2D Cephalometric Radiographic Image Template

Cephalometric radiograph.

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
Orthodontic evaluation.
Orthognathic surgery planning.
Growth assessment.
Sleep apnea evaluation.
Other: Other

Technique: Technique
Digital cephalometric unit.
Lateral view.
Patient positioned in cephalostat.
Frankfort plane horizontal.
Image diagnostic quality.

Radiographic Findings: Radiographic findings

Skeletal Analysis:
ANB angle: ANB angle
SNA: SNA
SNB: SNB
Facial angle: Facial angle
Mandibular plane angle: Mandibular plane angle

Dental Analysis:
Upper incisor inclination: Upper incisor inclination
Lower incisor inclination: Lower incisor inclination
Overjet: Overjet
Overbite: Overbite

Soft Tissue Analysis:
Lip position: Lip position
Nasolabial angle: Nasolabial angle
Airway: Airway

Classification: Classification
Skeletal class: Skeletal class
Dental class: Dental class

Summary:

Findings discussed: Findings reviewed with patient/guardian.

NV: Next visit

Documentation requirements

A defensible D0340 chart note moves past "ceph taken" and ties the image to the diagnosis or the orthodontic/surgical plan it supports. Required components:

• Indication — the specific clinical reason: ortho records, growth assessment, orthognathic planning, airway/sleep workup, or mid-treatment progress check. A bare "ortho" is weaker than "comprehensive ortho records, Class II skeletal pattern suspected on clinical exam."
• Patient-of-record context — clinical signs/symptoms/risk factors that triggered the image. Carriers (and auditors) want a clinical narrative, not a checkbox.
• Consent / radiation discussion — benefits and risks reviewed; pediatric patients should reflect ALARA and a parent/guardian conversation.
• View — lateral (most common) vs frontal (PA). State whether it was a single image or part of a records set.
• Technique — digital cephalometric unit, cephalostat positioning, Frankfort plane horizontal, lips in repose (or function as required), exposure factors per ALARA.
• Diagnostic quality — explicitly stated. If a retake was needed, document the reason.
• Interpretation — radiographic findings in your own words. "No significant findings" is acceptable when true, but skeletal/dental analysis values do most of the documentation work for ceph.
• Skeletal analysis — ANB, SNA, SNB, facial angle, mandibular plane angle (FMA / SN-MP), or whichever analysis the practice uses (Steiner, Ricketts, McNamara, Tweed). The CDT 2018 revision makes this part of the code; omitting it weakens both the clinical record and the claim.
• Dental analysis — upper/lower incisor inclination (U1-SN, IMPA), overjet, overbite.
• Soft tissue analysis — lip position, nasolabial angle, airway dimension when relevant to the plan.
• Classification — skeletal class (I/II/III) and dental Angle class. State the cephalometric basis ("ANB 5.5° → skeletal Class II").
• Image labels / storage — patient, date, view; linked to the orthodontic record or claim attachment.
• Findings discussed with patient/guardian — particularly important for medical-necessity ortho or surgical cases.
• Operator initials and provider signature — required per most state radiation rules and many carrier policies.

For pediatric and adolescent patients, document growth status (cervical vertebral maturation or skeletal age proxy) when it informs treatment timing. For airway/sleep cases, document the airway measurement and how it links to the appliance plan.

Common denial reasons

The most common reasons D0340 is denied, downgraded, or audited:

• No orthodontic benefit on the plan — the single most common denial. The image was clinically appropriate, but the patient simply has no ortho coverage and the carrier rejects D0340 as not a covered service.
• Cosmetic exclusion — the carrier classifies the orthodontic case as cosmetic; the entire records set including D0340 is denied along with D8080.
• Frequency / lifetime limit exceeded — patient or a prior practice already used the ortho records allowance.
• Missing prior authorization — many plans require pre-auth for all orthodontic codes, including the records phase. Submission without authorization is auto-denied.
• Same-case bundling — repeat ceph during active treatment denied as included in the comprehensive case fee (D8080/D8090).
• No medical necessity / no qualifying malocclusion — Medicaid and medical-cross-coded claims denied for failing to meet HLD index thresholds or ICD-10 medical necessity criteria.
• Adult patient on a dependent-only ortho rider — code denied for age.
• Documentation does not support analysis was performed — under the CDT 2018 descriptor, D0340 includes "acquisition, measurement and analysis." A note that says only "ceph taken" without skeletal/dental measurements invites a downgrade or recoupment on audit.
• Wrong code billed — a panoramic image submitted under D0340 (should be D0330), or a CBCT submitted under D0340 (should be D0364–D0368).
• Image not retained / not retrievable on records request — carriers can recoup payment when the image cannot be produced for review.

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