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February 5, 2023

Coding and reimbursement for lactation services

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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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Last revised December 9, 2021 - Betsy Nicoletti
Tags: screening and counseling for behavioral conditions

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2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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