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Insurance Management is Easy if You Start with Evaluation by Tom M. Limoli, Jr.

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It is imperative that dental professionals, both clinical and administrative, have a sequential process that the entire team can follow. All too often I find offices that have slipped out of focus by thinking they have all the knowledge they need when it comes to the patient's benefit plan. Everyone has a role in both the business office as well as the operatory. It should go without saying that harmony, growth and overall profitability are more easily achieved when everyone is singing from the same songbook.

My father, Tom Limoli, DDS (1924-2006), founded Atlanta Dental Consultants with my mother, Christel, in the late 1970s. One of the business principles we teach is called the Trilogy of Reimbursement. Put simply, it's based on the three progressive, interdependent steps of diagnosis, treatment and documentation.

In other words—diagnose based on documented findings, treat based on the diagnosis and patient response, then bill and code for exactly what was performed. Your narrative report and supplemental information fall right into place because they are based on your clinical diagnostic and treatment documentation. Don't forget to note how the patient responded, not only to the procedure, but also the overall outcome.

It sounds simple enough. But if the business team is not coding and billing for exactly what the clinical team performed, you have the beginning of a treacherous downward spiral that will manifest itself in lost revenue, wasted time and unnecessary stress on both the dental office and the doctor's personal paycheck. As tempting as it may be to add a fourth step called, "What should we tell the insurance company?" don't do it. The patient deserves for you to tell the insurance company the truth. Anything other than the truth treads the path of insurance fraud.



Evaluation vs. examination
Let's briefly review the differences between evaluation and examination. This way you will be better prepared to appropriately deal with its reimbursement implications.

In the old days, there were three exam codes. They were known simply as periodic, initial and emergency. The periodic exam was when a doctor updated the patient's clinical status and began the next series in the sequential order of care. The initial exam was when a doctor first saw the patient and established him or her as a patient of record. The emergency exam was when the patient showed up at the office—most often in pain—and interrupted the daily schedule.

Next, examination was changed to evaluation.

Examination is simply defined as the gathering of clinical data. In the old days, the doctor gathered all the data and established a professional opinion and treatment plan to assist the patient in becoming as healthy as possible. The evaluation component was assumed, since the doctor was gathering the data. Then the doctors became less involved. The gathering of basic clinical data was delegated to other members of the doctor's clinical team.

Evaluation is essentially the interpretation of examination findings. Earlier versions of current dental terminology (CDT) specified that the collection and recording of some data and components of the dental examination may be delegated. But the evaluation, diagnosis and treatment planning are the responsibility of a licensed dentist.

In summary, examination is the gathering of data. Evaluation is the interpretation of that examination-gathered data. Evaluation and diagnosis can only be done by the dentist. In short, if the doctor's hands and/or eyes are not in the patient's mouth, an evaluation cannot be claimed or billed. Enough said.

So when do you use which evaluation code? Let's focus this discussion on the basics.

Limited Oral Evaluation is problem- focused and replaces what was previously known as the emergency exam. "Problem-focused" means that the doctor is diagnosing a patient's specific oral-health concern and is not evaluating all the dental systems.

Periodic Oral Evaluation is a complete update to previously existing data that has been actively maintained by the dentist of record. In other words, it covers what health-specific data has changed or been modified since the patient's previous evaluation.

Detailed and Extensive Oral Evaluation. This problem-focused report occurs when the doctor finds something in a previously completed comprehensive evaluation that warrants additional scrutiny. The specific diagnostic regimen and its findings are most often separately tracked and documented from the baseline data established in the previous comprehensive evaluation.

Comprehensive Oral Evaluation replaces what was previously known as the initial exam. This is when the doctor documents and confirms the patient's original baseline data. The establishment of the patient's periodontal health status is part of a comprehensive evaluation. Updating the patient's periodontal health status falls within the confines of a periodic evaluation. The initiation of the patient's complete clinical chart will most often begin at this visit.

Comprehensive Periodontal Evaluation is used primarily by periodontists for a referred patient from a general dentist. The same dentist in the same treatment series should not report this in addition to a comprehensive oral evaluation. This code is not intended for use as a separate code for periodontal charting. Almost all benefit plans process both procedures with the same payment criteria, limitations and fee data.

What about the patient's first encounter with the office?
If the patient's original diagnostic encounter with the office was for the immediate relief of pain or a second opinion, that initial visit would most likely be a limited oral evaluation or office visit because not all the dental systems would have been evaluated. Initial patient encounters will most often be either a comprehensive or limited oral evaluation based on the extent of data collection and subsequent diagnosis.

So who pays for what evaluation and when?
Comprehensive oral evaluation will most often occur once per treatment history of an individual patient. An exception occurs when the patient has been absent from the practice for a prolonged period of time. Most plans consider the exclusionary period to be somewhere between five and seven years. When will they benefit the replacement of a crown? An exception also occurs when the patient has undergone a major change in health status.

Since plan reimbursement is generated based on the terms of the patient's benefit contract, it's important to remember that almost all benefit plans simply reimburse for only two evaluations per benefit year. Which two specific evaluations do they pay for? Which ones did the doctor do? As this concerns your sequential order of diagnostic documentation—your clinical record must do all three:
  • Confirm what you are looking for.
  • Confirm what you are looking at.
  • Confirm what you found.
With proper education, you are better prepared to tell the patient and the bill-payer what you are going to do about what you found. You are now better prepared to code for exactly what completed procedure you performed.



Tom Limoli, Jr. is an expert on proper coding and administration of benefit claims. He received his Bachelor of Science in Criminal Justice from Valdosta State University. Since his work with the U.S. Treasury Department's Federal Law Enforcement Training Center, Limoli has actively investigated fraudulent claims for the insurance industry, as well as numerous other third-party fiduciaries. He is a licensed private investigator and currently serves as president of Limoli & Associates LLC. His professional affiliations include the National Association of Dental Plans, American Association of Dental Consultants, the American Association of Dental Editors, the National Speakers Association, and he is past president of the Academy of Dental Management Consultants. He can be reached at www.LIMOLI.com.


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