New Patient Visit Workflow Template

New patient examination.

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

Chief complaint: Chief complaint

Diagnostic support: Radiographs/photos ordered, reviewed, interpreted, and findings
Diagnosis/prognosis by tooth/area: Specific diagnosis and prognosis
Treatment options/no-treatment consequences: Options, alternatives, refusal/no-treatment risks, patient questions

Clinical examination: Clinical examination
Extraoral: Extraoral findings
TMJ evaluation: TMJ evaluation
Intraoral: Intraoral findings
Soft tissue: Soft tissue
Periodontal: Periodontal
Hard tissue: Hard tissue
Occlusion: Occlusion

Radiographs: Radiographs taken/reviewed and findings

Findings: Findings

Treatment plan discussed: Plan/options reviewed.
Options presented.
Questions answered.

NV: Next visit

Documentation requirements

The new-patient visit is among the most heavily audited appointment types in dentistry — it's the encounter that anchors every future code billed for that patient. A defensible note threads the documentation requirements of each CDT code billed on the date of service, not just the comp exam.

• Medical and dental history — fully reviewed and recorded for the first time, including current medications, allergies, ASA classification, systemic conditions (diabetes, hypertension, anti-resorptive therapy, immunosuppression, head/neck radiation history), tobacco/alcohol/recreational drug use, and pertinent family history. "No changes" is not appropriate on a new-patient visit because there's no prior record to compare against.
• Vitals — BP and pulse. Required by many state boards on comprehensive evaluations and by every sedation-capable practice. A blood pressure outside accepted ranges (commonly >180/110) is a documented reason to defer elective treatment.
• Chief complaint — in the patient's own words and in quotes when possible. "Here for a check-up, no specific concerns" still counts and should be recorded verbatim.
• Extraoral exam — head, neck, lymph nodes, TMJ (range of motion, clicking, deviation), masticatory muscles, skin. Patient-specific findings, not a default "WNL."
• Intraoral soft tissue exam — lips, labial and buccal mucosa, tongue (dorsal, ventral, lateral borders), floor of mouth, hard and soft palate, oropharynx, gingiva.
• Oral cancer screening — explicitly documented as a discrete line item, not buried inside "soft tissue WNL." Post-CDT-2021 this is a mandatory descriptor element of D0150.
• Hard tissue / dentition charting — teeth present and absent by number, existing restorations and their integrity, caries by tooth and surface, fractures, wear patterns, prostheses. The new-patient visit is when this baseline is built.
• Periodontal screening or full charting — at minimum a PSR; full 6-point charting if PSR triggers it or if perio risk factors are present. The output of this step decides the hygiene code.
• Occlusion — Angle classification, overjet/overbite, wear patterns, parafunction, signs of bruxism.
• Imaging — exposures taken today (FMX vs pano + BWX vs CBCT), diagnostic quality statement, and a one-line interpretation. Images are billed under their own codes (D0210/D0274/D0330/D0350) and are not bundled into D0150. State the rationale when ordering pano + BWX over an FMX (gagger, mixed dentition, edentulous, ortho/implant workup).
• Intraoral photos — note taken/reviewed if D0350 is billed. Most carriers expect a clinical purpose ("baseline photographic record for treatment planning and case discussion"), not just "photos taken."
• Diagnoses — caries by tooth and surface, perio stage and grade, occlusal/TMJ findings, mucosal findings. Specific, by tooth or area.
• Risk assessment — caries risk (low/moderate/high), periodontal risk, oral cancer risk. Drives recall interval and adjunctive recommendations.
• Treatment plan — sequenced, with options, alternatives, and the patient's choice noted. This is the deliverable that distinguishes D0150 from D0120.
• Hygiene code rationale — if D1110 is billed, document that perio screening was consistent with health/gingivitis. If D4341/D4342 is performed, document the staging/grading and the specific teeth treated. If hygiene is deferred, write why and what's scheduled.
• PARQ / informed consent — procedures, alternatives, risks, questions answered. Especially when the new-patient visit also includes prophy or any other treatment.
• Provider signature and operator initials — full provider signature on the note, plus initials for any auxiliary (RDH, RDA) who performed a discrete procedure (prophy, photos, radiographs).

The standard "amnesia test" applies with extra force on a new-patient visit: a third party reading the note must be able to reconstruct who the patient is, what was found, what's planned, and why. Auto-populated default-normal templating ("every soft tissue WNL, every tooth normal") on a brand-new patient is the single most common audit red flag.

Common denial reasons

Denials on the new-patient visit usually trace to a specific code on the claim, not to the workflow as a whole. The most common patterns:

• D0150 frequency violation — patient had a D0150 (or any pooled exam) with another in-network provider within the carrier's lookback window. The carrier denies the D0150 outright or downgrades to D0120.
• D0210 frequency violation — prior FMX or pano within 3–5 years. Common for transfer patients whose prior office's imaging is in the carrier's history but not the new chart.
• D0274 + D0210 same DOS — bitewings billed alongside an FMX. The FMX descriptor includes bitewings; only the FMX pays.
• D0350 not a covered benefit — many PPO and almost all Medicaid plans treat intraoral photos as a non-billable record-keeping cost. Common but expected; offices submit for documentation value, not reimbursement.
• D1110 billed when SRP was clinically appropriate — auditor reviews probing depths and bone levels and concludes the visit should have been D4341/D4342. Recoupment risk; patient may be told they "weren't actually treated for their gum disease."
• D4341/D4342 billed without supporting documentation — claim denied for missing 6-point probing, radiographic evidence of bone loss, or perio staging/grading. New-patient SRPs are flagged at higher rates than recall SRPs because the carrier has no perio history on file.
• D4341 + D1110 same DOS — mutually exclusive; only one hygiene code pays per quadrant per day.
• Default-normal templating — every soft-tissue site "WNL," every tooth "normal," same paragraph as the last 50 patients. New-patient visits are the most common context for this audit flag because the note is built fastest from a stock template.
• Missing oral cancer screening line — D0150 downgraded to D0120 because the screening isn't documented as a discrete element.
• No treatment plan — D0150 downgraded because the note doesn't include sequenced recommendations. "Comprehensive" requires comprehensive planning.
• Missing chief complaint or PARQ — frequent on routine new-patient visits where the front desk script ("here for a check-up") wasn't transcribed into the chart.
• Provider mismatch on imaging — radiographs taken by an unlicensed assistant in a state requiring DAANCE/CRDA certification. State board issue more than a payer issue, but it does surface in audits.

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