years. Many payers provide the alternate benefit of D0120, at a lower UCR fee, as they consider D0150 to be “once per lifetime” per office. Others use an every three or five year reimbursement rule for D0150.

Misconception: D0140 should not be used because all plans only allow two exams
per year.
Truth: Some plans may limit benefits to two exams per year; however, other plans do not have this limitation. Bill what you perform. Inform the patient that payment for this necessary exam may be subject to the plan limits and that they may be responsible for the fee.

Misconception: D9310 is never covered.
Truth: D9310 may be covered but must be supported by documentation that should include a copy of the referral letter provided by the referring entity. If the referral is made as a result of a medical condition that affects the oral cavity or if an oral condition affects a medical condition, include that information as justification for D9310.

Misconception: D0160 is never covered.
Truth: D0160 may be covered but must be supported by documentation that should include a report/copy of the complex diagnosis. History of the comprehensive oral evaluation (D0150) may be required prior to reporting D0160 for reimbursement. “Spell it all out” in the narrative for D0160.

As far as limitations by third-party payers for reimbursement for these procedures, it varies widely from plan to plan. Reimbursement is limited and governed by the provisions of that plan. Bill and code for what you perform, not for what you believe the carrier will pay. It is, however, acceptable to ask the payer to consider an alternative benefit, in the event that the exam provided is subject to the plans limitations.

The intent of this article has been to provide a basic understanding of the coding nomenclature and the components of each of the evaluation codes. Some of these evaluation codes are more straightforward than others; however, armed with the information contained herein, you have a greater opportunity to pass your next exam “with flying colors.”

Dr. Charles Blair is the publisher of the Coding With Confidence Manual, Insurance Solutions Newsletter, and PracticeBooster Web site. Order these breakthrough products through your Henry Schein Sales Consultant.

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This article was originally published in Sidekick Magazine.