What should the D9985 chart note include?
Pick your PMS to format the placeholders, then copy.
Teledentistry (synchronous, real-time). Visit Information: Date: Date Time: Time Platform used: Platform used Connection quality: Connection quality Patient Information: Teledentistry support: Consent, synchronous/asynchronous modality, limitations explained Materials reviewed: Photos/radiographs/questionnaire/history received Response/follow-up: Findings communicated, response date/time, in-person follow-up need RMH: Medical history reviewed/updates Location: Location Patient identity verified. CC: Chief complaint Duration: Duration Severity (1-10): Severity 1-10 Virtual Examination: Video quality: Video quality Patient-assisted examination: Patient-assisted examination Areas visualized: Areas visualized Findings: Findings Limitations: Limitations Patient-Submitted Images (if any): Photos received: Photos received Quality: Quality Findings from images: Findings from images Assessment: Preliminary diagnosis: Preliminary diagnosis Confidence level: Confidence level Recommendations: Recommendations In-person examination needed: In-person examination needed Prescription provided: Prescription or none Home care instructions: Home care instructions Referral: Referral details Watch and wait: Watch and wait Patient education: Education/instructions provided Follow-Up Plan: Schedule in-person visit: Schedule in-person visit Follow-up teledentistry visit: Follow-up teledentistry visit Contact if symptoms worsen. PRN. Documentation: Documentation Visit recorded: Visit recorded Consent for teledentistry on file. Billing Notes: Service provided via real-time video consultation. Duration: Duration NV: Next visit
What documentation is required for D9985?
A defensible synchronous teledentistry note has to prove three things: (1) a real-time audiovisual encounter occurred, (2) the same standard of care as an in-person visit was met, and (3) the underlying clinical service (D0140, D9310, etc.) was actually performed. The required elements:
- Date, start time, and duration of the live encounter — payers and state boards expect a clear time stamp; some Medicaid programs require start and end times
- Modality statement — explicit language that the encounter was synchronous, real-time, two-way audio and video. "Telephone call" or "video message" is not sufficient.
- Platform used — the HIPAA-compliant platform name (e.g., Doxy.me, Zoom for Healthcare, the practice's PMS-integrated portal). Note whether business associate agreements are in place.
- Patient identity verification — how the patient was identified at the start of the encounter (DOB, address, photo ID held to camera). State boards explicitly cite identity verification as a teledentistry requirement.
- Patient location at time of service — city and state at minimum. The dentist must be licensed in the state where the patient is physically located, and most carriers will deny if the location field is blank.
- Provider location and credentials — dentist's name, license number, and state of licensure. If a remote facilitator (hygienist, assistant, another provider) is on-site with the patient, document their name and role.
- Informed consent for teledentistry — that consent for the modality was obtained and is on file, including the limitations of a remote exam, privacy/security considerations, and the patient's right to request an in-person visit.
- Connection quality and any technical limitations — "video clear, audio intermittent for 2 minutes, otherwise stable." If technology limited the assessment, that limitation must be in the chart and tied to the clinical conclusions.
- Chief complaint and HPI — the same depth as an in-person problem-focused visit
- Patient-assisted examination — what the patient (or on-site facilitator) was directed to do (e.g., "patient instructed to open wide, retract cheek with finger, angle phone toward upper right; visualized tooth #3 and surrounding gingiva")
- Areas visualized and findings — what was actually seen on video, with anatomic specificity
- Patient-submitted images — if photos or radiographs were reviewed during the visit, list each, comment on diagnostic quality, and tie findings to the diagnosis (these may be billed under their own image codes when applicable, e.g., D0350 oral/facial photo)
- Limitations of the virtual exam — explicit statement of what could not be assessed (percussion, EPT, palpation depth, mobility, periodontal probing) and how that affected the differential
- Preliminary diagnosis with confidence level — "preliminary diagnosis: symptomatic irreversible pulpitis #30, moderate confidence pending in-person percussion and cold testing"
- Recommendations — including whether an in-person follow-up is needed and the urgency
- Prescriptions — drug, dose, sig, quantity, refills; for controlled substances, document compliance with the Ryan Haight Act and state PDMP/e-prescribing rules
- Patient education and home-care instructions — what was reviewed verbally during the encounter
- Underlying clinical code(s) reported — explicitly note in the chart that the encounter is being reported with D0140 / D9310 / etc. and the teledentistry code, so an auditor can reconcile the claim to the note
- Provider signature — and any on-site facilitator's signature/initials
- Whether the encounter was recorded — most state boards permit but do not require recording; if recorded, document where it is stored and the retention policy
Several state Medicaid programs and dental boards require additional language: that the encounter "met the same standard of care as an in-person visit," that the patient was offered an in-person alternative, and that any prescription written followed the same standard as in person.
Why does D9985 get denied?
The most common reasons synchronous teledentistry claims are denied, downgraded, or audited:
- Reported without an underlying clinical code — the teledentistry code is adjunctive; submitted alone it has nothing to attach to and denies on nearly every plan
- Audio-only encounter billed as synchronous — synchronous requires real-time audiovisual; phone-only encounters are denied as not meeting the modality definition
- Asynchronous encounter miscoded as synchronous — store-and-forward review of photos/records with a delayed written response is D9996 (asynchronous), not synchronous; mismatched modality and chart language is a frequent audit finding
- Patient location missing or out-of-state without licensure — the dentist must be licensed in the patient's state; missing location or a state where the dentist is unlicensed is grounds for denial and a state board complaint
- No consent for teledentistry on file — most state boards and Medicaid plans require documented consent specific to the teledentistry modality
- Inadequate documentation of the encounter — missing platform, missing time stamps, missing identity verification, or no statement that real-time audiovisual technology was used
- Limitations not addressed — the note doesn't acknowledge what couldn't be assessed virtually, but the diagnosis reads as definitive — auditors view this as a standard-of-care concern
- Same-day evaluation conflict — billed alongside a same-day in-person evaluation by the same provider; only one eval pays per DOS
- Frequency exceeded on the underlying code — patient already used the combined eval allowance; the teledentistry visit denies even though the modality coverage exists
- Prescription without exam-equivalent assessment — controlled substance Rx via teledentistry without compliance with Ryan Haight requirements (or state PDMP rules) is flagged for both denial and DEA scrutiny
- Recording issues — a few state Medicaid programs require either a recording or contemporaneous documentation sufficient to reconstruct the encounter; absence of either has triggered recoupment
- Place-of-service / claim-form mismatch — on medical-style claims, telehealth POS codes (02, 10) are required; dental claims use carrier-specific indicators — submitting on the wrong form or with the wrong indicator is a clean-claim failure
What do practices ask about D9985?
What's the difference between D9985 / D9995 (synchronous) and D9996 (asynchronous) teledentistry?+
Synchronous teledentistry is a real-time, two-way audiovisual encounter — the dentist and patient are connected live at the same time. Asynchronous (store-and-forward, D9996) is review of patient-submitted photos, radiographs, or records at a different time, with a written response sent later. The modality code follows the actual interaction: live video = synchronous; offline review = asynchronous. Note that CDT teledentistry coding has shifted across cycles — historically D9995 reported synchronous teledentistry and many carriers and Medicaid manuals still reference D9995 specifically. Verify which code your patient's plan accepts for the current date of service.
Can a teledentistry code be billed by itself?+
No. The teledentistry code is adjunctive and reports the modality of delivery, not a clinical service. It must be billed alongside an underlying clinical code that describes what was actually done — most commonly D0140 (limited oral evaluation), D9310 (consultation), or D0170 (re-evaluation of a known problem). Reported alone, it denies on virtually every plan because there is no service for the modality code to attach to.
Does an audio-only phone call count as synchronous teledentistry?+
Generally no on dental plans. Synchronous teledentistry requires real-time audiovisual technology — live video and audio together. Most carriers and state Medicaid programs explicitly exclude audio-only encounters from synchronous teledentistry coverage on the dental side, even where some medical plans recognize audio-only telehealth. A phone-only encounter should be documented in the chart but typically is not separately billable as teledentistry.
Which state's licensure governs a teledentistry encounter?+
The state where the patient is physically located at the time of the visit. The dentist must hold an active license in the patient's state, not just in the dentist's state of residence or practice. This is the most common audit and disciplinary issue for cross-state teledentistry — claims are denied and state boards have opened investigations when a dentist treated a patient in a state where the dentist was not licensed. Always document the patient's location in the chart and verify licensure before connecting.
Is informed consent for teledentistry different from regular consent?+
Yes — most state dental boards and many Medicaid programs require a teledentistry-specific consent that addresses the modality, its limitations (what can't be assessed virtually), privacy/security considerations of the platform, and the patient's right to request an in-person visit instead. General treatment consent is not a substitute. The consent should be on file before the encounter starts and re-confirmed verbally at the start of the visit.
Can I prescribe via synchronous teledentistry?+
Yes for non-controlled substances when a focused exam-equivalent assessment occurred during the live visit and the standard of care is met. For controlled substances, the federal Ryan Haight Act and state-specific telehealth/PDMP rules apply — and there are post-pandemic transitional rules in flux. The safe practice is to limit teledentistry prescribing to short courses of non-controlled medications, document the assessment that supports the prescription, and use an in-person follow-up before any controlled-substance prescribing where indicated.
What if the platform connection drops mid-visit?+
Document the technical limitation in the chart with time stamps and whether the encounter was completed, partially completed, or rescheduled. If the live audiovisual portion was not actually completed, the visit does not meet the synchronous teledentistry definition and the modality code should not be reported. Either reconnect and complete the encounter, convert to an in-person visit, or document a non-billable attempt. Some state Medicaid programs require explicit notation of any technical failure that affected the assessment.