Billing Codes

Medical billing and coding IS standardized for the most part even between private payers not involved in Medicare. And the elements required on the BCBS bill are commonly required by all insurers.

Interesting reading here: https://www.aapc.com/resources/medical- ... use%20them.

When I worked in healthcare in the 80's and 90's before CPT codes were universal, billing was a nightmare. Payors were looking for certain key words (to either approve or DENY payment) and if the provider didn't know the magic words to put in the notes (or avoid) the bills were often denied. Appeals often succeeded but cost the provider more time and money. I actually took classes, GIVEN BY BCBS and AETNA which were Medicare fiscal intermediaries in my region, on how to document to get paid and avoid denials by them. CPT codes largely eliminated many of the denials on the provider side--if you billed under the correct code and it matched the diagnosis code and the standards of treatment for that diagnosis, it was far less likely to be denied, and to some degree payment was sped up because computers could do the initial analysis instead of some bean counter having to sit there and read actual provider notes they didn't understand in the first place. Errors in billing codes are now the most common cause of denials. Eventually our charge slips had the CPT codes right next to the procedure, so that the biller could just plug it in on the computer. Now I'm guessing the coding happens automatically in the electronic medical record. (The charge slips and CPT codes didn't always match what our patients NEEDED and benefitted from most, that's one of the reasons I got out of the field, because it overrode clinical judgment).

An Aside: Some of the standards they drilled into us in those classes were absolutely INCORRECT according to Medicare Policy and Procedure Manuals--in particular, they insisted that Medicare only paid for therapy services (PT, OT, Speech) if there was demonstrable progress toward improvement goals (Not in the manuals!). It took until 2013 (long after I got out of healthcare) in a case called Jimmo v. Sebelius to turn that around and recognize that Medicare does not have an "Improvement standard" and also covers services to maintain function or prevent further decline, and in my area at least, insurers continue to ignore the court ruling in that case. BS about an "improvement standard" was another reason I got OUT of being a health care provider and on to a different career path. I went in to healthcare to help people, and sometimes helping was preventing them from getting worse.

All this to say that YES, medical billing IS standardized. The layout on a bill may not be exactly as is given in the BCBS example, but the elements the provider must include are all there, assuming the provider wishes to get paid for their services. DME billing is fairly straightforward, assuming the DME has a biller who knows what they are doing and the doctor provides the correct diagnosis code.