Hi Briana! Great question. Typically dental practices performing an evaluation for TMD and OSA will have the documentation to support a level 1 or 2, sometimes a level 3 (i.e. 99201-99203 for new patients, 99211-99213 for established patients). The level of code should be selected based on three items: 1) the level of history collected from the patient (problem focused, expanded problem focused, detailed, or comprehensive) 2) the level of examination performed (problem focused, expanded problem focused, detailed or comprehensive) **keep in mind a comprehensive oral exam does not qualify on it”s own as a comprehensive medical evaluation 3) the level of medical decision made (complexity that is straightforward, low, moderate high) Of course, the level 4 and 5 codes require detailed or comprehensive history taking and exams, and medical decision making of moderate and high complexity, which is why many dental practices will fall into the level 1-3 visits. Hope this helps!
