Bundling of Procedure Codes

A frustrating experience for contracted dentists is the situation where a procedure is “disallowed” by the payer. When a procedure is “denied”, the dentist’s fee for a procedure is not benefited but the dentist is allowed to charge the patient for that procedure. However, when a procedure is “disallowed”, the dentist’s fee for a procedure is not benefited by the payer AND is not collectible from the patient by a participating dentist. Examples of procedures that have been reported to the ADA as being commonly disallowed include the restorative foundation (D2949) for an indirect restoration or pulp capping (D3120) below a restoration.

The ADA strongly opposes such practices. Each unique procedure is identified by a distinct CDT Code. Existence of a code allows the dentist to accurately record the unique services provided.

Some would infer that by “disallowing” a service, payers are taking the stance that the procedure is not “medically necessary”. How can payers deem a distinct dental procedure (evidenced by a unique CDT Code) as being “not medically necessary”? Medical necessity is established by the treating dentist responsible for diagnosing and planning treatment for a patient. Seeking documentation to support the treatment rendered from contracted dentists is a prerogative of the plan in the spirit of serving as the administrator for the patients’ dental benefit. However, the ADA believes that this function should not extend to determining “medical necessity” under the pretext of cost containment for the patient.

Further, a payer’s dental consultant making a determination that a service can be “denied” for a non-contracted dentist; but the same service would be “disallowed” for a contracted dentist may be placing themselves in an ethical bind by applying different standards of care for the same service simply based on network status of a dentist. The ADA argues that this is inappropriate. A dental benefit plan that is meant ONLY to cover some of the patients’ dental care costs, should limit its decisions to how that benefit is appropriately disbursed.

Dentists should watch for these situations and coach their patients to approach their employers to identify solutions to benefit plan designs. Further, language within the explanation of benefits (EOB) should be appropriate and not imply that the treatment was unnecessary or that the dentist was in error. The ADA encourages member dentists to bring forward issues with EOB language to our attention by calling us at 800-621-8099.  For more information on bundling and other third party issues, please visit http://success.ada.org/en/practice/dental-benefits/.

When communicating with patients, dentists may want to use language similar to the following. “The maintenance of the CDT Code is through a multi-stakeholder process that includes payer and provider groups. The existence of a code allows for recording and reporting of that service and recognizes the unique nature of that care. Your benefit plan is only intended to pay for a portion of your dental care costs.”