D0160 - Extensive Eval
Detailed, extensive problem-focused evaluation by report.
- Procedure Code
- D0160
- Clinical Category
- Diagnostic
- Primary ICD-10 Justification
- See mapped diagnoses below
- Reference Fee & Claim Types
- DENTAL
Insurance Verification Benchmarks & Billing Guidelines
Payer policy benchmarks, pre-submission attachment requirements, and denial prevention rules for D0160.
- Frequency Limitation
- Subject to group/individual contract frequency limitations (none)
Required Claim Attachments & Pre-Submission Checklist
- Standard ADA claim form with CDT procedure code and date of service
Bill When (Allowable Clinical Criteria)
- Benefits are limited to one per dentist/dental office. Code Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi- disciplinary consultation, sleep related breathing disorders, etc.
Restrictions & Clinical Exclusions
- Infection control is included in the fee for the dental services provided. Separate fees are not billable to the patient.
- Oral evaluations are only a benefit when the elements included in the descriptor are completed.
- All services and treatment provided remotely via tele-health modalities, be they synchronous or asynchronous, must be performed by a licensed dentist or their supervised staff, acting within the scope of applicable law. Services and treatment delivered virtually are only a benefit when the elements included in the descriptor of the CDT procedure code are completed and only when they meet generally accepted clinical guidelines.
- Benefits for restorations for altering occlusion, adjusting vertical dimension, replacing tooth structure lost by attrition, erosion, abrasion, abfraction, corrosion, TMD, or for periodontal, orthodontic, or other splinting are denied, unless covered by group contract.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10-CM Justification & Crosswalk Mappings for D0160 (0)
Click any ICD-10-CM diagnosis code below to inspect its reverse procedure mappings and differential coding guide.
No direct ICD-10 mappings recorded for D0160.
Frequently Asked Questions — D0160 (Extensive Eval)
Quick answers for dental billers and treatment coordinators submitting claims for D0160.
What ICD-10 diagnosis codes link to dental procedure D0160?▾
Currently no specific ICD-10 crosswalk mappings recorded for CDT D0160.
Can CDT code D0160 be billed to medical insurance?▾
Billing CDT D0160 (Extensive Eval) to medical insurance depends on the underlying clinical necessity and trauma/pathology documentation. Supported claim types across linked diagnoses: DENTAL.
What attachments and documentation are required for billing CDT D0160?▾
Required claim attachments for CDT D0160 (Extensive Eval) include: Standard ADA claim form with CDT procedure code and date of service.
What is the insurance frequency limitation for CDT D0160?▾
Standard commercial insurance frequency for D0160: Subject to group/individual contract frequency limitations (none).
What are common insurance denial reasons and appeal tips for CDT D0160?▾
Denial Code CO-119 (Benefit maximum or frequency limitation exceeded for procedure): Overturn appeal strategy - Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria.