Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

Plan Stipulations vs. Patient Needs: Consultations and Evaluations

In the dental world, we can sometimes use the words “consultation” and “evaluation” interchangeably when talking with patients. However, from a clinical and billing perspective, these two terms are distinctly different. Misunderstanding the nuances of these two terms – and the codes that go along with them – can lead to administrative headaches, insurance denials, or even mismanaged patient expectations. 

Scenario: You work at a general dentistry practice that has a periodontist in-office every Wednesday. Your periodontal patients may need to see the periodontist for implants, gum grafting, bone grafting, etc.

What is the proper coding for the initial visit with the periodontist?

Remember that how the patient got to the office does not determine the code used; the scope of what was actually completed does. The type of consultation appointment may be reported in several different ways based on the scope of the consultation. One of the following codes would be reported by the practitioner performing the consultation or evaluation:

• D9310 Consultation – Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Dentist Or Physician 
  • This code would be appropriate if a specialist receives a referral from a general dentist.
  • D9310 may not be reimbursed by all payors, particularly if the referring dentist has the same NPI 2; however, if reimbursed, it is typically done so at a higher rate than a comprehensive oral evaluation.
• D0140 Limited Oral Evaluation – Problem Focused
  • This code is appropriate when the evaluation is limited to a specific problem or chief complaint and includes a patient who self-refers themself to see a specialist for a problem-focused issue, rather than being formally referred by another provider.
  • Many payors have frequency limitations in place for oral evaluations, so there may or may not be coverage for this procedure code, depending on whether the patient has exhausted their evaluation frequencies for their benefit period. Some plans may allow coverage for an additional evaluation if performed by a specialty provider.
• D0160 Detailed And Extensive Oral Evaluation – Problem Focused, By Report
  • This code would be appropriate if the case is complex in nature (e.g., planning a fixed hybrid case that requires a general dentist and periodontist working together).
  • As stated above with D0140, frequency limitations vary widely, with some payors considering this part of the plan’s oral evaluation frequency.
  • Reimbursement, when available, may be higher than other evaluation types.
• D0180 Comprehensive Periodontal Evaluation – New Or Established Patient
  • This code would be appropriate in the scenario listed above if the periodontist performs full periodontal probing and charting, to include pocket depths, recession, bleeding points, etc.
  • This code is for patients exhibiting signs or symptoms of periodontal disease, systemic medical conditions, or social risk factors that would increase the susceptibility to periodontal disease. It evaluates oral cancer, medical history, general wellness, and current dental conditions.

In summation, while it’s tempting to let insurance frequencies dictate your documentation, your clinical integrity depends on coding for what you actually do. The CDT code set is the universal language of our profession. By selecting the code that matches the nomenclature and descriptor of the service performed — regardless of whether a payor covers it or the office can receive reimbursement for it — you ensure clear documentation, protect your practice’s bottom line, and provide the highest level of transparency for your patients. Accuracy in the chair leads to clarity in the ledger.

Log in to Code Advisor TODAY to assist you in making sure you are selecting the correct code for what is done in the chair during your patient’s next visit.