Bundling And Downcoding Issues In Dental Billing And How To Address Them

Bundling And Downcoding Issues In Dental Billing And How To Address Them

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.


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.


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.

How Can Outsourcing Of Back Office Functions Help A Dental Office During Worker Shortage

How Can Outsourcing Of Back Office Functions Help A Dental Office During Worker Shortage

During the public health emergency prompted by COVID-19, many states issued orders instructing dental offices to cancel or postpone elective or non-urgent procedures that could be delayed without much risk to the patient’s health. In April 2020, CNBC reported that the health care sector lost a record 1.4 million jobs and that dental practices accounted for over half a million job cuts. According to the American Dental Association, all but 3% of dental offices nationally were shut down except for emergency appointments in March last year and nearly 9 out of 10 had laid off staff. Many practices resorted to teledentistry to deliver virtual care and dental billing companies played a key role in helping them manage their revenue cycle.

Dental and medical offices across the U.S. are now reopening in a phased manner based on recommendations and mandatory safety and health standards issued by the Occupational Safety and Health Administration. With the worker shortages driven by the COVID-19 pandemic, it would be highly beneficial for dental practices to outsource their back office duties as they navigate the challenges of reopening.

2020 IDA Survey reveals Major Dental Office Staffing Concerns

Data released by the Indiana Dental Association (IDA) in July 2020 provides a clear picture of the negative impact that the COVID-19 pandemic has had on dental practices in the state. At the time of the IDA survey, many dentists and dental offices were still suffering from acute and sustained financial losses due to the COVID-19 pandemic. Dental offices had been experiencing staffing shortages prior to the pandemic and many reported worsening of the situation. Key findings of the IDA 2020 survey include:

  • Up to 60% of dentists reported their office is still not operating at full capacity
  • Many dentists reported trouble filling positions
  • 37% of dentists reported that some of their staff quit or retired
  • 17.6% reported having trouble filling office staff positions

The problems experienced by practices due to staffing challenges included

  • not being able to schedule as many treatments, and
  • the office failing to run smoothly

The reasons mentioned cited for not being able to find dental staff were:

  • Fear of returning to works
  • Competition for qualified staffs
  • Unemployment benefits

In the new normal, dental practices need to review their staffing practices. According to a 2020 Dental Economics article, this may mean not employing as many staff as they previously did, changing employees’ duties, reducing hours or pay, and so on. The goal should be to keep the business functioning. In this situation, outsourcing dental back office duties can benefit both the practice and patients.

Benefits of Dental Back Office Outsourcing during the Pandemic

Dental practices can reemploy furloughed or temporarily laid off employees, but staffing levels should align with the level of business to ensure expenses are in line with budgeted costs and revenue. This means that not everyone, including back office staff, can be brought back. In the circumstances, outsourcing the back office to a dental billing company is a practical solution to rein in costs while promoting better patient care and practice efficiency. Experienced service providers can take care of the entire billing cycle, from the front desk and dental eligibility verification to patient scheduling, dental billing and coding, accounts receivable (AR) management, and more.

Dental insurance verification services provided by outsourcing companies involve verifying coverage benefits for both new and existing patients before they are treated. The process involves verifying the following details for each patient:

  • Effective coverage dates
  • Waiting periods
  • Maximums and deductibles
  • Treatment history
  • Benefits used to date
  • Type of plan and fee schedule
  • Claim submission information (address, phone number, payor ID etc.)
  • Coverage percentage by category
  • Implant and orthodontic coverage
  • Frequencies, limitations, and exclusions
  • Missing tooth clause, and more

With a dedicated dental insurance verification expert managing this time-consuming and often complex task, dentists can rest assured that claims go out accurately and are paid in a timely manner. Proper insurance verification means reduced risk of denials and happier patients and is one of the most important aspects when it comes to improving the practice’s bottom line.

Patient scheduling involves optimizing the appointment system to maintain a steady patient flow. Managing patient scheduling can be a challenge when adhering to COVID social distancing mandates. Outsourcing companies can provide efficient online patient scheduling and appointment management solutions to help dental practices improve patient flow.

A dental billing company will work on your software to manage your coding and invoicing. Billing specialists stay up to date with coding changes and industry regulations and can ensure accurate claim submission. They will ensure you have an efficient AR operation that gets you paid accurately and faster.

To sum up, outsourcing back office duties during the COVID-19 pandemic can help improve dental practice efficiency and improve the patient experience. It will allow dentists to focus better on patient care and their (limited) staff to save valuable time that would go into verifying patient coverage. Outsourcing insurance verification and authorization to a specialist will also ensure eligibility review before the appointment, which is crucial to prevent claim denials due to eligibility problems.

The IDA survey reported that dental practices suffered loss of income due to staffing challenges associated with inability to meet demand, patient fear resulting in reduced demand, and new clinic protocols resulting in lower productivity. It’s clear that in these challenging times, dental practices need to find cost-effective ways of managing their operations. A reliable dental billing service provider can help them overcome back office staffing shortage and navigate office reopening more easily.

How To Code Stomatitis And Related Lesions In Dentistry

How To Code Stomatitis And Related Lesions In Dentistry

Stomatitis is an oral condition referred to as inflamed and sore mouth. This is a type of mucositis, caused by inflammation of the mucous membrane. It can disrupt one’s ability to eat, talk, and sleep. It can occur anywhere in the mouth, including the inside of the cheeks, gums, tongue, lips, and palate. The treatment often focuses on managing the symptoms. Dentists treating this condition can rely on professional dental billing companies to get the dental claims submitted with the right diagnosis and procedure codes.

ICD-10 Codes to Report Stomatitis and Related Lesions

  • K12 Stomatitis and related lesions

    • K12.0 Recurrent oral aphthae
    • K12.1 Other forms of stomatitis
    • K12.2 Cellulitis and abscess of mouth
    • K12.3 Oral mucositis (ulcerative)

      • K12.30 …… unspecified
      • K12.31 …… due to antineoplastic therapy
      • K12.32 …… due to other drugs
      • K12.33 …… due to radiation
      • K12.39 Other oral mucositis (ulcerative)

Additional codes can be used to identify:

Alcohol Abuse and Dependence

  • F10 Alcohol related disorders

    • F10.1 Alcohol abuse
    • F10.2 Alcohol dependence
    • F10.9 Alcohol use, unspecified

Exposure to Environmental Tobacco Smoke

  • Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)

Exposure to Tobacco Smoke in the Perinatal Period

  • P96.81 Exposure to (parental) (environmental) tobacco smoke in the perinatal period

History of Tobacco Dependence

  • Z87.891 Personal history of nicotine dependence

Occupational Exposure to Environmental Tobacco Smoke

  • Z57.31 Occupational exposure to environmental tobacco smoke

Stomatitis coding excludes

Cancrum oris, noma and gangrenous stomatitis

  • A69.0 Necrotizing ulcerative stomatitis


  • K13.0 Diseases of lips

Herpesviral [herpes simplex] gingivostomatitis

  • B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis

The types of stomatitis include canker sore or aphthous ulcer, cold sores or fever blisters and mouth irritation. While canker sores appear as ulcers in the mouth, usually on the cheeks, tongue, or inside the lip, cold sores appear as fluid-filled sores on or around the lips. At the same time, mouth irritation can be caused due to gum disease (gingivitis), chewing tobacco, oral inflammation and ulcers or any other type of mouth infection. Such sores can be caused by poor nutrition, stress, mouth injury, a weak immune system, lack of sleep, hormonal changes, or side effects of chemotherapy and sometimes radiotherapy. Depending on the area of the mouth affected, stomatitis can be broken down into different categories such as – cheilitis (inflammation of the lips and around the mouth), glossitis (inflammation of the tongue), gingivitis (inflammation of the gums) and pharyngitis (inflammation of the back of the mouth).

Common symptoms include mouth ulcers, red patches, swelling, lesions that heal in 4 days – two weeks. Treatment options for severe sores include Lidex gel, Aphthasol anti-inflammatory paste, Peridex mouthwash, and anti-inflammatory drugs like corticosteroids. To submit error-free medical claims, practices can consider partnering with an experienced dental billing service. Make sure that the coders are up to date with the changing coding standards.

Our services include

At Outsource Strategies International (OSI), our comprehensive suite of dental billing services include comprehensive dental eligibility verifications and other services to help run your practice efficiently.

  • Patient Scheduling and Registration
  • Authorizations & Pre-determinations
  • Payment and Cash Posting
  • Insurance Billing and Collections
  • Patient Billing and Follow-up
  • Accounts Receivable Management

Call our toll-free number 1-800-670-2809

New CDT Coding Changes For 2022

New CDT Coding Changes For 2022

The American Dental Association (ADA) Code Maintenance Committee (CMC), the body that evaluates and votes on proposed changes to the Code of Dental Procedures and Nomenclature (CDT Code) has acted on many code change requests for CDT 2022. Effective Jan. 1, 2022, CDT has 16 additions, 14 revisions and six deletions, including eight codes adopted in March 2021 for vaccine administration and molecular testing for a public health-related pathogen. CDT 2022 also has a section on ICD-10 codes related to dentistry. As a reliable dental billing company, we stay up to date on CDT coding changes to help dentists use current and specific codes to document and accurately report what they do, bill patients correctly, and communicate to payers about treatments submitted for reimbursement.

  • New CDT Codes: CDT 2022 includes new codes for:

    • Pre-visit patient screenings
    • Fabricating, adjusting and repairing sleep apnea appliances
    • Intra-coronal and extra-coronal splints
    • Immediate partial dentures
    • Rebasing hybrid prostheses
    • Removal of temporary anchorage devices
  • Orthodontic Code Action Requests Approved: The American Association of Orthodontists (AAO) made three Code Action Requests and the CMC approved all (orthodonticproductsonline.com). The AAO announced that these changes will come into effect in CDT 2022, and will be reflected in services provided on or after January 1, 2022.

The three approved Code Action Requests are:

  1. Deletion of the Interceptive Orthodontic Treatment subcategory nomenclature, descriptor, and codes D8050 and D8060

    The AAO believes that the deletion of the Interceptive Orthodontic Treatment codes and the revision of the Limited Orthodontic Treatment descriptor will eliminate any ambiguity and redundancy, as the procedures previously described as “interceptive” were thought to be substantively similar clinically to the Limited Orthodontic Treatment procedures.
  2. Revision of the Limited Orthodontic Treatment descriptor

    The AAO has stated that new language for Limited Orthodontic Treatment will be written as follows:

    Orthodontic treatment utilizing any therapeutic modality with a limited objective or scale of treatment. Treatment may occur in any stage of dental development or dentition.

    The objective may be limited by:

    • not involving the entire dentition.
    • not attempting to address the full scope of the existing or developing orthodontic problem.
    • mitigating an aspect of a greater malocclusion (i.e., crossbite, overjet, overbite, arch length, anterior alignment, one phase of multi-phase treatment, treatment prior to the permanent dentition, etc.).
    • a decision to defer or forego comprehensive treatment.

    D8010: limited orthodontic treatment of the primary dentition

    D8020: limited orthodontic treatment of the transitional dentition

    D8030: limited orthodontic treatment of the adolescent dentition

    D8040: limited orthodontic treatment of the adult dentition

  3. Deletion of D8690 “orthodontic treatment (alternative billing to a contract fee).”

    The AAO requested deletion of D8690 in order to reduce confusion for members who observed that “D8690 does not truly represent a procedure, is redundant with other exiting codes, and is no longer required”.
  • 8 Pandemic-related CDT Procedure Codes

    Included in CDT 2022 are eight COVID-19 codes relevant to vaccine administration that were approved in CDT 2021. The CDT Code already has entries for documenting antigen and antibody testing. The new pandemic related codes are:

    D1701: Pfizer-BioNTech COVID-19 vaccine administration – first dose

    D1702: Pfizer-BioNTech COVID-19 vaccine administration – second dose

    D1703: Moderna COVID-19 vaccine administration – first dose

    D1704: Moderna COVID-19 vaccine administration – second dose

    D1705: AstraZeneca COVID-19 vaccine administration – first dose

    D1706: AstraZeneca COVID-19 vaccine administration – second dose

    D1707: Janssen (Johnson & Johnson) COVID-19 vaccine administration

    D0606: Molecular testing for a public health-related pathogen, including coronavirus

    New code D0606 that supports molecular testing for a public health-related pathogen, including coronavirus, complements two codes approved in 2020:

    • D0604 antigen testing for a public health-related pathogen, including coronavirus; and
    • D0605 antibody testing for a public health-related pathogen, including coronavirus.

The use of codes related to the AstraZeneca vaccine are contingent upon that vaccine being granted Emergency Use Authorization by the U.S. Food and Drug Administration (FDA). The Ontario Academy of General Dentistry notes that dentists who seeking to provide their patients with either COVID-19 testing or vaccination services may want to consider cross-coding for those procedures under patients’ medical insurance.

Practices need to start preparing for these changes slated for 2022. Dental billing service providers keep up to date with the code changes to ensure that they can help dentists report their services correctly on claims and receive appropriate reimbursement.

Medical Codes For Pulpitis And Its Causes

Medical Codes For Pulpitis And Its Causes

Also known as a toothache, pulpitis occurs due to the inflammation of the dental pulp or tissue in the center of a tooth. The innermost part of each tooth comprises an area called the “pulp” – which is formed of soft connective tissue, nerves, and the blood supply for the tooth. This pulp delivers nutrients to the tooth. The condition can occur in one or more teeth and is caused by bacteria that invade the tooth’s pulp, causing it to swell. Practicing good oral habits and scheduling regular dental visits can help people deal with the condition in a better manner. Treatment modalities depend on the type and severity of the condition. Medical billing and coding for pulpitis can be quite challenging. Dental billing service providers knowledgeable in the dental codes and related guidelines can easily manage the coding and claim submission processes for dentists.

There are two different forms of pulpitis – reversible and irreversible. Reversible pulpitis refers to instances where inflammation in the pulp is mild and people have short-lived pain. Typically, the tooth pulp is healthy and with the correct treatment, it is possible to save the tooth and let the nerve to heal. Irreversible pulpitis occurs when there is significant inflammation inside the pulp and the bacteria spreads to the nerves, causing the nerves to die (this is called pulp necrosis, or pulp death). It is estimated that 40 percent of irreversible pulpitis may be painless. If left untreated, the infection can spread to other parts of the body, including the brain.

What Causes Pulpitis?

This condition commonly occurs when bacteria irritate the dental pulp through an area of tooth decay, including dental caries. Typically, in a healthy tooth, the enamel and dentin layers protect the pulp from infection. Pulpitis occurs when these protective layers are compromised, allowing bacteria to get in to the pulp, causing swelling and infection. Other related causes of pulpal inflammation include –

  • Trauma or injury to a tooth (such as an impact to the tooth)
  • Grinding or clenching the teeth
  • Repetitive trauma caused by dental issues, such as jaw misalignment or bruxism (tooth grinding)
  • Repeated, invasive dental procedures
  • Having a fractured tooth (which exposes the pulp)
  • Cavities or tooth decay, which causes erosion to the tooth
  • A bad bite or malocclusion (causing extra wear on certain teeth)

Severe and irreversible pain (that can occur throughout the day and night) is one of the typical symptoms of pulpitis. Other related symptoms include – swollen lymph nodes, inflammation, bad taste in the mouth, bad breath and sensitivity to hot and cold and sweet food. The severity of symptoms depends on the type of pulpitis. Pulpitis is diagnosed by conducting a detailed tooth examination wherein X-rays may be taken to determine the extent of tooth pulp damage, decay and inflammation. A sensitivity test may also be done to check the amount of pain or discomfort when the tooth comes in contact with heat, cold, or sweet stimuli. Treatment methods vary depending on whether the pulpitis is reversible or irreversible. Treatments include a combination of pain management medications and other procedures like pulpectomy or tooth extraction.

Medical Codes for Pulpitis

ICD-10 Codes

  • K04 Diseases of pulp and periapical tissues
  • K04.0 Pulpitis
    • K04.01 Reversible pulpitis
    • K04.02 Irreversible pulpitis

CDT Codes

  • D3110 Pulp cap – direct (excluding final restoration)
  • D3120 Pulp cap – indirect (excluding final restoration)
  • D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament
  • D3221 Pulpal debridement, primary and permanent teeth
  • D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development
  • D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)
  • D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)
  • D3310 Endodontic therapy, anterior tooth (excluding final restoration)
  • D3320 Endodontic therapy, premolar tooth (excluding final restoration)
  • D3330 Endodontic therapy, molar tooth (excluding final restoration)
  • D3331 Treatment of root canal obstruction; non-surgical access
  • D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
  • D3333 Internal root repair of perforation defects
  • D3346 Retreatment of previous root canal therapy – anterior
  • D3347 Retreatment of previous root canal therapy – premolar
  • D3348 Retreatment of previous root canal therapy – molar
  • D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.)
  • D3352 Apexification/recalcification – interim medication visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)
  • D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.)
  • D3355 Pulpal regeneration – initial visit
  • D3356 Pulpal regeneration – interim medicament replacement
  • D3357 Pulpal regeneration – completion of treatment

Dental medical billing and coding involves using the specific medical codes to report various dental conditions on the claims that providers submit to health insurers. In addition to billing and coding, dental insurance verification and pre-authorization services are crucial to verify the patient’s coverage.

As mentioned above, practicing good oral hygiene and visiting the dentist regularly can help prevent the occurrence of pulpitis. Practicing good oral hygiene habits like – brushing the teeth twice daily, flossing daily, and limiting or avoiding sugary foods – can help remove unhealthy bacteria from the mouth and teeth. Visiting dentists regularly can help seek immediate attention for tooth pain or sensitivity. In addition, individuals who have bruxism can consider wearing a mouth guard at night.

Medical billing and coding for dental disorders like pulpitis can be complex. For accurate and timely billing and claims submission, dental practices can outsource their medical coding tasks to a reliable dental billing company that provides the services of AAPC-certified coding specialists.