Comprehensive Periodontal Evaluation Template

Comprehensive periodontal evaluation - new or established patient.

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

CC: Chief complaint
Periodontal history: Periodontal history
Previous perio treatment: Previous perio treatment
Last SRP date: Last SRP date
Smoking history: Smoking history
Diabetes status: Diabetes status

D0180 support: Signs/symptoms, systemic medical condition, or social risk factor supporting comprehensive periodontal evaluation
Full-mouth probing confirmation: Six-point probing/full periodontal charting completed
Not reported with D0120/D0150/D4355 today: Yes/no

Extraoral Exam:
Head/neck: Extraoral findings
Lymph nodes: Lymph node findings

Intraoral Exam:
Gingival description: Gingival description
Color: Color
Contour: Contour
Consistency: Consistency
Texture: Texture

Full Periodontal Charting:
Probing depths recorded.
Clinical attachment levels recorded.
Bleeding on probing: Bleeding on probing
Suppuration: Suppuration
Recession: Recession
Mucogingival defects: Mucogingival defects
Furcation involvement: Furcation involvement
Mobility: Mobility
Fremitus: Fremitus

Radiographic Evaluation:
Radiographs: Radiographs taken/reviewed and findings
Bone loss pattern: Bone loss pattern
Bone loss severity: Bone loss severity

Occlusal Analysis:
Fremitus: Fremitus
Wear facets: Wear facets
Occlusal trauma signs: Occlusal trauma signs

Risk Assessment:
Smoking: Smoking
Diabetes: Diabetes
Genetic factors: Genetic factors
Stress: Stress
Compliance history: Compliance history

Periodontal Diagnosis:
Stage: Stage
Grade: Grade
Extent: Extent
Distribution: Distribution

Prognosis: Prognosis
Overall: Overall
Individual teeth: Individual teeth

Treatment Plan:
Phase I: Phase I
Phase II (if indicated): Phase II (if indicated)
Maintenance interval: Maintenance interval

Patient education provided.
Treatment options: Options/alternatives discussed.

NV: Next visit

Documentation requirements

D0180 is one of the most audited evaluation codes because the descriptor itself sets the bar: signs/symptoms or risk factors, plus full-mouth six-point charting. The chart note must show both. A defensible note includes:

• Medical history and medications reviewed — diabetes/HbA1c when known, smoking/vaping status in pack-years, immunosuppressants, bisphosphonates, anticoagulants, pregnancy
• Vital signs — BP and pulse
• Chief complaint and periodontal history — bleeding gums, mobility, halitosis, recession the patient noticed, prior SRP/surgery dates, prior maintenance interval
• Explicit D0180 justification line — the specific sign/symptom, systemic condition, or social risk factor that triggered the comprehensive perio exam (e.g., "generalized BOP with 5–6 mm pockets and Type 2 diabetes")
• Extraoral exam — head/neck, lymph nodes, TMJ
• Intraoral soft-tissue exam and oral cancer screening — explicit, not implied
• Gingival description — color, contour, consistency, texture (e.g., "generalized erythematous, edematous, rolled margins, loss of stippling")
• Full six-point periodontal charting on every tooth — probing depths, recession, calculated CAL, BOP, suppuration, mucogingival defects, furcation grades (Glickman or Hamp), Miller mobility, fremitus. Reference the chart entry/page; don't paraphrase
• Radiographic interpretation — bone-loss pattern (horizontal vs vertical/angular), severity in mm or % of root length, crown-to-root ratios, calculus, widened PDLs, furcation involvement on imaging
• Occlusal analysis — fremitus, wear facets, parafunction, occlusal trauma signs
• Risk factors — smoking pack-years, diabetes control, stress, family history, compliance history
• Periodontal diagnosis using current AAP/EFP framework — stage (I–IV), grade (A–C), extent (localized < 30% / generalized ≥ 30%), distribution (molar-incisor pattern, etc.)
• Prognosis — overall and per-tooth (good / fair / poor / questionable / hopeless)
• Phased treatment plan — Phase I (SRP, OHI, behavior modification), re-eval timing, Phase II (surgical) if indicated, maintenance interval
• Patient education and informed-consent discussion — risks, alternatives, no-treatment consequences, smoking-cessation referral when applicable
• Provider signature

The CDT descriptor also lists oral cancer evaluation, medical-history evaluation, and a general wellness assessment as components of D0180 — these must be in the note, not assumed. Carriers and state boards that audit will recoup payment when full-mouth charting is missing or when the supporting sign/symptom is not stated.

Common denial reasons

The most common reasons D0180 is denied, downgraded, or recouped:

• Insufficient sign/symptom documentation — the note doesn't state the perio finding or risk factor that justified the comprehensive perio code; carrier downgrades to D0120 or D0150 fee
• Missing or incomplete full-mouth charting — six-point probing, CAL, recession, BOP, furcation, and mobility were not all recorded on every tooth that visit
• PSR-only documented — a Periodontal Screening Record was performed instead of full charting; D0180 is not supportable
• Frequency exceeded — patient already used the combined evaluation allowance this year (often via a prior D0120, D0140, or D0150)
• Same-day conflict — billed alongside D0120, D0150, or D4355 on the same DOS; one will be denied per CDT rules
• No periodontal diagnosis — note describes findings but never states a stage/grade/extent or even "generalized chronic periodontitis"; carrier reads it as a routine exam
• Used as a substitute for D0150 in healthy new patients — auditors flag offices that bill D0180 routinely without supporting findings
• Frequent-flyer perio coding — billing D0180 at every recall visit for the same patient instead of alternating with D0120 or D4910 raises an audit pattern
• Missing AAP staging language — newer carrier policies (post-2018 AAP framework) increasingly expect stage/grade in the note for periodontitis claims that depend on D0180

Related templates