D0120 - Periodic Evaluation
Periodic oral evaluation for established patient.
- Procedure Code
- D0120
- Category
- Diagnostic
- Reference Fee
- $100
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental National / PPO Standard
- Frequency Limitation
- 2 per benefit year (1 every 6 consecutive rolling months) (ROLLING_MONTHS)
- Age Limitation
- Covered for all ages. Typically billed after age 3 (replaces infant evaluation D0145).
Required Claim Attachments & Pre-Submission Checklist
- Updated medical and dental history documented in patient chart
- Clinical examination findings recorded by licensed dentist
- Treatment plan updates documented if pathology detected
- Date of previous evaluation verified to avoid frequency denial
Bill When (Allowable Clinical Criteria)
- Patient is established and returning for a routine recall checkup
- Dentist reviews updated medical/dental history and performs a complete oral evaluation
- Patient has a comprehensive evaluation (D0150) already on file
Restrictions & Clinical Exclusions
- Do NOT bill on the same date of service as comprehensive exam D0150 or limited exam D0140
- Do NOT bill if dentist was not present (hygienist assessment alone does not qualify)
- Do NOT bill for new patients (use D0150 instead)
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Frequency limit reached (less than 6 months since last evaluation) | Verify benefit year calculation. If patient switched employers, submit prior carrier termination date. |
| CO-16 | Mutually exclusive with other exam billed on same date | Void duplicate evaluation code and submit corrected claim with single exam code. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| Z01.20 | Encounter for dental examination and cleaning without abnormal findings | Encounter for other special examination without diagnosis | Yes (Primary) | BOTH | periodic oral evaluation – established patient indicated for Encounter for dental examination and cleaning without abnormal findings |
| Z01.21 | Encounter for dental examination and cleaning with abnormal findings | Encounter for other special examination without diagnosis | Secondary | BOTH | periodic oral evaluation – established patient indicated for Encounter for dental examination and cleaning with abnormal findings |
| Z13.84 | Encounter screening for dental disorders | Encounter for screening for other diseases and disorders | Secondary | BOTH | periodic oral evaluation – established patient indicated for Encounter screening for dental disorders |
| Z86.16 | Personal History of COVID-19 | Personal history of certain other diseases | Secondary | BOTH | periodic oral evaluation – established patient indicated for Personal History of COVID-19 |
| U07.1 | COVID-19 | Emergency use of U07 | Secondary | BOTH | periodic oral evaluation – established patient indicated for COVID-19 |