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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
Evaluation: Correct Suggested Procedure Code: N/A Identified Issues: No issues found Suggested Fix: N/A 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 Correct or Needs Correction Identified Documentation Concern: 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. Recommended Correction: 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		Treasur Iseland	D0150, D0274, D0220,D0230, D0230,D0230, D2391,D2392, D2392,D2331, D1110,D1206	Needs Correction
Evaluation: Correct Suggested Procedure Code: N/A Identified Issues: No issues found Suggested Fix: N/A 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 Correct or Needs Correction 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 Recommended Action: No corrections needed.
	Capt. Hook	26625330	z2134114		Treasur Iseland	D2930,D3220	correct
Evaluation: Correct Suggested Procedure Code: N/A Identified Issues: No issues found Suggested Fix: N/A 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. Evaluation: Needs Correction IdentifiedIssues: 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. SuggestedFix:: 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		Treasur Iseland	D2393, D2391	Correct
Evaluation: Correct Suggested Procedure Code: N/A Identified Issues: No issues found Suggested Fix: N/A 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. Evaluation: Needs Correction IdentifiedIssues: 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. SuggestedFix:: 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.
	Sleeping Beauty	26418681	w2418640		Never land	D2393, D2391	Correct
Evaluation: Correct Suggested Procedure Code: N/A Identified Issues: No issues found Suggested Fix: N/A 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. Evaluation: Needs Correction IdentifiedIssues: 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. SuggestedFix:: 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.