Trojan Today: “Decoding the Codes: Exam Billing” by Ramona Colbert

Decoding the Codes - Trojan Today Article

Do you get confused by the multitude of codes and/or want to expedite payments? There are a few things to know that can make your claims go more smoothly.

Many payers limit evaluations (of any type) to “two evaluations per year/12 months” or “one per six months.” This type of evaluation (D0140) is often denied as an “extra” evaluation. There are exceptions to this general rule. Some payers will reimburse a problem focused evaluation (D0140) or evaluation with a specialist in addition to the two annual periodic oral evaluation visits per year.

In addition, there are a few plans that allow up to three limited oral evaluations per year. Some plans have no frequency limitations. Sometimes a consultation (D9310) is reimbursed for a visit to a specialist in addition to the typical “two oral evaluations per year.” Thus, the reimbursement for D0140 or D9310 is highly variable

Some payers will not reimburse D0140 in conjunction with a definitive procedure (e.g., extractions, fillings, etc.) on the same service date. For example, the extraction and periapical diagnostic images are typically reimbursed, while D0140 performed on the same service date may be denied. However, D0140 is a stand-alone code and may be charged in addition to the clinical procedure provided. If the doctor is out-of-network, the patient can be expected to pay out-of-pocket for the D0140 evaluation under this scenario.

Ready for more? Following are a few other tips to help you:

Some offices charge for D0140 in conjunction with an extraction when the patient is not a patient of record, as the new emergency patient requires additional time and effort to process and set up a chart. This being the case, the office policy and protocol should be consistent for both insured and non-insured patients.

Pulp vitality test (D0460) is a stand-alone code. The UCR fee for D0460 is often a little less than D0140. Some payers limit the benefits to either D0140 or the pulp vitality test (D0460) reported on the same service date. When the “two evaluations per year” are exhausted, D0460 may possibly be reimbursed on a “stand-alone” basis. See D0460 for further details on reporting this code on a “stand-alone” basis at the emergency visit

Consider limiting the use of problem-focused limited oral evaluations (D0140), as they often count toward the “one evaluation per six months” or “two evaluations per year/12 months” limitation. Consider reporting palliative treatment of dental pain (D9110) along with any necessary periapical radiographic images as an alternative, when a minor procedure is performed to relieve the pain. See D9110 for comments about the proper usage of the palliative code, D9110. D0140 can always be reported in conjunction with D9110, but payers often have limits that apply to the payment of D0140.

These guidelines should help you collect, with more skill and intention than prayers for good luck.

Ramona Colbert is the founder and CEO of 1 Source Solutions and has more than twenty-five years of dental practice management strategy consulting experience.

FMI: info@1sourcedentalsolutions.com or www.1sourcedentalsolutions.com

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