The benefits of breastfeeding have been proven invaluable to our children’s growth and development in the early stages of life. However, breastfeeding is a complicated process and requires care and skill from the parent. Lactation consultant services can be an incredibly helpful resource in navigating the world of breastfeeding a newborn. They are able to offer counsel, provide hands-on training, and extend resources to support new parents. 

As lactation consultants become a common part of the care team for new parents, patients and providers alike will look to their insurance companies for coverage for such essential services. Here, we’ve broken down insurance billing and CPT codes for lactation consultant services. 

Insurance coverage for lactation consultants

In 2012, the Affordable Care Act required that new health plans in the US were generally required to cover breastfeeding support, supplies and counseling. This included “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” While this seemed like a step towards insurance coverage for lactation consultants, coverage has not become as widespread as hoped. 

IBCLCs are actually not licensed providers in 47 out of 50 US states; only Rhode Island, Georgia, and Oregan have a licensure process, or one in progress of being created.  Most insurance companies, unfortunately, will only contract with licensed providers, making it incredibly difficult for lactation consultants to bill for their services. This forces IBCLCs without licensure to charge new parents, already struggling with hospital bills and the stress of a newborn child, self-pay prices for their essential services. In some cases, already licensed providers, such as OBs, NPs, dietitians, or pediatricians, are also IBCLCs. These types of providers would be able to bill insurance for breastfeeding services, because they are licensed as a different type of provider. 

This means that, while IBCLCs can submit Superbills or attempt to become in-network with insurance payers, it is unlikely that they will receive reimbursement at this time. It is important for IBCLCs and licensed providers who work alongside lactation consultants to advocate for insurance coverage for their services. Breastfeeding services are a key aspect of many WIC and other wellness programs designed for new parents; increasing insurance coverage will increase the likelihood that new parents will seek out lactation services, and therefore increase their health and nutrition literacy for their infants. If your practice qualifies under these new regulations, click here to learn how Healthie’s Free Starter Plan can help you deliver in-person or virtual lactation care  today. 

CPT codes for lactation consultation services 

There are no dedicated CPT codes for lactation services. This means lactation consultants who are able to bill insurance (i.e. providers who are licensed in another specialty) for their services must use more general CPT codes, commonly evaluation and management codes for new or returning patients. These codes must be used with care and caution, in order to ensure maximum reimbursement: 

Home visit, Evaluation and Management with a New Patient:

• CPT code 99341: Low severity, 20 minutes with patient 
• CPT code 99342: Moderate severity, 30 minutes with patient
• CPT code 99343: Moderate to high severity, 45 minutes with patient 

Home visit, Evaluation and Management with an Established Patient:

• CPT code 93347: Self-limited or minor problem, 15 minutes with patient
• CPT code 99348: Low to moderate problem, 25 minutes with patient
• CPT code 99349: Moderate to high problem, 40 minutes with patient

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Physician office or clinic, Evaluation and Management with a New Patient:

• CPT code 99201: Self limited or minor problem, 10 minutes with patient
• CPT code 99202: Low to moderate problem, 20 mins with patient
• CPT code 99203: Moderate severity, 30 minutes with patient

Physician office or clinic, Evaluation and Management with an Established Patient:

• CPT code 99212: Self limited or minor problem, 10 minutes with patient
• CPT code 99213: Low to moderate severity, 15 minutes with patients
• CPT code 99214: Moderate to high severity, 25 minutes with patient
  

There is one Level II HCPCS code available for IBCLCs to use: S9443, which designates a lactation class with a non-physician provider. 

IBCLCs should avoid billing evaluation and management CPT codes that end in 4 or 5, such as 99xx4 or 99xx5. This is because the complexity and review of body systems that these codes require is likely not met by a visit with an IBCLC; these CPT codes require the examination of 8+ body areas or systems. Additionally, these visits tend to assess high-risk conditions, and require an extensive data and patient history review. Using these codes as an IBCLC is a red flag for insurance companies, and may increase your chances of an audit. 

If providers are providing lactation services at a baby well visit, in which much of the time is spent on feeding problems, they can bill modifier code 25.  For example, you can bill CPT code 99391 for the baby, in conjunction with one of the above codes for the mother, and use modifier 25 to indicate these services were performed together by the provider. Healthie makes it easy to organize codes and services, all for $0. Click here to get started today. 

To increase the chances of reimbursement for lactation consultation services, you must meet the rule of the “3 R’s.”  This means you must have obtained a referral from your patient’s primary care provider; it should be in your hands before the appointment takes place. You should then render care, and report back to the referring provider. 

Healthie for lactation consultants

Healthie is a HIPAA-compliant, web, and mobile solution, complete with lactation consultant  tools, that enables you to deliver in-person lactation services or virtual lactation care. Now you can get all these benefits for $0 with our free starter plan.

• Add your calendar to your website for new moms to book directly online
• Send forms and E-signatures to mothers to complete electronically
• Electronic charting via Healthie's integrated EHR feature to document breastfeeding visits, maternal exams, and infant exams
• Send notes via E-fax to other healthcare providers, like pediatricians, your patients work with
• Credit card processing and electronic invoices for packages
• Share documents and educational resources like meal plans, feeding guides, and treatment recommendations
  

Read more about Healthie for lactation consultants here. Get started with Healthie today.