Getting paid for services rendered is a major challenge for dental practices. While a dental billing company can help dentists manage the claims submission process, bundling and downcoding are two major concerns when it comes to getting paid by insurance companies. Let’s take a look at the problems that these practices cause and how dentists can address them.

Bundling

The American Dental Association (ADA) bundling as “The systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.”

Bundling results in a reduced benefit for the patient, or beneficiary. Payers consider bundling as an effort to follow guidelines established in the code. When payers practice bundling, it means that they do not recognize each separate service for payment. The component services are considered as part of the main procedure in accordance with the code, and benefits are paid according to this.

Concerns arise when dental practices find that distinct procedures submitted with separate codes on claims are:

  • bundled inappropriately, or
  • bundled due to contract provisions without explanation

When dental procedures that are legitimately separate are combined, it reduces benefits for the patient or beneficiary.

Common instances of bundling:

  • Radiographs are the most common service for which bundling occurs. Multiple radiographs are be combined and the code for the full mouth series (FMX) will be assigned. FMX is defined by the FDA as “a set of intraoral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone crest”. Though a panoramic radiograph has many diagnostic uses, its innate distortion does not allow for the clinical differentiation required for many dental procedures. Panoramic images and bitewings may be combined and recoded as an FMX. The D0210 code (Intra-Oral-Complete Series of Radiographic Images) including bitewings, does not specify the number of intraoral films that would compose a full mouth set of radiographs. The number of films to adequately view what is defined in a complete series will vary from patient to patient. So, payers may consider multiple intraoral films on the same date of service as a complete series of intraoral radiographs or limit them to the maximum reimbursement of an FMX (ADA). Future D0210 claims are then subject to benefit plan frequency limitations, such as 1 FMX every 5 years.
  • If a two-surface restoration and a single surface restoration are placed on the same tooth on the same date of service, the dental plan may pay for a three-surface restoration.
  • Though each core build-up is a distinct procedure as listed in the CDT Code, many payers consider core build-ups as part of the crown procedure.
  • Even if direct or indirect pulp caps are separate and distinct procedures, a payer may consider them non-billable for contracted dentists when provided in conjunction with the final restoration or sedative filling for the same tooth.
  • Dentists should code for services provided. If the dentist has signed a participating provider agreement with the dental plan, this would determine the amount a dentist can bill the patient. The explanation of benefits (EOB) statement has to specify the patient’s out-of-pocket responsibility. In the situations mentioned above, an out-of-network dentist can bill up to their full fee for all of the submitted procedures.

Downcoding

The ADA defines downcoding as “A practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.”
Examples of downcoding:

  • when three sites of D4263 (bone replacement graft–first site in quadrant) within the same quadrant are included in the claim, but the payer recodes the two additional D4263 codes to D4264 (bone replacement graft– each additional site in quadrant) in accordance with the code.
  • A claim for a posterior composite restoration is paid based on the fee for an amalgam.

Payers may change a submitted code when a professional review of the submitted charges and supporting clinical information such as x-rays, photographs, periodontal charting, narratives, and treatment notes, indicates that the original coding may have been inappropriate. However, this does not include the denial or adjustment of claims for covered services in accordance with the terms of a member’s dental benefits plan. Payers will adjudicate claims in accordance with the terms, exclusions and limitations of a member’s dental benefits plan, including, but not limited to, any contractual alternate treatment/alternate benefit provisions (ABP).

Dealing with Bundling and Downcoding

  • If dentists feel that a claim has not been properly adjudicated, they can ask their dental billing company to help them appeal the decision.
  • Submitting additional documents can strengthen the case. Providing copies of radiographs or narrative descriptions can help the dental billing service provider in the claims appeals process.
  • To combat bundling and get the correct reimbursements, claims submissions should be tracked checked against the EOB forms. EOBs should be checked for coding changes and reimbursements that do not meet the dentist’s contract. All denials, delays, partial payments, and their explanation codes should be checked.
  • When a procedure code is listed and there’s no payment, check if the carrier bundled the charge with an unrelated procedure for a different diagnosis.
  • Make a list of procedures likely to bundle, the CPT codes for these procedures, and the names of insurers that underpaid. Then check the EOBs from these payers.

Partnering with an experienced provider of dental billing services can speed up claims submission and increase billing accuracy through dental insurance eligibility verification and proper reporting of procedures and services using the latest codes. Experts will also know to file a proper claims appeal. The ADA says that while appealing a claim may not always result in greater reimbursement, it could help prevent misperceptions by the patient.