Billing Guide for D0150 (Comprehensive Oral Evaluation - New Patient)
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Description
Billing Guidelines, Tips and Reminders for D0150 (Comprehensive Oral Evaluation - New Patient)
February 02, 2025
Used by a general dentist and/or a specialist when evaluating a patient comprehensively. This applies to new patients; established patients who have had a significant change in health conditions or other unusual circumstances, by report, or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.
This includes an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc.
WARNING
1. It is improper to report a comprehensive oral evaluation (D0150) or any other oral evaluation unless the doctor has physically (hands in mouth!) evaluated the patient.
2. It is improper to charge insured patients for a comprehensive oral evaluation (D0150) while the evaluation is "free" for non-insured patients. Treatment and fee protocols should be identical for both insured and non-insured patients. Otherwise, this practice may be considered "discriminatory" and may be deemed "overbilling" by payors, a potentially fraudulent billing activity. PPO contracts commonly require charges be consistent between patients regardless of insured status.
3. D0150 should only be repeated if a patient has been absent from the practice for three years or has had significant changes to their health. Do not routinely repeat D0150 every three years for all patients.
4. The comprehensive oral evaluation (D0150) code includes an oral cancer evaluation (OCE). The fact that the oral cancer evaluation was completed and any significant findings should always be documented in the clinical notes.
5. If the patient has signs or symptoms of periodontal disease or risk factors such as smoking or diabetes, consider reporting D0180 comprehensive periodontal evaluation instead of D0150. D0180 would be the more accurate code and the fee and reimbursement may be higher.
WATCH
1. Consider reporting D0150/D0180 when the self-referring patient has already been treatment planned by a previous dentist for comprehensive treatment and is requesting a second opinion. If the patient has been referred by another provider, consider reporting D9310.
2. D0150 may be reported on the same service date with scaling in the presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346). See D4346.
3. In cases where there are access to care issues, D0150 may be reported on the same service date as full mouth debridement (D4355), but this should not include periodontal records or diagnosis. See D4355.
LIMITATIONS
1. The comprehensive oral evaluation (D0150) is comprehensive and extensive in nature and may include periodontal screening and/or charting, depending on the age/circumstances of the patient. The comprehensive evaluation includes mandatory evaluation for oral cancer. The general dentist would either report D0150 or D0180 for most new patients since these evaluations by definition are all encompassing and extensive. A general dentist or periodontist would generally use D0180 for the new and established patient if he/she exhibit signs and symptoms of periodontal disease, or has risk factors such as smoking or diabetes. Nothing precludes the general practitioner from using D0180 for the new and established patient, provided the patient has signs and symptoms of periodontal disease or risk factors such as smoking or diabetes. If D0180 is reported, a mandatory full mouth (six points/tooth) probing and charting is necessary and should be completed on the day D0180 is reported. D0180 is encouraged in the GP office for new patients exhibiting signs or symptoms of periodontal disease as it is the more accurate code and the fee and reimbursement may be higher. D0150 applies to both new child and adult patients. (For a child less than three years of age, see D0145 for an oral evaluation.) The benefit for the comprehensive oral evaluation (D0150) is generally subject to the "one per six months" or "two evaluations per year limitation. Some payors will reimburse a third evaluation within the limitation period when a specialist performs the oral evaluation in a different office or if the evaluation is a problem focused oral evaluation (D0140) or a consultation (D9310).
2. D0150 may be reported again for an extensive evaluation of an established patient in very limited circumstances. Generally, this requires a significant change in health status (these can include, but are not limited to, a new diagnosis of cancer, HIV/AIDS, diabetes, Sjögren's syndrome, GERD, bulimia, epilepsy, heart disease, asthma, etc.) or absence from active treatment for a period of three years or more. In spite of criteria in the descriptor, many payors still remap D0150 down to D0120, at the lower fee. The payor may consider D0150 to be "once per lifetime" per office. Others use an every "three" or "five" year reimbursement rule for D0150. Some payors reimburse consultation (D9310) on a case-by-case basis to specialists. D9310 should generally be reported when rendering a consultation by a specialist or general practitioner who may or may not provide treatment. See "consultation" (D9310) for further details.
3. Some payors reimburse orthodontic evaluations (consultations) as either D0120 or D0150 and limit the reimbursement to the lower UCR fee. These evaluations are generally subject to the "one per six months" or "two evaluations per year* limitation. In some cases, a third oral evaluation may be reimbursed if it is provided by a different office or a specialist.
TIPS
1. The vast majority of payors reimburse the same fee for a comprehensive oral evaluation (D0150), whether for child or adult. The first visit for a child the age of 3 years and above may include the comprehensive oral evaluation (D0150), as well as billing out a prophylaxis, fluoride, and diagnostic radiographic images. Some practices charge less for the child's comprehensive oral evaluation (D0150). Practices may establish two fees (child and adult) for D0150. To distinguish between the two scenarios, establish separate in-office codes with different fees. The office may establish "in house" codes of D0150A (child) and D0150B (adult) with different fees. Using this approach, the corresponding code is reported (D0150A, child or D0150B, adult). By implementing this system, the reimbursement level will typically be higher for the D0150A, child evaluation, than the periodic oral evaluation (D0120). This will allow the fee for the child comprehensive evaluation to be less than the adult comprehensive evaluation. If configured correctly, the computer software will reference the "A" or "B" from the code when assigning the fee but remove the "A" or "B" from the code when posting the procedure on the claim form. For a child less than three years of age, see D0145 for reporting an oral evaluation. Note that counseling must be provided to the primary caregiver at the D0145 visit.
2. A comprehensive oral evaluation (D0150) may include a periodontal screening and/or charting:
a. Periodontal screening includes selected six-points-per-tooth probing. The words "may include" in the descriptor, simply acknowledges that some patients may not require a periodontal screening or charting (e.g., young children or edentulous patients).
b. Periodontal charting includes, but is not limited to, recording six-points-per-tooth pocket depths, recessions, furcations, areas of mobility, bleeding points, minimal attached gingiva notations, suppuration, etc.
i. A dentist "may" determine a full-mouth periodontal charting is not necessary if the periodontal screening was within normal limits.
ii. A dentist "may" decide not to perform a full-mouth periodontal charting if he/she intends to refer the patient to a periodontist based on the results of the periodontal screening.
c. If the patient has signs and symptoms of periodontal disease and/or risk factors such as smoking or diabetes, and periodontal records are obtained, consider reporting D0180 comprehensive periodontal evaluation instead of D0150, as D0180 may carry a higher fee and reimbursement.
3. Additional diagnostic procedures should be reported separately such as radiographs, caries susceptibility tests, genetic tests, viral cultures, diagnostic casts, etc.
NARRATIVES
If a comprehensive oral evaluation (D0150) is reported for an established patient, list the significant change(s) in health status or the number of years the patient has been absent from active treatment (must be three years or more). Note that many payors consider D0150 “once in a lifetime” and will downgrade the payment based on the fee schedule for D0120.
CLINICAL FLOWCHARTS
Typical new patient scenario (assuming that calculus/debris still permits the comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180) at the initial visit):
This includes an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc.
WARNING
1. It is improper to report a comprehensive oral evaluation (D0150) or any other oral evaluation unless the doctor has physically (hands in mouth!) evaluated the patient.
2. It is improper to charge insured patients for a comprehensive oral evaluation (D0150) while the evaluation is "free" for non-insured patients. Treatment and fee protocols should be identical for both insured and non-insured patients. Otherwise, this practice may be considered "discriminatory" and may be deemed "overbilling" by payors, a potentially fraudulent billing activity. PPO contracts commonly require charges be consistent between patients regardless of insured status.
3. D0150 should only be repeated if a patient has been absent from the practice for three years or has had significant changes to their health. Do not routinely repeat D0150 every three years for all patients.
4. The comprehensive oral evaluation (D0150) code includes an oral cancer evaluation (OCE). The fact that the oral cancer evaluation was completed and any significant findings should always be documented in the clinical notes.
5. If the patient has signs or symptoms of periodontal disease or risk factors such as smoking or diabetes, consider reporting D0180 comprehensive periodontal evaluation instead of D0150. D0180 would be the more accurate code and the fee and reimbursement may be higher.
WATCH
1. Consider reporting D0150/D0180 when the self-referring patient has already been treatment planned by a previous dentist for comprehensive treatment and is requesting a second opinion. If the patient has been referred by another provider, consider reporting D9310.
2. D0150 may be reported on the same service date with scaling in the presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346). See D4346.
3. In cases where there are access to care issues, D0150 may be reported on the same service date as full mouth debridement (D4355), but this should not include periodontal records or diagnosis. See D4355.
LIMITATIONS
1. The comprehensive oral evaluation (D0150) is comprehensive and extensive in nature and may include periodontal screening and/or charting, depending on the age/circumstances of the patient. The comprehensive evaluation includes mandatory evaluation for oral cancer. The general dentist would either report D0150 or D0180 for most new patients since these evaluations by definition are all encompassing and extensive. A general dentist or periodontist would generally use D0180 for the new and established patient if he/she exhibit signs and symptoms of periodontal disease, or has risk factors such as smoking or diabetes. Nothing precludes the general practitioner from using D0180 for the new and established patient, provided the patient has signs and symptoms of periodontal disease or risk factors such as smoking or diabetes. If D0180 is reported, a mandatory full mouth (six points/tooth) probing and charting is necessary and should be completed on the day D0180 is reported. D0180 is encouraged in the GP office for new patients exhibiting signs or symptoms of periodontal disease as it is the more accurate code and the fee and reimbursement may be higher. D0150 applies to both new child and adult patients. (For a child less than three years of age, see D0145 for an oral evaluation.) The benefit for the comprehensive oral evaluation (D0150) is generally subject to the "one per six months" or "two evaluations per year limitation. Some payors will reimburse a third evaluation within the limitation period when a specialist performs the oral evaluation in a different office or if the evaluation is a problem focused oral evaluation (D0140) or a consultation (D9310).
2. D0150 may be reported again for an extensive evaluation of an established patient in very limited circumstances. Generally, this requires a significant change in health status (these can include, but are not limited to, a new diagnosis of cancer, HIV/AIDS, diabetes, Sjögren's syndrome, GERD, bulimia, epilepsy, heart disease, asthma, etc.) or absence from active treatment for a period of three years or more. In spite of criteria in the descriptor, many payors still remap D0150 down to D0120, at the lower fee. The payor may consider D0150 to be "once per lifetime" per office. Others use an every "three" or "five" year reimbursement rule for D0150. Some payors reimburse consultation (D9310) on a case-by-case basis to specialists. D9310 should generally be reported when rendering a consultation by a specialist or general practitioner who may or may not provide treatment. See "consultation" (D9310) for further details.
3. Some payors reimburse orthodontic evaluations (consultations) as either D0120 or D0150 and limit the reimbursement to the lower UCR fee. These evaluations are generally subject to the "one per six months" or "two evaluations per year* limitation. In some cases, a third oral evaluation may be reimbursed if it is provided by a different office or a specialist.
TIPS
1. The vast majority of payors reimburse the same fee for a comprehensive oral evaluation (D0150), whether for child or adult. The first visit for a child the age of 3 years and above may include the comprehensive oral evaluation (D0150), as well as billing out a prophylaxis, fluoride, and diagnostic radiographic images. Some practices charge less for the child's comprehensive oral evaluation (D0150). Practices may establish two fees (child and adult) for D0150. To distinguish between the two scenarios, establish separate in-office codes with different fees. The office may establish "in house" codes of D0150A (child) and D0150B (adult) with different fees. Using this approach, the corresponding code is reported (D0150A, child or D0150B, adult). By implementing this system, the reimbursement level will typically be higher for the D0150A, child evaluation, than the periodic oral evaluation (D0120). This will allow the fee for the child comprehensive evaluation to be less than the adult comprehensive evaluation. If configured correctly, the computer software will reference the "A" or "B" from the code when assigning the fee but remove the "A" or "B" from the code when posting the procedure on the claim form. For a child less than three years of age, see D0145 for reporting an oral evaluation. Note that counseling must be provided to the primary caregiver at the D0145 visit.
2. A comprehensive oral evaluation (D0150) may include a periodontal screening and/or charting:
a. Periodontal screening includes selected six-points-per-tooth probing. The words "may include" in the descriptor, simply acknowledges that some patients may not require a periodontal screening or charting (e.g., young children or edentulous patients).
b. Periodontal charting includes, but is not limited to, recording six-points-per-tooth pocket depths, recessions, furcations, areas of mobility, bleeding points, minimal attached gingiva notations, suppuration, etc.
i. A dentist "may" determine a full-mouth periodontal charting is not necessary if the periodontal screening was within normal limits.
ii. A dentist "may" decide not to perform a full-mouth periodontal charting if he/she intends to refer the patient to a periodontist based on the results of the periodontal screening.
c. If the patient has signs and symptoms of periodontal disease and/or risk factors such as smoking or diabetes, and periodontal records are obtained, consider reporting D0180 comprehensive periodontal evaluation instead of D0150, as D0180 may carry a higher fee and reimbursement.
3. Additional diagnostic procedures should be reported separately such as radiographs, caries susceptibility tests, genetic tests, viral cultures, diagnostic casts, etc.
NARRATIVES
If a comprehensive oral evaluation (D0150) is reported for an established patient, list the significant change(s) in health status or the number of years the patient has been absent from active treatment (must be three years or more). Note that many payors consider D0150 “once in a lifetime” and will downgrade the payment based on the fee schedule for D0120.
CLINICAL FLOWCHARTS
Typical new patient scenario (assuming that calculus/debris still permits the comprehensive oral evaluation (D0150) or comprehensive periodontal evaluation (D0180) at the initial visit):
