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coding corner

October 14, 2019

What’s the difference between bundling and downcoding?

Have you traveled by airline recently? Priced out a flight?  Look at the fees and how they are advertised…a flight from Allentown, Pennsylvania. to Nashville, Tennessee is $43 per person.  That’s a great deal…now, if you want to check a bag or even carry on, that’s an additional $40.  If you want to pre-book an assigned seat, another $20, don’t have online check-in for your boarding pass? Another $10, then add tax, surcharge etc. by the time you are done, your $43 flight is $100 plus.

I often equate some real-life experiences with our dental practices, so on that note let’s talk about bundling and downcoding.

Can you imagine if we did this in dentistry?  Imagine offering a new patient exam and prophy for   $60 - but if you want to sit in a chair for the service, that’s another $40, sterilized instrument charge $25 - a bib and highspeed suction? $30.  Water with that prophy?  another $20 ….you get my drift……cha ching, cha ching $$$$. I call that UNBUNDLING.  If we did that, what would be the consequences?

What’s the difference between bundling and downcoding?

The definition of bundling is officially “Systematic combining of distinct dental procedures by third parties that result in a reduced benefit”.

We dentists get concerned when procedures that are legitimately separate are bundled either because of contract provisions in a plan or bundled inappropriately with little explanation to the patient.

One common example of this is bundling a panorex with bitewings to issue a benefit of an FMX. Clearly there is a difference between a panorex and bitewing radiographs – however, for “benefit determination purposes” they get bundled together and the benefits issued are indeed reduced. Is it fair, these are clearly two different procedures?

I see both sides of the argument. If you take a panorex and 2 bitewings, then you report a panorex and 2 bitewings. The carriers will do what is most cost effective for them and their plan holders…and also keep in mind, some of these codes are highly abused. I would hope that if you are taking a panorex, you must realize that you cannot see the interproximal spaces in detail the way you could with bitewing radiographic images. Sure, a panorex is a lot easier and quicker than the conventional FMX, but if you are trying to diagnose interproximal caries and loss of attachment, you will have no choice but to take additional radiographs. The 2012 ADA/FDA report says we should not expose our patients to unnecessary radiation unless it is medically necessary.  If we use that argument, then the “old fashioned” FMX pretty much did the trick in most cases.  So then what’s the real advantage of the panorex versus the FMX?  Well, obviously it depends on what you are using the films for.  I don’t believe there is a right or a wrong answer. I believe you should use your best clinical judgement based on the patient, their history and your clinical observations and radiate as little as possible.

Whatever you decide, report what you do, do what you report; but remember, the carriers have the ability to issue benefits based on their internal guidelines and the patients’ plan design.  To me the bigger issue really becomes future benefits that the patient was entitled to for D0120.  Typically, we have seen a frequency limitation of one FMX every 3-5 years. Recently we have seen some plans extend that frequency. In the words of Dr. Art Bilenker “I digress”.

What was I talking about again? Bundling and downcoding, let me get back to that.

Downcoding is when a third-party reduces the benefit to a less complex or less expensive procedure than what was reported (unless it is a contractual requirement). In my humble opinion, when a third-party payer downcodes, patients can get confused. A common assumption is that a lower level of care should have been provided. It sometimes interferes with the dentist-patient relationship if the EOB doesn’t indicate that this coding change was a result of a business decision, not treatment decision.  Since a lot of carriers don’t disclose their downcoding policies, dentists and patients have no way of knowing what the reimbursement will be until the EOB is received.

A common example of downcoding would be a claim submission for a posterior composite restoration and the carrier processes the claim and reimburses based on the fee for an amalgam restoration.

A payor (insurance carrier) and plan holder should have the right to decide what is covered; I don’t think that anyone would disagree with that BUT if the payors would clearly disclose and explain that these are simply “economic” decisions between the plan purchaser and the payor in a way that doesn’t interfere with the dentist-patient relationship….that would certainly go a long way in cementing the patients’ confidence in their oral health care providers professional judgement and recommendations. Just saying.

The dental office and the dentist cannot be held responsible for the plans processing policies or procedures – although there seems to be no other educational resource to take on that burden. I want to remind everyone that there is a website out there for patients to utilize. “Tooth Truth For You”.  Take advantage of it and drive your patients there so they can educate themselves about how their benefits work and what they are intended to provide in terms of coverage.  Check it out for yourselves, who knows, you may learn something too.

It is vital that dentist and staff explain to patients (in advance of treatment) that the treatment plan recommended is based on medical necessity and what the dentist and the patient feel is clinically appropriate.  The treatment recommendations should not be based on plan reimbursement.

What can you do if a claim is bundled or downcoded or in your opinion not processed correctly? You can appeal the claim in writing.  Include any additional supporting documentation and consider additional copies of radiographic images, perio charting or narrative descriptions to support your claim for reconsideration.  Keep in mind, if you are a participating provider, then you already agree to the insurance carriers’ policies and procedures for claim processing; that includes bundling and downcoding. For anyone left out there that doesn’t participate – you win the prize- you get to charge your patients for the services you provide.