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Downcoding & Bundling

Downcoding

"Downcoding" means the adjudication of claims in a manner that reduces dental procedure codes to a less complex or lower-cost code, unless expressly provided for in the CDT Code of Dental Procedures and Nomenclature. 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.

Aetna does not automatically change a dentist’s submitted procedure code to a less complex or lower-cost code, subject to the following: (a) A submitted code may be changed 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; and (b) Aetna 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).

The following are examples of downcoding that may occur following a professional review:

  • D7210 "Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap  and removal of bone and/or section of tooth" to D7140 "Extraction, erupted tooth or exposed root (elevation and/or forceps removal)" or D7111 "Extraction, coronal remnants – deciduous tooth"

    Surgical removal of teeth involves cutting of the gingiva for flap design and removal of bone for     access to non-diseased tooth structure in order to extract/remove the tooth. Teeth     considered to exhibit difficulty upon removal, such as teeth that demonstrate advanced caries,     large restorations, crowns, or a history of root canal therapy may be considered as surgical     extractions/removal (D7210).

    In addition, teeth that are periodontally involved and exhibit excessive bone loss or exposed     roots are considered as routine removal of teeth. No benefits are available for these teeth as     surgical extractions.

  • D7140 "Extraction, erupted tooth or exposed root (elevation and/or forceps removal)"

  • Aetna considers fully erupted teeth (primary or permanent) extracted for orthodontic or non-orthodontic purposes to be the "routine removal of tooth structure and closure, as necessary".

Most Aetna plans contain contractual ABP language, although these provisions may vary among employers (and other plan sponsors, such as unions). Specific provisions applicable to a given plan are communicated in plan specific documents distributed to members from plan sponsors.

These ABP provisions can operate in various situations including, but not limited to, the following common general examples:

1. Two or more services, all of which are suitable for the condition being treated, are covered under the member’s plan.

(a) Two or more services that, under standard practices, are separately suitable for the condition being treated may be included as covered dental services under a member’s plan. However, the provisions of that plan may provide coverage only for the least costly treatment that would have produced a professionally acceptable result. This alternate procedure must be deemed by the dental profession to be an appropriate method of treatment and must meet broadly accepted national standards of dental practice. 

(b) The current, most common ABP provision included in dental plans offered and/or administered by Aetna in this situation is as follows: 

"Alternate Treatment Rule — If more than one service can be used to treat a covered person’s dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that both of the following terms are met:

  • The service selected must be deemed by the dental profession to be an appropriate method of treatment; and
  • The service selected must meet broadly accepted national standards of dental practice"

(c) The following are two examples of how Aetna administers this alternate benefit provision:

Alternate benefit of a removable partial denture for a fixed bridge

If the dentist proposes a fixed bridge replacing teeth #s 19 and 20, and teeth #s 28-32 are also missing, the benefit amount will be that of a removable partial denture if appropriate to replace all the missing teeth in the arch. The dentist and patient may still choose to replace teeth #s 19 and 20 with a fixed bridge, however, the benefit provided will be that for a removable partial denture that can be applied toward payment for this treatment.

Alternate benefit of an amalgam restoration for a resin-based composite restoration submitted for a posterior tooth 

If a resin-based two surface posterior composite restoration (e.g. D2392) is submitted for a posterior tooth, the benefit amount will be that of a comparable amalgam restoration if it is appropriate for the involved tooth. The dentist and patient may choose to restore the tooth with the resin-based composite restoration, however, the benefit provided will be that for an amalgam restoration that can be applied toward payment for this treatment. 

OR

2. The service requested is not covered under the plan for the dental care of a specific condition, but an allowance up to the amount of an alternate covered service(s) is available.

(a) Many Aetna plans contain a list of Eligible Dental Services. This means that only those services that are specifically listed are covered under the plan. If a service is not on the list, it is not covered. However, in some cases, if the list does provide coverage for another service which is a suitable alternative for the condition being treated, the plan will provide an allowance, up to the covered amount for that alternate service, in lieu of the noncovered service. 

 (b) The current, most common ABP provision included in dental plans offered and/or administered by Aetna in this situation is as follows:

"This Dental Care Schedule includes only services in the list below.

Alternate Treatment

The next sentence applies if:

  • A charge is made for an unlisted service given for the dental care of a specific condition; and
  • The list includes one or more services, that, under standard practices, are separately suitable for the dental care of that condition

In that case, the charge will be considered to have been made for a service in the list that Aetna determines would have produced a professionally acceptable result"

(c) The following is an example of how Aetna administers this type of alternate benefit provision:

Alternate benefit of a complete denture for an overdenture:

Certain Aetna dental plans do not include D5863 (complete maxillary overdenture) and D5865 (complete mandibular overdenture) on the List of Dental Services, but do include complete dentures (D5110 and D5120) on the List of Dental Services. If a claim is submitted for a complete overdenture for a member covered by this type of plan, the benefit for a complete denture will be allowed for the overdenture.

Bundling

"Bundling" means the adjudication of claims in a manner that denies payment for one or more of multiple dental procedure codes unless expressly provided for in the CDT Code on Dental Procedures and Nomenclature. 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.

Bundling includes situations where similar procedure codes submitted by a dentist for dental benefit consideration are grouped or lumped together, resulting in combined submitted charges for the applicable procedures.

Aetna does not automatically bundle claims for covered services under any dental plans. However, Aetna may bundle selected procedure codes, 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 or where the CDT Code on Dental Procedures and Nomenclature itself specifically bundles such services.

The following is a common example of bundling:

D3120: "Pulp cap – indirect (excluding final restoration) with restorations

When D3120 is submitted on the same date of service as a permanent restoration such as an amalgam or resin-based composite, Aetna considers the D3120 to be part of the restorative procedure. If reported this way, the procedure is considered the same as placement of a base, and according to CDT, "… liners and bases are included as part of the restoration."

Pulp capping is a procedure in which the exposed or nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin. This code is not to be used for bases and liners when all caries has been removed.

Please note the following additional information:

  1. Aetna may deny or adjust claims for covered services in accordance with the terms of the applicable dental benefits plan or plans. In addition, the information above does not apply to Aetna's adjudication of claims involving dental procedure codes if submitted for covered services under an Aetna medical benefits plan.
  2. Aetna may reduce reimbursement for selected claims based on a review of the information in the written dental record for those claims, a review of information derived from Aetna's fraud and abuse detection programs that creates a reasonable belief of fraudulent, abusive or other inappropriate billing practices, or other tools that reasonably identify inappropriate coding of services; provided that the decision to reduce is based in significant part on a review of the individual clinical record by a licensed dentist.
  3. Aetna may apply any rates that it has negotiated with a dentist for the services provided or to apply the express terms of the CDT Code on Dental Procedures and Nomenclature in adjudicating claims for covered services under any applicable dental benefits plan.
  4. Aetna may request clinical information or records from dentists for customary purposes such as disease management, patient management, quality review, quality management, claims payment, and audit purposes.  

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