D9450 Case Presentation Template (Detailed Tx Planning)

The template

Pick your PMS to format the placeholders, then copy.

PMS format

[Prompt:"name"]

Case presentation (detailed treatment planning).

RMH: Medical history reviewed/updates
CC: Chief complaint
Patient goals: Patient goals

Diagnostic Records Reviewed:
Clinical examination.
Radiographs: Radiographs taken/reviewed and findings
Intraoral photographs.
Extraoral photographs.
Study models/digital scans.
Periodontal charting.

Diagnosis Summary:
Periodontal: Periodontal
Restorative: Restorative
Endodontic: Endodontic
Prosthodontic: Prosthodontic
Orthodontic: Orthodontic
Other: Other

Treatment Options Presented:

Option 1: Option 1
Description: Description
Procedures involved: Procedures involved
Estimated fee: Estimated fee
Pros: Pros
Cons: Cons

Option 2: Option 2
Description: Description
Procedures involved: Procedures involved
Estimated fee: Estimated fee
Pros: Pros
Cons: Cons

Option 3: Option 3
Description: Description
Procedures involved: Procedures involved
Estimated fee: Estimated fee
Pros: Pros
Cons: Cons

Discussion: Discussion
Risks, benefits, and alternatives discussed.
Consequences of no treatment discussed.
Patient questions: Answered/no questions.
Visual aids used.

Financial Discussion:
Insurance benefits reviewed.
Payment options discussed.

Patient Decision:
Treatment option selected: Treatment option selected
Patient ready to proceed: Patient ready to proceed
Consent signed: Consent signed

Treatment Sequence (if proceeding):
1. Option 1
2. Option 2
3. Option 3

Next Steps:

NV: Next visit

Field glossary

What each placeholder represents.

Medical history reviewed/updates
Document that you reviewed the medical history and note any updates relevant to the plan — diabetes control, anticoagulants, bisphosphonates, immunosuppression, recent radiation/chemo, malignancy history. Medical status often drives sequencing decisions on complex plans.
Chief complaint
The patient's reason for the visit in their own words, in quotation marks. For D9450 this often reads like a goal statement ("I want to fix everything," "I'm tired of dentures") rather than a symptom complaint.
Patient goals
What the patient explicitly wants the plan to accomplish — esthetics, function, cost containment, avoiding removable prosthetics, time horizon. Patient goals frame the option comparison and document informed consent.
Radiographs taken/reviewed and findings
Imaging reviewed at this visit (FMX, panoramic, CBCT, cephalometric) and a one-line interpretation linking the images to the plan. Reference the date the images were captured — D9450 presupposes records were collected at a prior visit.
Periodontal
Periodontal diagnosis with AAP staging and grading, generalized vs localized, and any modifying medical factors (diabetes, smoking).
Restorative
Tooth-by-tooth restorative diagnosis — caries, fractures, failing restorations, cracked teeth — with surfaces and severity.
Endodontic
Pulpal status of any tooth in the plan — symptomatic vs asymptomatic, vital vs necrotic, prior RCT status, retreatment vs surgical considerations.
Prosthodontic
Edentulous spaces, prosthetic options under consideration, and structural compromises that drive the prosthodontic plan (e.g., "multiple compromised cusps; full-coverage indicated").
Orthodontic
Orthodontic findings relevant to the plan, even if ortho is not part of the chosen path. Document why ortho is or isn't indicated.
Other
Other diagnostic findings — bruxism, TMD, occlusal collapse, sleep, mucosal pathology, or medical considerations that affect sequencing.
Option 1
Title or short label for the first treatment option (e.g., "Full restorative + perio + implant #18"). Indicate whether this is the recommended option.
Description
One- or two-sentence summary of what the option entails — the goal and the approach.
Procedures involved
List each CDT procedure code in the option, with tooth numbers/areas where applicable. The level of specificity expected on a defensible D9450 narrative.
Estimated fee
Total fee for the option, plus insurance estimate (covered vs patient responsibility) and any financing disclosed. Note timeline (e.g., "~$18,200 over 9–12 months").
Pros
Clinical and patient-experience advantages of the option — predictability, longevity, esthetics, function, fewer visits.
Cons
Trade-offs — cost, timeline, biological risk, prognosis caveats, home-care demands. Honest "cons" make the consent record defensible.
Option 2
Title or short label for the second treatment option. Most D9450 visits compare 2–3 options.
Option 3
Title or short label for the third treatment option, often a phased/minimal-intervention path or "no treatment" comparator.
Discussion
Narrative summary of the conversation — what was reviewed, who attended, key questions asked and answered, visual aids used, consequences of no treatment, and the patient's process for arriving at a decision.
Answered/no questions
Whether patient (and any family member or referring provider present) had questions, and whether they were answered to satisfaction. Specific questions are stronger than "questions answered."
Treatment option selected
The option the patient chose, by label. "Deferring decision" is a valid entry — document the follow-up plan if so.
Patient ready to proceed
Yes/No, with timeframe if yes (e.g., "Yes, will start phase 1 in next 2 weeks") or follow-up plan if no.
Consent signed
Whether master treatment-plan consent was signed today and what procedure-specific consents will be obtained later. Signed master consent is part of the D9450 deliverable.
Next visit
What's scheduled next — first treatment visit, financial follow-up, second case presentation if patient wants more time, specialist referral. Specify date if scheduled.

Documentation requirements

D9450 is a "by report" service in practice — even though the descriptor doesn't use that exact phrase, every carrier that pays D9450 expects a narrative establishing why a separate planning visit was clinically necessary. A defensible D9450 record contains:

Reason a dedicated planning visit was required — explicit statement of complexity (e.g., "full-arch implant case with three viable prosthetic options requiring sequenced surgical and restorative phases"). This sentence is the spine of the narrative for any appeal.
Date that diagnostic records were collected — D9450 presupposes records exist. The chart should reference the prior visit(s) where the comprehensive evaluation, radiographs, models/scans, and photographs were captured.
Records reviewed at this visit — clinical examination findings, radiographs (FMX, panoramic, CBCT), intraoral and extraoral photographs, study models or digital scans, periodontal charting, occlusal analysis, and any specialty consult reports. List them; don't summarize as "records reviewed."
Diagnosis summary by discipline — periodontal, restorative, endodontic, prosthodontic, orthodontic, occlusal, and any medical considerations. Specific by tooth or area.
Treatment options presented — typically two to three viable options. For each option: description, procedures involved with CDT codes, estimated total fee, prognosis, expected longevity, time commitment, biological and financial trade-offs, pros, and cons.
Risks, benefits, and alternatives discussed — for each option, including the consequences of no treatment (regularly cited as a missing element in audits and malpractice reviews).
Visual aids used — diagnostic images displayed on monitor, intraoral camera, study models, mock-ups, wax-ups, articulated photographs, animation/video. Documenting the visual aids supports both the cognitive-effort claim and the informed-consent record.
Patient questions and the responses given — specific questions, not "questions answered."
Who attended the presentation — patient, spouse/family member, treatment coordinator, referring dentist, specialist. Multidisciplinary cases often involve multiple stakeholders.
Financial discussion — insurance benefits reviewed, payment plan options, third-party financing offered, written estimate given. Note who in the office covered this and what the patient took home.
Patient decision — option selected (or "deferring decision"), readiness to proceed, consent signed where applicable. If the patient defers, document the follow-up plan.
Sequenced treatment plan — phased order of operations with timing estimates and which provider performs each phase.
Time spent — many auditors and carriers expect documentation of the time spent on the case presentation itself (e.g., "60 minutes face-to-face with patient and spouse"). This is one of the strongest objective markers separating D9450 from a quick post-evaluation chat.
Provider signature

Two non-obvious requirements specific to D9450:

The narrative must accompany the claim. Most carriers will not adjudicate D9450 without an attached narrative explaining the complexity and the clinical necessity of a separate visit. A claim sent without one denies as "included in evaluation" by default.
"Detailed and extensive" means demonstrable. Carriers and OIG audits flag boilerplate D9450 narratives that read identically across the practice. Each note must reflect the specific complexity of this patient's plan — the disciplines involved, the options compared, the trade-offs discussed.

Common denial reasons

The most common reasons D9450 is denied, downgraded, or audited:

"Included in evaluation" — by far the leading denial. The carrier defaults to bundling treatment planning into the D0150/D0160/D0180 already paid. Avoidable only with a narrative showing a separate, subsequent visit dedicated to a complex case presentation.
No narrative attached to the claim — without the report, every carrier defaults to denial as bundled. D9450 effectively requires "by report" treatment whether or not the carrier formally labels it that way.
Same-day conflict with an evaluation code — D9450 billed on the same DOS as D0150, D0160, D0140, or D0180 is a near-automatic denial as duplicative.
Documented work doesn't justify a separate visit — the chart note describes a brief plan walkthrough that any post-D0150 conversation would cover. Carriers downgrade or deny.
Boilerplate narratives — every D9450 in the practice's claim history reads identically. Auditors view this as evidence the dedicated cognitive work wasn't actually performed and may trigger a chart audit.
Used as a high-fee substitute for the comprehensive evaluation's plan discussion — a well-known audit pattern. Practices that bill D9450 on a high percentage of new-patient cases see special-investigations review.
Plan not for a sufficiently complex case — the descriptor implies multidisciplinary, multi-phase, or multi-option planning. A two-tooth restorative plan presented in a separate visit will deny as not "detailed and extensive."
Frequency exceeded — some carriers that cover D9450 cap it once per case or once per patient per provider.
Non-covered benefit — many PPO and most Medicaid plans simply don't cover D9450 at all. PPO contracts vary on whether non-covered services may be charged to the patient.
No time documentation — auditors increasingly look for an explicit time-spent field on D9450 chart notes. Its absence weakens appeals.
Missing informed-consent elements — failure to document risks, benefits, alternatives, and consequences of no treatment is both an audit issue and a malpractice exposure point.