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Consultant’s Corner: Clinical Oral Evaluations

July 02, 2020

The oral examination comprises a uniform and consistent inspection of the head and neck and an intraoral evaluation of the hard and soft tissues - in conjunction with a thorough medical and dental history. The entire mouth should be inspected regardless of the patient’s chief complaint and reasons for the visit. Let's take a look at the various types of oral evaluations available to dental practitioners.

D0120 - Periodic Oral Evaluation – Established Patient

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. Evaluation includes an oral cancer screening and periodontal screening/charting where indicated.

D0140 - Limited Oral Evaluation – Problem Focused

An evaluation limited to a specific oral health problem or complaint. Typically, patients present with a specific problem, trauma, acute infection, emergency, etc.

D0145 - Oral Evaluation for A Patient Under Three Years of Age and Counseling with a Primary Caregiver

Diagnostic services performed for a child under the age of three. Evaluation includes recording the oral and physical health history, evaluation of caries susceptibility, and development of an appropriate preventive oral health regimen. Evaluation includes counseling the child’s primary caregiver with respect to fluoride recommendations, diet recommendations, and instructions for cleaning the child’s teeth.

D0150 - Comprehensive Oral Evaluation – New or Established Patient

A thorough evaluation and recording of the extra oral and intra oral hard and soft tissues. Evaluation includes an evaluation for oral cancer, evaluation and recording of the patient’s dental and medical history, a general health assessment, recording of dental caries, missing or unerupted teeth, restorations, existing prosthesis, occlusal relationships, periodontal condition (including periodontal screening/charting), and tissue anomalies.

D0160 - Detailed and Extensive Oral Evaluation – Problem Focused, by report

A detailed and extensive problem focused evaluation based on the findings of a comprehensive oral evaluation. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, and facial pain of unknown origin. The condition requiring this type of evaluation should be described and documented.

D0170 - Re-evaluation – Limited, Problem Focused (Established Patient; Not Post-Operative Visit)

Assessing the status of a previously existing condition. Typically, D0170 would be preceded by another evaluation.

D0171 - Re-evaluation – Post Operative Office Visit

Assessing the status of a previously performed procedure.

D0180 - Comprehensive Periodontal Evaluation – New or Established Patient

An evaluation performed for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking and diabetes. Procedure 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 recording of dental caries, missing or unerupted teeth, restorations, existing prosthesis, and occlusal relationships.