What should the D0220 chart note include?
Pick your PMS to format the placeholders, then copy.
Periapical radiograph - first image. RMH: Medical history reviewed/updates Image order/necessity: Clinical signs/symptoms/risk factors supporting image Patient consent/radiation discussion: Benefits/risks reviewed and consent Image quality: Diagnostic quality or retake reason Interpretation: Findings or no significant findings Image labels/storage: Patient/date/tooth or area labels; linked to note/claim if needed Indication: Indication/diagnosis Tooth: #Tooth number(s) Reason: Reason Technique: Technique Digital sensor. Paralleling technique. Image diagnostic quality. Radiographic Findings: Radiographic findings Crown: Crown Root(s): Root(s) PDL space: PDL space Lamina dura: Lamina dura Periapical area: Periapical area Bone levels: Bone levels Other: Other Findings reviewed with patient. NV: Next visit
What documentation is required for D0220?
D0220 is one of the most commonly under-documented codes. The image existing is not the documentation — the chart must capture why it was taken, what was seen, and that the dentist interpreted it. ADA/FDA selection-criteria guidelines and most carrier audit policies require this. A defensible D0220 chart note includes:
- Indication / clinical justification — the specific signs, symptoms, or risk factors that prompted the image. "Routine" alone is not a defensible indication. Examples: "spontaneous throbbing #30," "deep distal caries #14, evaluate proximity to pulp," "trauma to #8, rule out root fracture," "post-op endo recall #19."
- Tooth number or anatomic site — required by virtually every carrier when a single PA is billed. "Lower right" or "anterior" is not specific enough.
- Patient consent / radiation discussion — confirm benefits and risks were reviewed. Pregnancy status confirmation when applicable; thyroid collar / lead apron use per office protocol.
- Technique — paralleling vs bisecting angle, digital sensor vs PSP, kVp/mA if your office documents it. The auto-notes default reflects current best practice (digital sensor, paralleling).
- Image quality / diagnostic acceptability — explicit "diagnostic quality" statement, or document the retake reason if the first exposure was nondiagnostic. Nondiagnostic images that were retaken are not separately billable.
- Interpretation by the dentist — the heart of the note. Carriers (and state boards) treat an uninterpreted image as if the procedure was incomplete. Cover crown, root(s), PDL space, lamina dura, periapical area, bone levels, and any incidental findings. "No significant findings" is acceptable when truly the case — but it should appear as the dentist's conclusion, not a default.
- Linkage to diagnosis or treatment plan — connect the radiographic finding to what changes because of it (e.g., "PARL #19 confirms diagnosis of necrotic pulp; RCT planned").
- Image labeling / storage — date, patient identifier, and tooth/area on the image file; attached to the chart and available to the carrier on request.
- Operator and interpreting dentist — who exposed the image and who read it (often the same person, but document both when different).
Avoid template defaults left in place ("WNL," "no significant findings") on every PA. If the PA was taken because something was suspected, the interpretation should reflect what was found or explicitly rule it out.
Why does D0220 get denied?
The most common reasons D0220 is denied, downgraded, or audited:
- Bundled into D0210 (FMX rebundling) — the most common adjustment. Total intraoral images on the date of service hit the carrier's FMX threshold and the line items for D0220/D0230/D0274 are zeroed in favor of the D0210 fee.
- Same-date conflict with D0210 — D0220 billed alongside an FMX on the same DOS without a distinct, narratively justified clinical reason
- Missing tooth number or anatomic site — the single most preventable denial; most carriers require tooth-level specificity for any single PA
- No documented indication / clinical necessity — chart note shows the image was taken but not why
- No documented interpretation — image attached without the dentist's read of crown, roots, PDL, periapical area, bone levels
- Frequency exceeded — patient's plan caps total PAs in a 12-month window and the cap was already met
- D0210 frequency lookback triggers — carrier interprets the cumulative PA+BW activity as a comprehensive series and denies under D0210's 3- or 5-year limit
- More than one D0220 on the same DOS — the second and subsequent PAs must be billed as D0230, not D0220. Most claim editors auto-deny duplicates of D0220.
- Nondiagnostic / retake billed — only diagnostic-quality images are reimbursable; the retake of a nondiagnostic exposure is not separately billable
- Missing operator/interpreting dentist signature — flagged by Medicaid auditors and some commercial carriers
- Endodontic intraoperative imaging treated as inclusive — a small minority of payers consider working-length and master-cone PAs bundled into the endodontic fee
What do practices ask about D0220?
What's the difference between D0220 and D0230?+
It's a billing convention, not a clinical one. D0220 is the first periapical image taken on a given date of service; D0230 is each additional periapical taken on that same date. The images themselves are identical in technique and anatomy. If you take three PAs at one visit, you bill one D0220 and two D0230. You never bill more than one D0220 per patient per date.
Can I bill D0220 and D0210 (FMX) on the same day?+
Generally no. Most carriers consider PAs taken on the same date as the FMX inclusive of the D0210 fee and won't pay D0220/D0230 separately. The narrow exception is a clinically distinct, narratively justified PA — for example, an emergency PA of a traumatized tooth taken in addition to a planned FMX. Even then, payment is at the carrier's discretion.
Why did my claim of one D0210 plus several D0220/D0230 lines come back paid as just D0210?+
Carrier rebundling. When the total intraoral images submitted for a date of service reach the FMX-equivalent threshold (commonly 14+ images), most claim editors automatically collapse the D0220 and D0230 lines into D0210 and pay the single FMX fee. This is by design — billing the components separately is treated as unbundling. If 14+ images are clinically indicated on one day, code D0210 from the start.
Do I need to document a tooth number for D0220?+
Yes. Virtually every commercial carrier and Medicaid MCO requires tooth number or specific anatomic site for D0220, and missing tooth numbers are one of the most common reasons single-PA claims deny. Document the tooth or area in the indication line and in the radiographic findings, and ensure the image file itself is labeled.
How often can D0220 be billed in a year?+
Most plans don't impose a strict per-year cap on D0220 — periapicals are paid as clinically taken, contingent on documented indication. However, some Delta Dental contracts and Medicaid MCOs cap combined D0220 + D0230 at a fixed number (commonly 8, 16, or 20) per 12 months, and the cumulative-image rebundling rule with D0210 still applies regardless. Always verify the patient's specific benefit.
Are working-length and master-cone PAs taken during a root canal billable?+
In most jurisdictions, yes. Pre-op, working-length, master-cone, and post-fill PAs taken on the same date as the RCT are billable as one D0220 plus the appropriate number of D0230s. A small number of payers consider intraoperative endo radiographs included in the endodontic procedure fee — verify the patient's plan when in doubt.
Can a retake of a nondiagnostic PA be billed?+
No. Only diagnostic-quality images are reimbursable. If the first exposure was nondiagnostic, document the retake reason in the chart and bill only one D0220 for the diagnostic image. Billing both the nondiagnostic image and its retake is a known audit flag.