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	Name	Appointment	Patient #	Date	Clinic	Procedures	Evaluation	Action
	Peter Pan	26560783	p1878596		Wonderland	D0150, D0274, D0220,D0230, D0230, D0230, D2391,D2392, D2392,D2331, D1110,D1206	Needs Correction
Procedure Notes: Procedure Codes: D0120, D1110, D1206, D0603, D0274, D0220, D0230, D2392 Procedure Note Reason for visit: Exam and cleaning Chief Complaint: None Accompanying Adult's Relationship to Patient: Father Patient Identification: Parent/guardian confirmed the patient's identity using name and date of birth. Interpreter Requirement: No interpreter was needed or present. Medical History Review: Reviewed with the parent/guardian and confirmed to be current and accurate. Premedication: Not required. Examining Dentist: Dr. Dolittle Oral Cancer Screening: Within Normal Limits (WNL) Intraoral Soft Tissue Exam: WNL Extraoral Exam: WNL The dentition was examined and findings including existing restorations, dental conditions, and caries were charted in the dental record. Occlusion: Normal Dental Habits: No detrimental oral habits noted Oral Hygiene: Presence of visible plaque observed Caries Risk Assessment: ADA Caries Risk Assessment completed and reviewed. Overall Risk Level: High Gingivitis: Generalized Prophylaxis: Completed with a prophy cup due to medical necessity for disease prevention. All contacts were flossed. Fluoride gel was applied to support enamel and prevent caries. Oral Hygiene Instructions (OHI): Provided, including advice to use a soft-bristled toothbrush, floss daily, maintain routine hygiene visits, and reduce sugar intake for better oral health. 4 bitewings (BWX) taken to assess proximal surfaces not visible clinically 2 periapicals (PA) taken for evaluation of areas with a history of pain, sensitivity, or trauma X-rays Taken By: John Watson Intraoral Photos: Not taken Treatment Discussion: Explained proposed treatments, including benefits and potential risks, as well as alternative options and associated outcomes. The parent/guardian was given the opportunity to ask questions. Orthodontic Referral: Not recommended Patient Behavior: Cooperative Dental Hygienist (RDH): Julie Watson Dental Assistant: Sally Watson Next Visit X-rays Requested: 4 BWX for interproximal surface evaluation 2 PA for assessing bone levels and interproximal surfaces Next Visit Plan: Operative appointment with nitrous oxide sedation AI Evaluation: Needs Correction Identified Issues: Procedure code D1206 was billed for fluoride varnish, while the clinical note indicates that fluoride gel was applied. This discrepancy could present billing compliance issues. Suggested Fix: Update the documentation to reflect that fluoride varnish was used if that was the case, or change the billed procedure code to D1208 if fluoride gel was actually applied. All other procedures are appropriately documented and compliant.
	Snow White	26424090	p2435682		Treasure Island	D0150, D0274, D0220,D0230, D0230,D0230, D2391,D2392, D2392,D2331, D1110,D1206	Correct
Procedure Notes: Procedure Codes: D0150, D0210, D1110, D1208, D5226 Procedure Note Visit Purpose: Comprehensive exam and cleaning Chief Complaint: None Patient Identification: ID checked; patient confirmed name and date of birth. Interpreter Needed: No Medical History: Reviewed with patient and confirmed accurate. Premedication: Not required Blood Pressure: 120/80 Pulse: 72 bpm Exam Performed By: Dr. J Jules Oral Cancer Screening: Within Normal Limits (WNL) Intraoral Soft Tissue Exam: WNL Extraoral Exam: WNL The patient's dentition was examined, including restorations, existing conditions, and any carious lesions, and documented in the tooth chart. Social Habits Affecting Oral Health: None reported Last Cleaning: Not documented Oral Hygiene Assessment: Visible plaque observed Full Mouth Periodontal Probing: Completed Gingivitis: Generalized Periodontal Disease: Generalized Caries Risk Assessment: Not completed Caries Risk Level: Not assessed Prophylaxis: Completed due to medical necessity to prevent disease. Full-mouth ultrasonic and hand scaling performed, followed by polishing and flossing. Fluoride Treatment: Gel applied to support enamel and reduce caries risk. Oral Hygiene Instructions (OHI): Provided—recommended use of a soft-bristled toothbrush, daily flossing, routine hygiene appointments, and dietary guidance to limit sugar intake. Radiographs: Full Mouth X-rays (FMX) taken to assess bone levels, interproximal surfaces, and periapical areas Taken by: Jonathan Intraoral Photos: None taken Treatment Discussion: All proposed treatment options, potential benefits, risks, and alternatives (including no treatment) were reviewed. Patient was given the opportunity to ask questions. Dental Hygienist (RDH): R. Ricks Assistant: R. Rolands Patient Comment: Patient reported, "feels like a piece of a filling came out," pointing to tooth #5. Intraoral photo confirmed the MO composite on #5 was intact. Patient agreed that no treatment is needed at this time. X-rays Requested for Next Recall: 4 bitewings (BWX) for interproximal evaluation 2 periapicals (PA) for assessing bone levels and hidden interproximal surfaces Next Visit Plan: Mandibular flexible partial AI Evaluation: Correct Identified Issues: No inconsistencies found. All billed procedure codes (D0150, D0210, D1110, D1208, D5226) are appropriately supported by the clinical documentation. There were no improperly billed or unbilled procedures, and state-specific documentation requirements are met. The treatment-planned procedure was correctly omitted from billing Suggested Fix: No corrections needed.
	Capt. Hook	26625330	z2134114		Treasure Island	D2930, D2930, D9230	Needs Correction
Procedure Notes: Reason for Visit: Treatment Chief Complaint: No complaints reported Accompanying Adult: Mother Parent/Guardian Present During Treatment: Yes Patient Identification: Confirmed via parent/guardian verification of name and date of birth and by checking ID Interpreter Required: No Medical History: Reviewed and confirmed as current and accurate with parent/guardian Premedication: Not required Consent and Treatment Discussion: The dentist discussed the proposed treatment, including potential benefits, risks, and available alternatives (including no treatment), with the parent/guardian. Written consent was obtained, and an opportunity to ask questions was provided. Treatment Verification: Dental record reviewed to ensure the correct procedure and site were identified prior to initiating treatment. Topical Anesthetic: Not used Local Anesthesia: Not administered Treatment Narrative: The patient arrived for scheduled placement of crowns and strip crown fillings. The parent was informed that the patient would need to remain still for the duration of the procedure. The dental assistant noted that the patient was restless and had difficulty remaining still even prior to starting treatment. This behavior was consistent with prior visit records indicating challenges with cooperation. Isodry was placed successfully with patient cooperation. However, the patient continued to move excessively. Upon attempted administration of local anesthesia, the patient became increasingly uncooperative—raising hands, making sudden movements, and exhibiting behavior that posed safety concerns. Due to the ongoing disruptive behavior and safety risks, it was determined that further treatment could not continue and that sedation would be recommended for future appointments. The guardian understood and agreed with the recommendation. AI Evaluation: Evaluation: Needs Correction Identified Issues: Code D9230 (nitrous oxide/analgesia) was billed, but the procedure note lacks required documentation to support its use. There is no mention of nasal hood placement, oxygen or nitrous oxide delivery, duration of administration, or confirmation of the procedure being carried out. Suggested Fix: Update the Procedure Note or Group Note to include: Placement of nasal hood Start and end times or duration of nitrous oxide delivery (e.g., 3 minutes) Oxygen flow rate and nitrous mix Confirmation that the procedure was completed as intended This added detail is necessary to comply with billing criteria for D9230. No other documentation or billing issues were found.
	Little Mermaid	265224402	L2134123		Treasure Island	D0150, D1120, D1206, D0120	Needs Correction
Procedure Notes: Comprehensive oral evaluation - new or established patient; prophylaxis - child; topical application of fluoride varnish; periodic oral evaluation - established patient AI Evaluation: Evaluation: Needs Correction Identified Issues: 1. D0150: Criteria not met – patient has a D0150 recorded in the ProcedureHistory on the same day (2025-03-11) rather than a history of no exam or exam 3+ years ago. 2. All billed procedure codes (D0150, D1120, D1206, D0120) lack any supporting documentation in the ProcedureNote or GroupNote. 3. SignedByValidProvider is false and no GroupNote exists, thereby violating the signature requirement for chart notes. 4. The appointment status is marked as NO SHOW despite procedures being billed. Suggested Fix: 1. For D0150, verify if a comprehensive exam is appropriate – if a prior D0150 was done on the same day, remove or adjust the billing since it does not meet the 3-year rule. 2. Add detailed supporting documentation for each billed procedure in the ProcedureNote or GroupNote, ensuring that each entry clearly supports the corresponding procedure code. 3. Ensure that a valid provider signs the documentation. Correct the signature status or have a GroupNote that fulfills the signature requirement. 4. Reconcile the appointment status (NO SHOW) with billed procedures – update status to reflect completed procedures if applicable or remove improperly billed codes.
	Sleeping Beauty	26418681	w2418640		Neverland	D1120, D1206, D0150, D1310, D1330	Needs Correction
Procedure Notes: Reason for today’s visit: cleaning Patient’s Chief Complaint: no questions Relationship of the adult who accompanied the patient to the appointment: Mother The patient has been identified by: Parent/ guardian confirmed correct patient is in the chair by name and date of birth Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with parent/guardian. Premedication, if required has been taken as directed: Not Required No X-Rays Taken due to patient’s age PIntraoral Photos: No Oral evaluation performed by: Dr. Merlin Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Dental oral habits: none Oral hygiene assessment revealed: Visible plaque,, Fair OH ADA Caries Risk Assessment completed and reviewed: Yes Overall assessment of dental caries risk: High Risk Manual Toothbrush Prophylaxis completed because it was medically necessary in order to prevent dental disease. Flossed all contacts. Fluoride varnish given to prevent caries and support tooth structure OHI was given including recommending brushing 2x daily by caregiver and stressed importance of regular hygiene visits. Discussed diet relating to oral health, limiting of sweets and juices and advised not to give bottle at night and to only give water after brushing. The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. RDH: Dr Daisy Assistant: Arthur Behavior: Age appropriate anxiety NV: 6 month recall —--- Patient’s Chief Complaint: no questions Relationship of the adult who accompanied the patient to the appointment: Mother . The patient has been identified by: Parent/ guardian confirmed correct patient is in the chair by name and date of birth Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with parent/guardian. Premedication, if required has been taken as directed: Not Required No X-Rays Taken due to patient’s age Intraoral Photos: No Oral evaluation performed by: Dr Merlin Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Dental oral habits: none Oral hygiene assessment revealed: Visible plaque,, Fair OH ADA Caries Risk Assessment completed and reviewed: Yes Overall assessment of dental caries risk: High Risk Manual Toothbrush Prophylaxis completed because it was medically necessary in order to prevent dental disease. Flossed all contacts. Fluoride varnish given to prevent caries and support tooth structure OHI was given including recommending brushing 2x daily by caregiver and stressed importance of regular hygiene visits. Discussed diet relating to oral health, limiting of sweets and juices and advised not to give bottle at night and to only give water after brushing. The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. RDH: Dr Daisy Assistant: Arthur Behavior: Age appropriate anxiety NV: 6 month recall Patient’s Chief Complaint: no questions Relationship of the adult who accompanied the patient to the appointment: Mother . The patient has been identified by: Parent/ guardian confirmed correct patient is in the chair by name and date of birth Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with parent/guardian. Premedication, if required has been taken as directed: Not Required No X-Rays Taken due to patient’s age Intraoral Photos: No Oral evaluation performed by: Dr. Haein Kil Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Dental oral habits: none Oral hygiene assessment revealed: Visible plaque,, Fair OH ADA Caries Risk Assessment completed and reviewed: Yes Overall assessment of dental caries risk: High Risk Manual Toothbrush Prophylaxis completed because it was medically necessary in order to prevent dental disease. Flossed all contacts. Fluoride varnish given to prevent caries and support tooth structure OHI was given including recommending brushing 2x daily by caregiver and stressed importance of regular hygiene visits. Discussed diet relating to oral health, limiting of sweets and juices and advised not to give bottle at night and to only give water after brushing. The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. RDH: Dr Daisy Assistant: Arthur Behavior: Age appropriate anxiety Note:Nutritional counseling was recommended to improve oral health and prevent further dental issues. Discussed the relationship between diet and oral health. Explained how specific foods and beverages can affect dental health. Encouraged a balanced diet rich in fruits, vegetables, and whole grains. Advised reducing the intake of sugary snacks and acidic beverages. Recommended drinking water instead of soda or juice. Reinforced the importance of regular brushing and flossing, especially after consuming sugary or acidic foods. Suggested using fluoride toothpaste and rinsing with fluoride mouthwash. Provided tips for reducing sugar cravings, such as opting for healthier snacks. The patient/guardian was receptive to the counseling and expressed willingness to make dietary changes. Will monitor the patient’s oral health at subsequent visits to evaluate the effectiveness of the nutritional counseling. hygiene instructions was provided to the patient/ guardian to improve and promote good oral health. Patient/ guardian was instructed to brush twice daily, as well as gentle massaging of the gingiva, with a soft bristled toothbrush. Patient/ guardian was recommended to floss at least once a day to remove soft debris between teeth that toothbrush bristles may be unable to reach. An age-appropriate mouth rinse was recommended, alcohol free in nature as well as a fluoride containing toothpaste that has been approved by the ADA. Patient/ guardian was guided on how to properly, and completely, brush the posterior teeth; ensuring that the tongue is brushed in addition to the buccal tissue. An ultrasonic toothbrush (w/ soft bristles) was suggested to help brush in a more thorough manner. After brushing for the evening, patient/ guardian was directed to avoid eating or drinking before and during bedtime hours. AI Evaluation: Evaluation: Needs Correction Identified Issues: D0150 was billed for a patient aged 2, but its criteria require the patient to be over 3 years old. - The procedure history shows prior D0150 entries within 3 years, further conflicting with the criteria for D0150 (which should only be used if there is no history or at least 3 years since the previous D0150). Suggested Fix: Remove D0150 from the billing and, if an oral evaluation is required for this patient, consider using D0145 which is appropriate for patients under 3 years old. - Update the procedure note to clearly document the rationale for using D0145 and ensure the evaluation criteria are met.
	Simba	20920424	p2591242		Neverland	D0120, D1110, D0220, D0230, D0230, D0230, D2331, D2330, D2330, D2330, D2330, D2330, D7210, D7210, D7140	Needs Correction
Procedure Notes: Reason for today's visit: exam and cleaning Patient's Chief Complaint: None The patient has been identified by: Checking ID., Patient confirmed name and date of birth in patient record. Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with patient. Premedication, if required has been taken as directed: Not Required BP: 116/78 Pulse: 70 Oral evaluation performed by:Dr. PB Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Social Habits effecting oral health: None Pt's last cleaning: 6+ months ago Oral hygiene assessment revealed: Visible plaque Full mouth periodontal probing completed: Yes Gingivitis: Generalized Periodontal disease: Generalized ADA Caries Risk Assessment completed and reviewed: No Overall assessment of dental caries risk: N/A Prophylaxis completed because it was medically necessary in order to prevent dental disease. Ultrasonic and hand scaled full mouth followed by polish and flossing. No fluoride applied. OHI was given including recommending a soft toothbrush and flossing daily, stressed importance of regular hygiene visits and discussed diet relating to oral health. X -rays requested and reviewed by the dentist. 4 BWX’S taken to evaluate proximal surface that cannot be visualized. 4 PA’S taken to eval hx of pain/ sensitivity/ trauma. X-rays taken by: Rose Intraoral Photos: No The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. RDH: AT Assistant: Violet X -rays requested by dentist for the next recall are: 4 BWX’s to eval interproximal surfaces that cannot be visualized, 2 PA’s to evaluate bone levels & interproximal surfaces that cannot be visualized NV: fillings, OS for EXTs AI Evaluation: Evaluation: Needs Correction Identified Issues: The procedure note documents both PA and BWX radiographs. While PA radiographs are billed (one D0220 and three D0230), the 4 BWX radiographs (D0274) documented are missing billing. Suggested Fix: D0274 - Bitewing radiographs: Note indicates 4 BWX radiographs (D0274) but no corresponding billing code was provided.
	Bella	23151224	p2412982		Neverland	D0150, D1120, D1206, D0272, D0220, D0230, D0601, D2392, D2392, D2392, D1351, D1351, D1351, D1351, D1351	Needs Correction
Procedure Notes: Reason for today's visit: exam and cleaning Patient's Chief Complaint: none Relationship of the adult who accompanied the patient to the appointment: Mother The patient has been identified by: Parent/ guardian confirmed correct patient is in the chair by name and date of birth. Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with parent/guardian. Premedication, if required has been taken as directed: Not Required Oral evaluation performed by:Dr. GL Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Occlusion: Overjet Dental oral habits: None Oral hygiene assessment revealed: Visible plaque ADA Caries Risk Assessment completed and reviewed: Yes Overall assessment of dental caries risk: High Risk Gingivitis: Generalized Prophy Cup Prophylaxis completed because it was medically necessary in order to prevent dental disease. Flossed all contacts. Fluoride varnish given to prevent caries and support tooth structure. OHI was given including recommending a soft toothbrush and flossing daily, stressed importance of regular hygiene visits and discussed diet relating to oral health and recommended limiting sweets. X -rays requested and reviewed by the dentist. 2 BWX’S taken to evaluate proximal surface that cannot be visualized. 2 PA’s taken to eval hx of pain/ sensitivity/ trauma. X-rays taken by: RV Intraoral Photos: No The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. Rec ortho consult: No Behavior: Cooperative RDH:MM Assistant: Y X -rays requested by dentist for the next recall are: 4 BWX’s to eval interproximal surfaces that cannot be visualized, 2 PA’s to evaluate bone levels & interproximal surfaces that cannot be visualized NV: Operative with Nitrous Sealants were recommended for caries prevention due to: presence of developmental occlusal pits and fissures. Sealants placed on tooth/teeth: A, J, K, T Tooth surface cleansed and etched with 35% Phosphoric Acid.Scotchbond Primer applied. BPA free 3M Clinpro Sealant applied and light cured. Mechanically and/or chemically prepared enamel surface sealed to prevent decay. An explorer was used to check for retention and flaws. The patient and guardian were advised to refrain from sticky foods and nothing to eat or drink for 30 minutes and instructed to call office with any questions or concerns. AI Evaluation: Evaluation: Needs Correction Identified Issues: There is a mismatch between the Risk Assessment code billed (D0601 for low risk) and the assessment noted in the ProcedureNote (High Risk). Sealant procedure on tooth S (D1351) is billed but not supported by documentation in the GroupNote, which only indicates sealants placed on teeth A, J, K, and T. Suggested Fix: Risk Assessment mismatch: D0601 billed for low risk while the procedure note indicates a high caries risk. Additionally, one sealant procedure (D1351 on tooth S) is billed but not documented in the group note which lists sealants placed on teeth A, J, K, and T.
	Tigger	23453424	p3242134		Neverland	D0150, D1110, D0274, D0220, D0230, D1206, D0220, D1351, D1351, D1351, D1351, D1351, D1351, D1351, D1351, D1351, D1351, D0601	Needs Correction
Procedure Notes: Reason for today's visit: exam and cleaning Patient's Chief Complaint: none The patient has been identified by: Checking ID., Patient confirmed name and date of birth in patient record. Relationship of the adult who accompanied the patient to the appointment: Father Is an interpreter required and present: No Reviewed medical history and confirmed that the information was current and accurate with parent/ guardian. Premedication, if required has been taken as directed: Not Required Oral evaluation performed by:Dr. JT Oral Cancer screening: WNL Intraoral soft tissue exam: WNL Extraoral exam: WNL Dentition examined and existing restorations, conditions, and dental disease including caries were charted in the tooth chart. Occlusion: Normal Occlusion Social Habits effecting oral health: None Pt's last cleaning: 6+ months ago Oral hygiene assessment revealed: Visible plaque Gingivitis: Generalized ADA Caries Risk Assessment completed and reviewed: Yes Overall assessment of dental caries risk: Low Risk Prophylaxis completed because it was medically necessary in order to prevent dental disease. Ultrasonic and hand scaled full mouth followed by polish and flossing. Fluoride varnish given to prevent caries and support tooth structure. OHI was given including recommending a soft toothbrush and flossing daily, stressed importance of regular hygiene visits and discussed diet relating to oral health. X -rays requested and reviewed by the dentist. 4 BWX’S taken to evaluate proximal surface that cannot be visualized. 2 PA’S taken to eval hx of pain/ sensitivity/ trauma. X-rays taken by:GT Intraoral Photos: No The nature of any proposed treatment, potential benefits and risks associated with that treatment, alternatives to the treatment, and the potential risks and benefits of alternative treatment including no treatment was discussed. Opportunity to ask questions about any proposed treatment was provided. RDH: LV Assistant: RM X -rays requested by dentist for the next recall are: 4 BWX’s to eval interproximal surfaces that cannot be visualized, 2 PA’s to evaluate bone levels & interproximal surfaces that cannot be visualized NV: 6 month recall Sealants were recommended for caries prevention due to: presence of developmental occlusal pits and fissures. Sealants placed on tooth/teeth: 3, 4, 5, 12, 15, 18, 20, 21, 28, 29 Tooth surface cleansed and etched with 35% Phosphoric Acid.Scotchbond Primer applied. BPA free 3M Clinpro Sealant applied and light cured. Mechanically and/or chemically prepared enamel surface sealed to prevent decay. An explorer was used to check for retention and flaws. The patient and guardian were advised to refrain from sticky foods and nothing to eat or drink for 30 minutes and instructed to call office with any questions or concerns. AI Evaluation: Evaluation: Needs Correction Identified Issues: D1110 is billed for prophylaxis in a 14-year-old patient from NJ; according to criteria, D1120 should be used for patients under 16. In addition, two D0220 entries were found for PA radiographs. For a case of 2 PA\u0027s, the first should be billed as D0220 and the second as D0230; the duplicate D0220 needs correction. Prophylaxis procedure for a patient under the NJ age threshold is misbilled (D1110 should be D1120) and duplicate PA codes (D0220) are present instead of the required D0220/D0230 pairing. Suggested Fix: D1110 is billed for prophylaxis in a 14-year-old patient from NJ; according to criteria, D1120 should be used for patients under 16. In addition, two D0220 entries were found for PA radiographs. For a case of 2 PA\u0027s, the first should be billed as D0220 and the second as D0230; the duplicate D0220 needs correction.