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Fast Facts: Coding Edition - Evaluation Codes

Fast Facts

Fast Facts: Coding Episode 8

[Andrew Johnston, RDH]
Welcome back everyone! You are listening to another episode of Fast Facts- Coding Edition brought to you by A Tale of Two Hygienists in partnership with DentistRX. And now, please welcome your host, Teresa Duncan, MS.
[Teresa Duncan, MS]
Hello. My name is Teresa Duncan. Welcome to this edition of your Coding Fast Facts. Today, let's talk about evaluation codes. Well, what are these codes? You will find them in the beginning of the CDT code book under the diagnostics section. Now, most of you are familiar with evaluation codes, D0140 & D0120 but there are other ones. So you have D0145, which is for the little kids, three and under. Then you have D0180 which is the periodontal evaluation and comprehensive evaluation is D0150. Fun fact, I was once told by somebody on the coding committee that it's not exam, and I needed to stop calling it exam. The term is evaluation. And so that's why I always say evaluation. You might be used to hearing exam. And once I get yelled at for something, I try not to do it again. So I usually will say the word evaluation. Okay, so what about the codes? What are those codes? They are meant to take a look at the condition of the patient and to assess it and create some sort of prognosis. So it's a diagnosis and a prognosis setting. That's typically what is in all of these evaluation codes.
Now, the question I get all the time regarding hygiene is, can a hygienist provide these services? Unless you're in a state that allows you to practice independently and your state practice act allows you to actually diagnose, then unfortunately, these codes are not meant for hygienists to use. You do have some codes, though. You have screening codes and you can find those in the same category. You do have screening codes, but remember to read the description fairly well, because it only really applies in certain situations, especially if you're doing, say, teledentistry, maybe you're seeing the patient assessing, and then you'll send it on to the doctor for a proper diagnosis, a full diagnosis. Now, what do you do with the reimbursement for this? So the compensation for this and this is definitely where you can see some of the battle uniforms coming out in an office. You know who gets credit for the evaluations. So there's three ways the RDH could get the credit, the hygienist could get the credit. Okay? Second way is that the associate or the owner doctor gets the credit for it. And the third way is that the practice gets the credit. So no matter which associate, dentist, owner, dentist saw it, the practice gets the credit, meaning that it doesn't show up on anybody's percentage. So any associate that you have, it doesn't matter if they do the evaluation, it goes to the practice. That's honestly not as common. Typically, you will see that the associate gets the evaluation. Now it will be billed out. Let me just be really clear here, you're going to be billing it out under the dentist most of the time. 99.9% of the time you'll be billing it out under the dentist. It will show up in the clinical notes written by the dentist. The dentist's name will be attached to the clinical notes because he or she is the one that is actually doing the diagnosis and prognosis and the assessment. But on the ledger, on the actual way to figure out collections, the initials could be either the hygienist or the associate dentist or again, the practice. But most of the time it's the hygienist and the associate dentist. And so because of that, you'll have to figure that out. You'll have to make sure that it's in your contract whether or not you get it. Same thing with associates. Associates will have to negotiate for that. And it's really nice if the RDH gets it because of course that increases your production, helps towards bonus all that if you have that in place in your office. But it should be only billed out to a provider that's licensed in your state and that typically is only the dentist.
So let me give you some tips on getting reimbursement for this. In the past, it was pretty easy to get evals paid. Now insurance carriers are typically asking for documentation on so many things that they didn't before. And sometimes you will receive what we call a request for statement of medical necessity. What that means is that they want to know why this evaluation was done and also that request will also apply to any radiographs that you took. So why do they need a statement of medical necessity? Doesn't the eval itself show that there was a medical necessity? But again, this is why your clinical notes have to show that there was a proper I mean, your soap notes is what's going to help you, right? So that there was a proper diagnosis, prognosis, discussion of it. What was the plan going forward? How are we going to do this? Whether it's comprehensive or limited in nature, all of that needs to be in there.
So the pitfalls with evaluations is that most carriers are going to only cover two per year, and some carriers are more specific in that they'll do one every six months. So typically you'll see a patient twice a year and that's kind of how they came up with that formula. However, if you have a patient that comes in for an emergency evaluation or something, maybe an evaluation after having some surgery done, that's your D171. That's a post op evaluation, which is a terribly underutilized code. I can go over that in a future Fast Facts edition. The insurance carrier is only going to pay for what's allowed under benefits, which is typically two, right? But that doesn't mean you only do two. And I hear from offices all the time that may see a patient for a couple of different things during the year, maybe they had to have two or three different limited evaluations because their teeth are just in a mess and they just keep working at it ad hoc.
What you end up doing is your billing still for the evaluation and you have to let the patient know your plan only allows for two per year, and unfortunately, you're at your 3rd, 4th, 5th, so this one's going to be out of pocket. That's what the admin team is going to have to say. But I don't want your admin team to pretend that it's all going to get paid if they know for sure that it's not. The fact that you have to do extra evaluations, what ends up happening is that the office starts to feel bad, like, well, they've already had to pay. Maybe we should just not charge for this one. Oh, you should charge because your disposables cost money, your time costs money, the overhead of the practice costs money. So, yes, carriers may only cover two per year, but that doesn't mean that you only charge for two per year. You charge for what you do when you did it and if insurance covers it, great. If insurance doesn't, okay, patient covers it on their end. So hopefully that will give you a good starting point to discuss evaluations with your patients and then also with your office on how you get reimbursed. Do you get credit or not? And if there's a different way that you find yourself getting reimbursed or you see the structure in a different way, I'd love to know. You can shoot me an email at My website, if you'd like to learn more, is And until your next edition of Coding Fast Facts, thank you so much for listening.
[Andrew Johnston, RDH]
Thank you for listening to another episode of Fast Facts -  Coding Edition, brought to you in part by DentistRX makers of the InteliSonic line of power brushes. Find out more by visiting their website at We'll see you next week for another Fast Fact!

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