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Insurance Coding and Billing for Primary Care Lactation Support

billing and coding insurance team-based lactation care Mar 27, 2023
a medical coder working on lactation billing

As a primary care provider (PCP), the breastfeeding support you provide in the office is covered by insurance.  When implementing team-based breastfeeding support, questions may arise regarding the Affordable Care Act (ACA), as well as coding & billing for the PCP and for lactation consultants. 

The following discussion provides an overview of terminology and resources to help your practice navigate billing, insurance, and family questions about their benefits. 

Breastfeeding support and the Affordable Care Act

Passed in 2010, the Affordable Care Act (ACA) states that insurance payers must cover with no cost-sharing “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period.” When the law was passed, it seemed like a great step forward in lactation support. However, because the law is vague, implementation by insurance companies remains varied. Additionally, not all insurances need to comply, including self-funded plans and those grandfathered in prior to ACA. The variability can lead to uncertainty when deciding how to provide lactation services at a primary care practice. 

No cost-sharing: typically a maternal benefit  

Most insurance plans follow the recommendations of Women’s Preventive Health Services Initiative (WPSI) which outlines lactation preventive benefits as a maternal benefit at no cost-sharing. If an insurance company must comply with ACA, then typically preventive education and counseling visits are covered at 100% as a mother benefit. While breastfeeding support involves care of the dyad, the breastfeeding parent and infant, only some insurance companies cover the babies’ visit with no cost-sharing. Ask your insurance provider: who receives lactation benefits with no cost-sharing?

Insurance diagnosis and procedure code choices

International Classification of Diseases (ICD) codes provide the diagnosis of the condition treated. The most common maternal lactation-specific ICD diagnostic codes are Z39.1 (care of lactating women) and O92.70 (lactation disorders). Common infant breastfeeding related codes include neonatal feeding difficulty at breast (P92.5), jaundice(P59.9), fussy infant(R68.12), and pediatric feeding difficulty(R63.31). The American Academy of Family Physicians and the American Academy of Pediatricians created guides for lactation billing which include CPT and ICD recommendations, and a list of breastfeeding related ICD-10 codes. 

Current Procedure Terminology (CPT) codes identify to insurance companies the procedure performed. Common CPT code groups used in outpatient lactation billing are preventive counseling (CPT  99401-04) and medical evaluation and management (E&M) (CPT 99202-05; 99212-15) codes.  Both the WPSI and AAP downloads explain CPT choices for coding when providing breastfeeding support and include additional options like health behavior and assessment codes. Depending on the insurance, ACA coverage with no cost-sharing may require use of specific CPT codes. Check out the National Breastfeeding Center presentation for a detailed overview of the challenges and considerations. 

Preventive counseling versus medical evaluation coding

Per ACA, breastfeeding support and education are covered as a preventative benefit with no cost-sharing.  For some insurance policies that means using the preventive counseling codes (CPT codes 99401-04) to access the benefits.

Given that continued breastfeeding decreases morbidity and mortality for numerous infant and maternal health conditions, we view all breastfeeding support as preventive medicine, including management of breastfeeding difficulties! 

Yet, for some insurers, medical evaluation for breastfeeding difficulties (i.e. cracked nipples and low milk supply) coded as evaluation & management (E&M) visits may be subject to co-pays and deductibles. Others will recognize E&M medical evaluation with no cost-sharing as an ACA benefit, if submitted with a lactation-specific diagnostic code (such as Z391 and O92.70) and possibly with a modifier-33 added to the claim.  

The variability in implementation of ACA coverage (preventive counseling codes vs. E&M codes vs. health behavior and assessment codes) leads to confusion for patients and providers and is generally inefficient and frustrating. As a physician or advanced care provider, the clinical visit will be covered by insurance; the question becomes: will there be cost-sharing for the patient?

Who is a trained lactation provider? Depends on who you ask.

ACA does not specify who is a trained provider. WPSI notes, “Clinical lactation professionals providing clinical care include, but are not limited to, licensed lactation consultants, the IBCLC®, … nurse practitioners, and physicians. Lactation personnel providing counseling, education or peer support include lactation counselors/breastfeeding educators and peer supporters.” While WSPI identifies many potential providers, a given insurer can choose who to recognize. Some consider the primary care provider as that trained provider. Yet, given the variability in medical education, we know breastfeeding support by a medical provider does not guarantee access to adequate support. 

Some insurances contract with lactation consultants to provide the services and others do not. If an insurer credentials a lactation consultant, they will be able to bill independently. The most commonly recognized credentials are International Board Certified Lactation Consultants (IBCLC).Yet even as more insurers are credentialing lactation consultants, many communities may not have access to IBCLCs. Increased availability of certified lactation counselors(CLC)/educators can increase access to breastfeeding support and education for families. The USLCA position statement: “Clarifying Clinical Lactation Care vs Breastfeeding Support” summarizes the different levels of care of lactation providers and training. The lactation support provided at your primary care office will depend on availability in your community, which in turn will impact the coding options. 

Keep up to date and learn your local insurers

With the variability between insurances, it is important to keep up to date and learn your local insurance plans. With time, you can determine which of your insurances will credential lactation consultants, which will reimburse if an IBCLC sees a patient independently, which allow incident-2 billing, and which require support by the primary care provider. 

Coding for team-based LC/PCP care

Your coding decisions will be determined by the trained lactation professional at your practice and how they are recognized by your insurance. The AAP outlines coding for a joint physician visit with an allied health professional: “This is a physician visit which is supported and facilitated by the initial work of the allied health. In this visit the lactation consultant can obtain the history, establish the physical findings and observe and document the breastfeeding and counsels the family on related lactation issues. Then the physician joins the lactation consultant and family partway through the visit to review the history, examine the breastfeeding dyad, document their findings, provide needed medical care. In this scenario the physician's time will be minimized as the lactation consultant will be providing the more time intensive portion. If the lactation professional is not recognized as an independent billing provider, then coding will be based on medical decision-making coding guidelines to determine level of visit code.” This billing model is a great starting point for team-based visits.

Check out these handy resources 

Keep these resources nearby as you consider which set up will work best for your practice: 

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