Are You Using the Right Exam Code?

A common source of confusion in dental billing revolves around the appropriate use of comprehensive exam codes—specifically D0150 and D0180. While both codes are considered comprehensive exams and share the same frequency limitations with insurance carriers, they serve different clinical purposes, and understanding those differences can directly impact your reimbursement.

The D0150 code is used when a patient is periodontally healthy. In contrast, D0180 is reserved for patients who either have periodontal disease or are at high risk for developing it, such as smokers or individuals with diabetes. Though both codes fall under the umbrella of comprehensive exams and are mutually exclusive (you use one or the other for a given visit), D0180 typically commands a significantly higher fee—often 20 to 50% more than D0150. This increased reimbursement reflects the additional time, assessment, and discussion required for patients with periodontal concerns.

One question that comes up frequently is whether there are different documentation requirements for D0180. The answer is generally no. Insurance companies treat these codes similarly, with no additional documentation requirements beyond what’s standard for a comprehensive exam. On rare occasions, a payer may request a periodontal chart to support D0180, but this is the exception, not the rule.

A very practical tip: if a patient is scheduled for a new patient exam coded as D0150, and you discover during the visit that they are a smoker, diabetic, or present with signs of periodontal disease, you should update the code to D0180 before completing the appointment. Doing so not only ensures accurate reporting but also results in appropriate reimbursement for the complexity of care provided.

Lastly, it's important to clarify that D9110 is not an exam code—it’s a code for palliative treatment and must always be accompanied by limited treatment. It is often mistakenly used as a type of exam, which can lead to claim denials or reduced payments.

In summary, understanding and correctly applying these codes is one of the simplest ways to ensure your office is both compliant and properly compensated. Knowing when to switch from D0150 to D0180 can make a financial difference immediately—starting today.