Oral exam (D0120):
An evaluation performed on a patient of record
to determine any changes in the patient’s dental
and medical health status since a previous comprehensive
or periodic evaluation. This may require interpretation
of information acquired through additional diagnostic
procedures. Report additional diagnostic procedures
separately.
Limited oral evaluation - problem focused
(D0140):
An evaluation or re-evaluation limited to
a specific oral health problem. This may require interpretation
of information acquired through additional diagnostic
procedures. Report additional diagnostic procedures
separately. Definitive procedures may be required
on the same date as the evaluation. Typically,
patients receiving this type of evaluation have been
referred for a specific problem and/or present with
dental emergencies, trauma, acute infections, etc.
Comprehensive oral evaluation (D0150):
Typically used by a general dentist and/or a specialist
when evaluating a patient comprehensively. 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 would include
the evaluation and recording of the patient’s
dental and medical history and a general health assessment.
It may typically include the evaluation and recording
of dental caries, missing or unerupted teeth, restorations,
occlusal relationships, periodontal conditions (including
periodontal charting), hard and soft tissue anomalies,
etc.
Detailed and extensive oral evaluation -
problem-focused, by report (D0160):
A detailed and extensive problem-focused evaluation
entails extensive diagnostic and cognitive modalities
based on the findings of a comprehensive oral evaluation.
Integration of more extensive diagnostic modalities
to develop a treatment plan for a specific problem
is required. The condition requiring this type of
evaluation should be described and documented. Examples
of conditions requiring this type of evaluation may
include dentofacial anomalies, complicated perio-prosthetic
conditions, complex temporomandibular dysfunction,
facial pain of unknown origin, severe systemic diseases
requiring multi-disciplinary consultation, etc.
Re-evaluation – limited, problem focused
(Established patient; not post-operative visit) (D0170):
Assessing the status of a previously existing condition.
For example:
- a traumatic injury where no treatment was rendered
but patient needs follow up monitoring;
- evaluation for undiagnosed continuing pain;
- soft tissue lesion requiring follow-up evaluation
Comprehensive periodontal evaluation - new
or established patient (D0180):
This procedure is indicated for patients showing signs
or symptoms of periodontal disease and for patients
with risk factors such as smoking or diabetes. It
includes evaluation of periodontal conditions, probing
and charting, evaluation and recording of the patient's
dental and medical history and general health assessment.
It may include the evaluation and recording of dental
caries, missing or unerupted teeth, restorations,
occlusal relationships and oral cancer screening.
