Comprehensive Oral Evaluation Template

Comprehensive oral evaluation - new or established patient.

RMH: Medical history reviewed/updates
BP: BP/Pulse

CC: Chief complaint

Exam baseline support: Decay/fractures/mobility/existing restorations/open margins/recession/bruxism/TMJ/occlusion/soft tissue findings
Radiographs/photos reviewed: Images taken/reviewed/interpreted and findings
Diagnosis/prognosis by tooth/area: Specific diagnosis and prognosis where applicable
Dental history: Dental history
Last dental visit: Last dental visit

Extraoral Exam:
Head/neck: Extraoral findings
TMJ: TMJ findings
Lymph nodes: Lymph node findings
Muscles of mastication: Muscles of mastication

Intraoral Exam:
Lips/labial mucosa: Lips/labial mucosa
Buccal mucosa: Buccal mucosa
Floor of mouth: Floor of mouth
Tongue: Tongue
Hard palate: Hard palate
Soft palate/oropharynx: Soft palate/oropharynx
Gingiva: Gingiva

Hard Tissue Exam:
Dentition: Dentition
Existing restorations: Existing restorations
Caries: Caries
Wear/erosion: Wear/erosion
Occlusion: Occlusion findings

Periodontal Screening:
Gingival condition: Gingival condition
Probing depths: Probing depths
Bleeding on probing: Bleeding on probing
Recession: Recession
Mobility: Mobility
Furcations: Furcations

Radiographs: Radiographs taken/reviewed and findings
Findings: Findings

Dx: Diagnosis

Caries risk: Caries risk
Perio classification: Perio classification

Treatment plan discussed: Plan/options reviewed.
Patient questions: Answered/no questions.

Recommended treatment: Recommended treatment

NV: Next visit

Documentation requirements

The CDT 2021 revision elevated oral cancer screening from "where indicated" to a mandatory, non-optional component of D0150. Every descriptor element below should be visible in the note — if the chart reads like a periodic exam, expect a downgrade.

• Medical and dental history — reviewed and updated, including medications, allergies, systemic conditions, ASA status, and risk factors (tobacco, alcohol, diabetes, HPV, immunosuppression). State what changed if anything; "no changes" is acceptable but should be written, not omitted.
• Chief complaint — in the patient's own words, even if the visit is a routine new-patient exam ("here for a check-up, no specific concerns" still counts).
• Vitals — BP and pulse where applicable. Some state boards and most sedation-capable practices require these on every comprehensive eval.
• Extraoral exam — head, neck, lymph nodes, TMJ (range of motion, clicking, deviation), masticatory muscles, skin.
• Intraoral soft tissue exam — lips, labial and buccal mucosa, tongue (dorsal, ventral, lateral borders), floor of mouth, hard and soft palate, oropharynx, gingiva.
• Oral cancer screening — explicitly documented as performed. Don't bury it inside "soft tissue WNL." Many auditors flag the absence of an explicit oral-cancer-screening line as a basis to downgrade.
• Hard tissue / dentition — caries, existing restorations and their integrity, missing or unerupted teeth, fractures, wear patterns, prostheses, abfraction.
• Periodontal screening or charting — at minimum a PSR or visual gingival assessment; full 6-point charting if indicated. The descriptor allows either; the choice between D0150 and D0180 turns on this point (see below).
• Occlusion — Angle classification, overjet/overbite, wear, parafunction, signs of bruxism.
• Radiograph review — note imaging interpreted today and any prior images consulted; radiographs are billed separately under D0210/D0220/D0270/D0274 etc. and are not bundled into D0150.
• Diagnoses — caries by tooth, perio status, occlusal/TMJ findings, mucosal findings. Be specific by tooth or area.
• Risk assessment — caries (low/moderate/high), periodontal, oral cancer.
• Treatment plan — sequenced, with options and the patient's choice noted; this is what makes the encounter "comprehensive."
• Provider signature and any auxiliary operator initials.

The standard "amnesia test" applies: a third party reading the note must be able to reconstruct the visit. Auto-populated default-normal findings (every tissue "WNL" for every patient on every visit) are a known audit pattern and a frequent cause of recoupment. Document what you actually observed.

Common denial reasons

The most frequent reasons D0150 is denied, downgraded, or recouped:

• Frequency violation — patient had any combined exam (D0120/D0140/D0150/D0180) within the carrier's lookback window. By far the most common cause of denial, and often the result of a prior provider's claim history the front desk can't see.
• Established patient with no significant change documented — carrier downgrades to D0120 because the note doesn't justify a fresh comprehensive. The phrase "patient returns for routine check-up" in the note is a self-inflicted downgrade.
• Insufficient documentation — missing extraoral exam, oral cancer screening, periodontal screening, or treatment plan. Auditors will downgrade if any descriptor element is silent in the note.
• Same-date conflict with another evaluation — D0150 billed alongside D0120, D0140, D0145, D0160, or D0180 on the same DOS. Only one evaluation pays per provider per day. D0150 + D0180 is the most common rejected pairing.
• D0150 billed routinely for recall visits — auditors flag offices whose D0150-to-D0120 ratio is elevated relative to specialty norms. The Texas OIG and several Medicaid MCOs have published audit findings citing exam-code overuse.
• Missing narrative when prior D0150 exists with another in-network provider — carriers see a duplicate and deny without a written explanation of significant change or 3-year absence.
• Default-normal templating — a note where every soft-tissue site is "WNL" with no patient-specific findings looks fabricated to a reviewer.
• No oral cancer screening line — post-2021, this is treated as a missing required element, not a missing optional one.

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