Other articles by Dr. Charles Blair & Associates
Truth: D0180 is a comprehensive periodontal evaluation code used to report evaluations performed on patients who have signs, symptoms, and/or risk factors associated with periodontal disease. The hygienist may gather much of the information, but the dentist must do the evaluation, diagnosis, and treatment planning. D0180 is a comprehensive evaluation with an extra focus on the patient’s periodontal status and needs.
Truth: D0180 represents a comprehensive periodontal evaluation performed by any licensed dentist on a patient who has signs, symptoms, and/or risk factors for periodontal disease.
Truth: D0150 may be reported for a comprehensive evaluation of an established patient in limited circumstances. Generally, this requires a significant change in health status or absence from active treatment for three or more years.
Some dental plans only reimburse D0150 once per provider but will pay an alternate benefit of D0120. Other plans will reimburse D0150 once every three or five years. Even so, the code stipulates that D0150 can only be reported for established patients if they have a significant change in health status or have been absent from active treatment for three or more years.
Truth: Some dental plans limit benefits to two evaluations per year, no matter how they are coded. However, others have no limitation for emergency exams (D0140). Bill and code for what you do—not what you believe will be paid. Physicians bill for all evaluations regardless of insurance coverage, and dentists should too. Simply inform patients prior to treatment that some dental plans limit the number of evaluations they pay each year. If that occurs, the patient will be responsible for the emergency evaluation fee.
Truth: While some dental plans do not pay for consultations (D9310), many do. Some require 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 vice versa, be sure to also include that information as documentation for D9310.
Truth: An extensive problem-focused evaluation (D0160) may be reimbursed but must be supported with documentation that includes a diagnosis. History of a comprehensive oral evaluation (D0150 or D0180) may be required prior to receiving reimbursement for D0160. Sending a copy of well documented treatment records is often adequate.
Dental plans vary widely in how often they pay for the various evaluation codes, so do not paint all dental plans with the same broad brush. Just because a local Delta Dental plan limits or does not cover a certain evaluation code does not mean that all dental carriers do the same.
Dentists must bill for what they do—not what they believe will be paid. Physicians bill for all evaluations, regardless of insurance coverage, and dentists should too. Simply inform patients prior to treatment that coverage varies for each plan. If a patient complains about plan limitations, remind the patient that his/her employer determines which dental services are covered and which are patient responsibility. Some employers are very generous; others are not. While you are happy to submit the claim for the patient, emphasize that you cannot guarantee coverage because only the patient and his/her employer have access to all the specific details of his/her dental plan.