this is what the provider documented “NP exam, pano, NV refer to pedo for space loss, decay, high anxiety” and charged for D0150 and D0330. is this sufficient documentation? I’m fairly new to dental and just wanted to clarify.
No this is not sufficient documentation for a D0150. A comprehensive exam must have documentation in the chart showing oral cancer screening, recording of patients dental and medical history, a general health assessment. Evaluation of dental caries, missing or erupted teeth, restorations, perio condition. It is basically a full assessment of the patients physical and oral health and must be clearly documented in the chart.