Healthcare Fraud Shield’s Latest Article: Medical Evaluation and Management Codes Billed by Dentists

11 Jun
The American Dental Association develops and publishes the Current Dental Terminology (CDT) code set. According to the American Dental Association (ADA), “The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately documenting dental treatment”.[1]

In a typical dental office, a patient is seen for preventative and problem focused services. While most dental offices utilize the CDT oral evaluation codes, some prefer to use the CPT outpatient/office visit procedure codes. There are monumental differences between the two classes as outlined below:
 
CDT office visit codes
 
D0120 – Periodic oral evaluation
D0140 – Limited oral evaluation -problem focused
D0145 – Oral evaluation for a patient under the age of three years of age and counseling with primary caregiver
D0150 – Comprehensive oral evaluation
D0160 – Detailed and extensive oral evaluation – problem focused, by report
D0180 – Comprehensive periodontal evaluation-new or established patient
Most oral evaluations include periodontal screening and may require interpretation of information acquired through additional diagnostic procedures. A brief history is sometimes taken as well. You can refer to your CDT book for further procedure code descriptions.
 
Evaluation and Management CPT codes

CMS’ Evaluation and Management Documentation Guidelines[2] states “The code sets to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code you may bill within the appropriate category…The three key components when selecting the appropriate level of E/M services provided are history, examination, and medical decision making.”

For example, if the dentist bills procedure code 99213, the documentation must include an expanded problem focused history. The history component includes a brief description of history of present illness (HPI), and a problem pertinent review of systems (ROS). The documentation must also include an expanded problem focused examination which is defined as a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Lastly, the documentation must include medical decision making of low complexity. Low medical decision making is comprised of a limited number of diagnoses, a limited amount or complexity of data to be reviewed, and low risk of complications or co-morbidity. Refer to the E/M Documentation Guidelines for definitions of each of these levels of key components.
 
What to look for

When billing an office visit for dental services, be mindful of what was performed during the visit. CPT E/M services require a lot more documentation to bill and, the services for a mid to high level E/M procedure code are generally not performed during a dental visit.  Investigators and analysts should look for:
  • Excessive comprehensive evaluations
  • Excessive medical E/M codes compared to peers
  • Excessive high level medical E/M codes
If you have general SIU questions or comments, please contact us at  SIU@hcfraudshield.com.
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