Coding and reimbursement for lactation services

Questions about coverage and payment for breastfeeding and lactation counseling services come up regularly.

• Is lactation counseling separately billable or considered part of the obstetrical package?
• What if the patient sees the physician and a lactation counselor? Can both be billed?
• Do payers recognize the services of a lactation counselor?
• What CPT or HCPCS codes can we use to be reimbursed?
• Are there diagnosis requirements?

The answers to these questions will depend on who the patient has for an insurer. Some payers have policies that allow for the work of a non-physician to be billed separately if all requirements are met. Other payers do not recognize the services provided by a lactation counselor as a covered service. This puts the responsibility on the clinic or provider to understand the policies of each of the payers they contract with to make sure that they comply with the rules.

The best first step is to call the insurer and speak with a provider representative to help you locate the applicable policy or policies for the services you plan to provide.

Lactation counseling can fall into the category preventive care, routine obstetric care or problem or illness related. This information will guide coverage and coding decisions.

With the Affordable Care Act (ACA) law enacted in 2016, Breastfeeding Support, supplies and counseling were listed as services considered to be preventive care.

Preventive care services are for visits not related to a problem or illness. Preventive care services are to be provided at no additional cost to the patient, meaning that health benefit plans are required to provide these benefits and are prohibited from cost-sharing. However, it is left to individual health benefit plans to determine who may provide the service, how frequently and in what setting.

To help you get answers to the questions posed at the beginning of the article, we will provide some helpful resources:

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