Coding watchdogs wanted

In response to 2007 House of Delegates Resolution 33鈥擬onitoring and Resolution of Code Misuse鈥攖he Council on Dental Benefit Programs is calling on ADA members to help eliminate misuse of the Code on Dental Procedures and Nomenclatures.

“Improper code use is something CDBP is continually working to minimize,” says Dr. Stephen J. Jaworski, CDBP chair. “Information gathered through this clarion call to members may be used as a basis for more aggressive action in responding to code violations.”

The ADA receives calls and correspondence from dentists in all areas of practice with concerns about code misuse. Each is a valid concern.

“It’s only by the diligence of the dentists in reporting instances of code misuse that the ADA is able to compile a database we can use to combat this practice,” said Dr. Jay Hight, chair, Dental Benefit Information Service Subcommittee. DBIS provides assistance to members and their staff who have questions and concerns with third-party payers.

“If we know about your code issue, we may be able to resolve it,” says Dr. Hight. “We do it all the time.”

To elicit useful member feedback and gain further insight into additional strategies that might end code misuse, CDBP wants to be sure dentists know incorrect code usage when they see it.

“Because code misuse comes in different forms, it’s not always easy to identify,” says Dr. Jaworski. “But we’re continually developing better resources to help members do it.”

Payers adjudicate claims based on benefit plan limitations and exclusions and provisions of participating provider contracts. Payer actions that do not adhere to contractual obligations may be misuse of the Code and are a good reason for a dentist to contact the CDBP.

Even if an objectionable use of the Code is not illegal, CDBP will work with payers to discuss member concerns and potentially resolve conflicts.

What constitutes potential misuse and appropriate use of the Code?

Insurance carriers will adjudicate claims based on agreements they have in force with plan purchasers (generally employers or union groups). Many of these plans have contract provisions that at least purport to allow bundling or downcoding of submitted procedure codes prior to claim adjudication. The ADA defines bundling and downcoding as follows:

• Bundling of procedures: The systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.
• Downcoding: 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.

The ADA considers bundling and downcoding to be potentially abusive practices. Denial or reduction of benefits based on the benefit plan or participating provider contract may not be considered misuse of the Code.

Potential bundling and downcoding misuses of the Code include:

• If a payer does not even accept a claim for adjudication submitted with a valid procedure code submitted by a dental office, a possible misuse of the Code exists.
• When a dental office submits a claim with a valid procedure code to a payer and the payer lists a different procedure code on the explanation of benefits sent to the patient, without reference to the code originally submitted, a possible misuse of the Code may exist.

For example, many payers will pay benefits for two separate one-surface restorations on the same tooth as a single two-surface restoration (a separate occlusal and buccal pit being paid as an OB), even though the Code provides distinct codes for these procedures with no limitation for being placed on the same tooth.

“Bundling of separate and distinct dental procedure codes by payers may send an erroneous message to a patient, namely, that the dentist did the wrong thing,” comments Dr. Jaworski. “Dentists should report these practices to the ADA staff so they can respond and attempt to correct them. This is particularly important when the EOB (explanation of benefit) language states a reason other than benefit plan design.”

Potential appropriate uses of the Code may inadvertently be perceived as misuse

When a payer adjudicates a claim based on a least expensive alternative treatment clause in an agreement with a plan purchaser and changes the submitted procedure code to another procedure code, there may be no misuse of the Code if the claim is properly adjudicated under the terms of the benefit plan agreement.

It is not uncommon for payers to apply least expensive alternative treatment clauses, for example, allowing an alternate benefit allowance for an amalgam restoration when a resin is placed. LEAT clauses are designed to limit the amount of benefits paid from the plan. Although treatment decisions should be between the dentist and the patient based on the clinical circumstances, sometimes benefit provisions are seen as influencing clinical decisions because patients may choose treatment options based on their benefits.

“We, as dentists, must educate our patients that what is paid by their benefit plan is not a recommendation of treatment,” says Dr. Hight.

Some carriers have even implemented policies where an age limit is applied to a patient for benefit adjudication purposes. For example, a carrier may only allow a benefit of a child prophylaxis for a 13-year-old even though the patient has adult dentition and should be coded as an adult prophylaxis. This is one of many instances where third-party carriers disregard the submitted procedure code and pay a benefit based on a lower cost procedure simply to save money.

“The response by some payers that must be resisted is when they require the dentist to resubmit the claim the way they adjudicate it, rather than what is correct for the procedure performed,” said Dr. Joseph Hagenbruch, chair of the CDBP Subcommittee on the Code. “Once again, dental offices can assist the ADA by reporting these practices to ADA staff for possible problem resolution.

“If members report this kind of activity we can get an actual track record on carriers that do these things regularly,” adds Dr. Hagenbruch. “We have more information at our disposal when confronting these folks, and have a better chance of working these things out for our members.”

Other appropriate uses of the Code that may inadvertently be perceived as misuse include when a third-party denies a claim based on frequency limitations after changing the submitted procedure code to another procedure code. There may be no misuse of the Code if the claim is properly adjudicated under the terms of the benefit plan agreement.

One example of this is the changing of a minimal number of periapical radiographs and bite-wings to a complete series and then denying the benefit due to frequency limitations for a complete series.

An illustration of how the ADA tries to remedy these issues is that the ADA was successful in obtaining a change to the Code, effective Jan. 1, 2009, that adds a descriptor defining a complete series. This should assist in working with payers to define benefits appropriately, but it does not prevent payers from designing benefit plans that contractually provide alternative benefits for submitted procedure codes.

What is the Code?

Dentists record and report dental treatment with a consistent format and at the appropriate level of specificity to adequately define commonly accepted dental procedures by using the Code on Dental Procedures and Nomenclature.

In 2000, the Code was designated by the federal government under the Health Insurance Portability and Accountability Act of 1996 as the national terminology for reporting dental services. Any claim submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the version of the Code in effect on the date of service. The Code is also used on dental claims submitted on paper, and the ADA maintains a paper claim form with data content reflecting the HIPAA standard electronic dental claim.