It's what the doctor does that count

In the old days, we only had three exam codes. They were known simply as periodic, initial, and emergency.

Tom Limoli Jr.

In the old days, we only had three exam codes. They were known simply as periodic, initial, and emergency. The periodic exam was when we updated the patient's clinical status and began the next series in the sequential order of care. The initial exam was when we first saw patients and established them as patients-of-record. The emergency exam was when the patient suddenly showed up at the office — usually in pain — and we encountered an interruption in the daily schedule.

As dentistry evolved, the examination became an evaluation. The examination was — and continues to be — academically defined as the gathering of clinical data. In the old days, the doctor gathered all of the data and established a professional opinion and treatment plan. Then, for some unknown reason, some doctors became less involved in the evaluation process. The gathering of basic clinical data began to be delegated to other members of the doctor's clinical team.

Evaluation is essentially the interpretation of examination findings. Earlier versions of the Current Dental Terminology (CDT) specified that the collection and recording of some data and components of the dental examination may be delegated. But, the evaluation, diagnosis, and treatment-planning are the responsibility of a (licensed) dentist.

So now the question: When do you use which evaluation code?

Limited Oral Evaluation — Problem-focused, D0140 simply replaces what was previously known as the emergency exam. Problem-focused means that the doctor is diagnosing a patient's specific oral health concern and is not evaluating all the dental systems.

Periodic Oral Evaluation — D0120 is a complete update to previously existing data that has been actively maintained by the dentist-of-record. In other words, what health-specific data has changed or been modified since the patient's previous evaluation?

Re-evaluation-Limited, Problem-Focused — D0170 differs from the periodic evaluation in that a complete update of patient data does not occur. Remember, problem-focused means that the doctor is looking only at a patient's specific oral-health concern that may or may not have been previously treated.

Detailed and Extensive Oral Evaluation, Problem-Focused, By Report — D0160 is used in a situation when the doctor finds something in a previously completed comprehensive evaluation that would warrant additional scrutiny. The specific diagnostic regimen and its findings are most often separately tracked and documented from the baseline data established in the previous comprehensive evaluation.

Comprehensive Oral Evaluation — D0150 replaces what was previously known as the initial exam. This is where the doctor documents and confirms the patient's original baseline data. The establishment of the patient's periodontal-health status is part of a comprehensive evaluation. Updating the patient's periodontal-health status falls within the confines of a periodic evaluation. The initiation of the patient's complete clinical chart will most often begin at this visit.

Comprehensive Periodontal Evaluation — D0180 is new in 2003, coinciding with the evolution and development of the CDT-4. It is anticipated that the code will be used primarily by periodontists for a referred patient from a general dentist. Time will tell. This code should not be used in addition to a comprehensive oral evaluation by the same dentist in the same treatment series. It also is not intended for use as a separate code for periodontal charting. Benefit plans process both D0150 and D0180 codes with the same criteria, limitations and fee data.

A risk management-problem exists with the CDT-4's redefinition of the terminolog "new or established patient." When would a new baseline ever be established without first considering the original findings? Are we supposed to ignore the original findings or should we continually document the patient's response to treatment? Prudence dictates that we establish the baseline and continually update it based on the individual patient's level of healing and resolution.

In summary, examination is the gathering of data. Evaluation is the interpretation of that examination- gathered data. Evaluation and diagnosis can only be done by the dentist. If the doctor's hands and/or eyes are not in the patient's mouth, then an evaluation can- not be claimed or billed.

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of Dental Insurance Today, a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of Dental Insurance and Reimbursement Coding and Claim Submission. He can be contacted by phone at (404) 252-7808. Visit his Web site at www.LIMOLI.com.Consultants.

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