Coding for patient examinations requires knowledge of the four types of clinical evaluations as defined by the ADA. The former CDT-1 identified three "clinical oral evaluations." These were: 00110-Initial Oral Examination, an exam performed the first time a patient visits the office or a visit after a prolonged absence; 00120-Periodic Oral Examination, which refers to exams performed on a patient of record; or 00130-Emergency Oral Examination, reported when performed during an appointment to relieve pain.
The current CDT-2 delineates four "clinical oral evaluations:" Code 00120-Periodic Oral Evaluation, describes a continuous (recall) appointment for former patients with an active chart. This procedure usually is limited to once per six-month period. Any additional diagnostic procedures and radiographs should be reported separately. (Prior to 1995, ADA Code 04910-Periodontal Maintenance, included a periodic exam. The current definition of 04910 excludes the exam. It now is correct to submit for a separate Code 00120, although most plans are not paying for it, when applying for benefits for 04910.)
Code 00140-Limited Oral evaluation, Problem-Focused. This new code describes an emergency exam. Necessary radiographs also should be coded, as well as any other diagnostic procedures. The ADA definition lists that definitive treatment may be required on the same day as the evaluation. This often is the case; however, benefits usually are paid only for the treatment and denied for Code 00140. If your emergency patient will be requiring a complete exam at a later date, it often makes financial sense to apply for benefits only for the procedures accomplished at the emergency time. This "saves" the exam code and insurance payment for the complete exam later. Remember, most plans will pay for only two evaluations of any type during a year.
Code 00150-Comprehensive Oral Evaluation-This new code includes visual examination, charting, periodontal probing, diagnosis, treatment recommendations and treatment conference for a new patient to the office or a former patient who has not been seen for three years. Radiographs and additional diagnostic procedures should be reported separately.
Code 00160-Detailed and Extensive Oral Evaluation, Problem-Focused, By Report, describes a complicated, problem-focused examination. It includes a visual examination, charting, periodontal probing, diagnosis, extensive treatment-planning and coordination and treatment conference for a new patient to the office or a former patient who has not been seen for three years. Patients requiring such an evaluation will have systemic diseases, perio-prosthetic conditions or other complicated problems. A detailed narrative must accompany this code when applying for benefits.
Keep in mind that there is no code for periodontal probing or periodontal re-evaluation. Probing is considered to be a part of any examination. If patients will be requiring multiple visits for re-evaluations, it is appropriate to use Code 09430-Office Visit for Observation, although a benefit seldom will be paid.
Carol D. Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart and a national lecturer. Contact her at 800-548-2164.