How to Address Bundling and Downcoding in Dental Billing

While delivering quality service and care is paramount for any dental practice, receiving prompt payments can get challenging. Billing and coding are complex tasks, and the dental team needs to be adept at handling this critical function. Acceptance of claims and
precise billing of services rendered are vital for a dental practice to get paid on time and to keep cash flows moving.
To manage billing and claims, a dental practice can outsource this function to a specialized agency to manage such intricacies associated with billing. Some of them include two very important components, such as bundling and downcoding.

One needs to understand what bundling and downcoding in dental billing are, issues thatcan crop up, and how to address them successfully.
Bundling in dental billing Bundling, as described by the ADA or American Dental Association, can be termed as a systematic combination of different dental procedures by an insurance firm that results in a lowered benefit for a dental practice or a patient. Bundling in dental billing can result in a reduced benefit for the practice based on procedures performed. It is used by insurance companies as a means of following
guidelines and protocols that are set in coding. This means that a practice cannot bill for services separately when not distinctly recognized as a separate service. As an example, a dental practice might perform a tooth extraction procedure. While billing, it can bill tooth extraction with one code and the usage of anaesthesia with another code. The insurance company will permit billing of anaesthesia separately as it is
a component service and is a part of the primary procedure of tooth extraction. Hence, a practice will get reimbursement only for tooth extraction.

Some queries can develop when a dental practice realizes that different procedures billed with unique codes are bundled incorrectly or even bundled due to contract provisions without explanation There can also be cases when dental procedures are legitimately separate but are
combined as per the insurance company, and this results in an additional financial burden to the patient or an opportunity loss for the practice.

A few instances of bundling:

Radiographs are typical examples in which bundling usually occurs. When various radiographs are combined for a full mouth series, a code will be assigned for it. FMX radiographs are usually a set of 16 to 20 intraoral radiographs that are useful in detecting cavities and infections, dental restorations, and overall oral health. It also offers a display of roots and crowns of all teeth. While a panoramic radiograph offers the dental team multiple diagnostic uses, its characteristic distortion does not enable clinical differentiation needed for various procedures. The D0210 code applies to a comprehensive series of radiographs. It does not have a fixed number of radiographs that can be permitted for a patient. Different patients may need a different number of radiographs.

An insurance firm can contemplate defining several radiographs on the same day of treatment as a complete series of intraoral radiographs. The firm can also limit the number of radiographs or might permit an FMX once every five years. Some insurance companies might not automatically bundle claims for covered services in an insurance plan. They might bundle selected codes when a professional assessment of
the claim, supporting clinical information, and relevant documents, infers that the codes used are not suitable.

Downcoding in dental billing

As per the American Dental Association, downcoding is a measure taken by insurance companies whereby the benefit code has been swapped to a lower cost procedure or a procedure that is less complex than claimed. In downcoding, an insurance company tries
to swap codes for less reimbursable options. Some cases of downcoding in dental billing are as follows:

• The code D4263 applies to a bone replacement graft and the first site in the quadrant, while D4264 is for any additional site in the quadrant. The dental team might include three sites of bone replacement graft within the same quadrant when submitting the claim using D4263. The insurance company might recode the additional two sites as D4264.
• An insurance firm can recode a complex or multi-surface restoration as a single- surface filling.
•  Insurance companies can downcode periodontal maintenance services to standard preventive care.
• An insurance company can downcode a claim by the dental practice for a posterior composite restoration by recoding it as a fee for an amalgam. Insurance organizations generally swap codes in claim submissions when all documents, notes, and attachments have been reviewed by a professional entity. If the report indicates any inappropriate coding, the insurance company might downcode as per guidelines.

This, however, will not include claim denials or adjustments for procedures included in the patient’s insurance plan. Adjudication of claims will be as per the terms and conditions of the policy of the patient. It will also include, but not be limited to, any alternate benefit provisions.

 How to address bundling and downcoding challenges

• Dental practices can seek support for their outsourced dental billing partner to file an appeal if they feel that claims have not been justly adjudicated.
• The dental team can send supplementary documents that can convince the insurance company of the merits of the claim. Copies of narrations and intraoral radiographs can aid the dental billing partner in getting claims approved.
• The dental team needs to counter potential loss due to bundling and maximize reimbursements from the insurance company. All claim submissions should be verified against EOB statements. Moreover, the EOB statement needs to be examined for any changes in codes or reimbursements that are not in sync with the

dental practice’s contract. Part payments, claim denials, or delays need to be checked.

• When the practice does not receive payment for a procedure code that is listed, the dental team needs to confirm if the insurance company bundled the code with an unrelated procedure for a separate diagnosis.
• As a pre-emptive measure, the dental team must make a list of procedures and their respective codes that could be bundled by the insurance company. These can be checked underpayments against insurance companies that underpaid.
• The dental team needs to examine EOBs from them. The dental team needs to confirm codes as per CDT descriptors and nomenclature. The team can contact the insurance company for an explanation of queries regarding the appropriate usage of codes. The team must check for the possibility of any bundling of codes by making a comprehensive list of all procedures performed and their respective
  codes. The practice can collaborate with a reputable billing partner to help with diagnostics and integrity in claim submissions. With the right tools, claim submission can be consistent and accurate.