What is the difference between D0150 and D0120 dental exam codes?

D0150 (comprehensive oral evaluation) is for new patients or established patients with significant changes requiring comprehensive assessment. It includes complete medical/dental history, full mouth charting, and treatment planning. D0120 (periodic oral evaluation) is for recall/maintenance visits for established patients. D0140 is limited problem-focused evaluation for specific complaints.

What documentation is required for a comprehensive dental exam?

Document: complete medical/dental history review, extraoral examination (TMJ, lymph nodes, soft tissue), intraoral soft tissue examination (including oral cancer screening), hard tissue/restorative evaluation, periodontal assessment (probing depths, bleeding, recession), radiographic findings, assessment with diagnoses (CDT/ICD-10 codes), and prioritized treatment plan.

How often can a comprehensive dental exam be billed?

D0150 is typically billed once every 3 years for an established patient, or when there has been a significant change in the patient's condition (new patient to office, patient returning after extended absence, significant treatment completed). Most insurance plans limit D0150 frequency. D0120 periodic exams are typically covered every 6 months.

What CDT codes are used for dental diagnostic imaging?

Common codes: D0210 (full mouth series), D0220 (periapical first film), D0230 (periapical each additional), D0270 (bitewing single film), D0272 (bitewings two films), D0274 (bitewings four films), D0330 (panoramic), D0350 (oral/facial photographic images). Document clinical indication for each radiograph taken.

How do I document periodontal disease severity?

Document: probing depths for all teeth (sites >4mm specifically noted), bleeding on probing, recession, furcation involvement, mobility, and bone loss on radiographs. Use AAP/EFP staging (Stage I-IV based on severity) and grading (Grade A-C based on progression rate). This documentation supports treatment planning and differentiates D1110 prophy from D4341/D4342 scaling and root planing.

Dental Exam Note Template (D0150) | Free Dental SOAP Note

Subjective

Chief Complaint: [Patient's main concern/pain] History: [Last dental visit, brushing/flossing habits, pain history] Medical History: [Review of systems, allergies, meds, premedication required?]

Objective

Vitals: BP: [x/x], HR: [x] Extraoral Exam:

* TMJ: [WNL / Popping / Clicking / Deviation / Pain]
* Lymph Nodes: [WNL / Palpable / Tender]
* Lips/Face: [WNL / Lesions / Asymmetry]

Intraoral Exam:

* Soft Tissue: [WNL / Lesions / Inflammation / Cancer screening negative]
* Occlusion: [Class I / II / III]
* Perio: [Gen WNL / Localized pockets / Gen Gingivitis / Perio Disease Type I-IV]

Pockets >4mm:* [List sites] Bleeding:* [Min / Mod / Severe] Hard Tissue / Restorative Findings:

* Missing: [Tooth #s]
* Decay: [Tooth #s and surfaces, e.g., #3 MO, #14 O]
* Existing Restorations: [Status of crowns, fillings]
* Endo: [Tooth #s needing testing/referral]

Radiographic Findings:

* [Bone levels, abscesses, impactions, calculus]

Assessment

Diagnoses:

1. [D0150] Comprehensive Oral Eval
2. [K02.xx] Caries: [Tooth #s]
3. [K05.xx] Gingivitis/Periodontitis: [Type]
4. [Condition] E.g., Fractured tooth, Abscess

Plan

Treatment Plan:

* Priority 1 (Urgent): [Ext, Endo, Pain relief]
* Priority 2 (Restorative): [Fillings, Crowns]
* Priority 3 (Perio/Hygiene): [Prophy, SRP, Maintenance]
* Priority 4 (Elective): [Whitening, Veneers]

Next Visit: [Procedure] in [Timeframe]. Informed Consent: Discussed risks, benefits, and alternatives of proposed treatment. Patient understood and agreed.

Dental — Comprehensive Exam Template (D0150)

Template

Subjective

Objective

Assessment

Plan

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