CurrentAlliance HealthPolicy 1-I

Dietary Evaluation and Counseling and Medical Lactation Services

Defines coverage, eligibility, and requirements for dietary evaluation and counseling and medical lactation services for North Carolina Medicaid beneficiaries, including special provisions for children, pregnant and postpartum women, and EPSDT rules.

Policy Summary

PayerAlliance Health

PolicyDietary Evaluation and Counseling and Medical Lactation Services

Policy CodePolicy 1-I

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument medical necessity (and for beneficiaries under 21, demonstrate EPSDT criteria) when providing dietary evaluation, counseling, or medical lactation services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

<21EPSDT applies

AllowedTelehealth

0-20Children eligible

4 / 270dInitial assessment limit

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Coverage Criteria

inv-01: Coverage — Beneficiaries Under 21

Medicaid shall cover dietary evaluation and counseling when medically necessary and meeting general criteria; specific coverage for beneficiaries under 21 is listed below.

General Coverage Preconditions: Service must be individualized, specific, and consistent with symptoms or confirmed diagnosis, not in excess of the beneficiary's needs; can be safely furnished; and no equally effective and more conservative or less costly treatment is available statewide; service not primarily for convenience.

General coverage criteria (3.1)

EPSDT Exception for <21: For beneficiaries under 21, dietary evaluation and counseling is covered when there is a chronic, episodic, or acute condition for which nutrition therapy is a critical component of medical management and at least one qualifying condition is present.beneficiary age <21

See list of qualifying conditions (chunk 19)

Qualifying conditions for beneficiaries under 21: Presence of any one of the following: inappropriate growth or weight gain (including inadequate weight gain, inappropriate weight loss, underweight, obesity, inadequate linear growth, or short stature); nutritional anemia; eating/feeding disorders resulting in medical conditions (e.g., failure to thrive, anorexia nervosa, bulimia nervosa); physical conditions impacting growth/feeding (e.g., very low birth weight, necrotizing enterocolitis, cleft palate, cerebral palsy, neural tube defects); chronic or prolonged infections with nutritional component (e.g., HIV, hepatitis); genetic conditions affecting growth/feeding (e.g., cystic fibrosis, Prader-Willi, Down Syndrome); chronic medical conditions (e.g., cancer, cardiac disease, hypertension, hyperlipidemia, gastrointestinal disease, liver disease, pulmonary disease, malabsorption syndromes, renal disease, significant food allergies, immune diseases); metabolic or endocrine disorders (including inborn errors of metabolism such as PKU; diabetes); non-healing wounds due to chronic conditions; acute burns over significant body surface area; metabolic syndrome; or documented first-degree relative with cardiovascular disease or significant cardiovascular risk factors.at least one condition present

From policy list (chunk 19)

inv-02: Coverage — Children and Pregnant/Postpartum Women

Other populations

Children through 20 years of age are eligible for dietary evaluation and counseling when they meet the medical necessity criteria listed in Subsections 3.2.1.age <=20

See Subsection 3.2.1 (referenced)

Pregnant and Postpartum Women: Pregnant and postpartum women are eligible for dietary evaluation and counseling when they meet the medical necessity criteria listed in Subsection 3.2.2.pregnant or postpartum status

See Subsection 3.2.2 (referenced)

inv-03: Coverage — Beneficiaries under 21 (ANY one of the following conditions)

Medicaid beneficiaries under 21 years of age: dietary evaluation and counseling covered when ANY one of the following conditions is present

Pediatric indications: Inappropriate growth or weight gain (including inadequate weight gain, inappropriate weight loss, underweight, obesity, inadequate linear growth, short stature); nutritional anemia; eating or feeding disorders causing medical conditions (e.g., failure to thrive, anorexia nervosa, bulimia nervosa); physical conditions impacting growth/feeding (e.g., very low birth weight, necrotizing enterocolitis, cleft palate, cerebral palsy, neural tube defects); chronic/prolonged infections with nutritional component (e.g., HIV, hepatitis); genetic conditions affecting growth/feeding (e.g., cystic fibrosis, Prader-Willi Syndrome, Down Syndrome); chronic medical conditions (cancer, chronic/congenital cardiac disease, hypertension, hyperlipidemia, gastrointestinal disease, liver disease, pulmonary disease, malabsorption syndromes, renal disease, significant food allergies, immune system diseases); metabolic and endocrine disorders (including inborn errors of metabolism such as PKU and diabetes); non-healing wounds due to chronic conditions; acute burns over significant body surface area; metabolic syndrome; or documented first-degree relative with cardiovascular disease or significant cardiovascular risk factors.

From chunk 19

inv-04: Coverage — Pregnant and Postpartum Women (ANY one of the following)

Pregnant and postpartum women: dietary evaluation and counseling covered when ANY one of the following conditions is present

Pregnancy/postpartum indications: Conditions that affect length of gestation or birth weight where nutrition is an underlying cause (including severe anemia with HgB <10 g/dL or Hct <30%; preconception underweight [<90% standard weight for height]; inadequate weight gain during pregnancy; intrauterine growth retardation; very young maternal age [<16]; multiple gestation; substance use); metabolic disorders (e.g., diabetes, thyroid dysfunction, maternal PKU, other inborn errors); chronic medical conditions (e.g., cancer, heart disease, hypertension, hyperlipidemia, inflammatory bowel disease, malabsorption syndromes, renal disease); autoimmune diseases of nutritional significance (e.g., SLE); eating disorders (e.g., severe pica, anorexia nervosa, bulimia nervosa); obesity meeting specified BMI thresholds (pre-pregnancy/postpartum BMI >30; BMI >35 at 6 weeks; BMI >30 at 12 weeks); or documented first-degree relative with cardiovascular disease or significant risk factors.See thresholds for anemia and BMI

From chunk 20

inv-05: Coverage — Medical Lactation Services (infant conditions ANY)

Medical lactation services: covered when breastfeeding infant has ANY one of the following

Infant lactation indications: Latch-on difficulties; prematurity; multiple birth; requires breastmilk and mother-infant dyad needs assistance continuing breastfeeding; special-needs infant affecting feeding (e.g., Down Syndrome, cleft lip/palate or other congenital feeding deformity); jaundice; dehydration with difficulty gaining weight; inadequate weight gain or inappropriate weight loss.

From chunk 21

inv-06: Not Covered

Not covered

General not covered conditions: When the beneficiary does not meet eligibility requirements in Section 2.0; does not meet the criteria listed in Section 3.0; the procedure/product/service duplicates another provider's procedure/product/service; or the procedure/product/service is experimental, investigational, or part of a clinical trial. Additionally, group medical lactation services are not covered under this policy.

From chunks 23 and 25

inv-07: Coverage prerequisites and billing requirements — contextual requirements for coverage

Covered when the following contextual requirements are met:

WIC referral precedence: Individuals categorically eligible for WIC must be referred to WIC for routine nutrition education and food supplements before billing Medicaid for dietary evaluation and counseling. For agencies that also administer WIC, required WIC nutrition education contacts must be provided prior to billing; staff time for Medicaid-reimbursable nutrition services must not be charged to WIC funds.

From chunk 40

Additional medical lactation services after WIC: If after required WIC services have been provided, additional medical lactation services will be reimbursed only if they are medically necessary and the medical documentation supports the need.

From chunk 40

Pregnant/postpartum diagnosis requirement for >=21: When the pregnant or postpartum beneficiary is 21 years of age or older, one of the primary diagnosis codes listed in the policy must be used on the claim.

From chunk 53

inv-08: Medical Lactation Service Coverage — Covered when ALL of the following are met

Covered when ALL of the following are met

Medical lactation coverage requirements: 1) A medical condition (e.g., feeding problem or low weight gain) diagnosed by a physician, NP, PA, or CNM; 2) If the beneficiary is seen by the physician and the IBCLC on the same date of service, the physician must include the IBCLC services by billing the appropriate E/M code and health and behavior codes (96156, 96158, 96159) may not be reported on the same date of service as an E/M when performed by the IBCLC; 3) The visit is not for generalized preventive counseling or risk factor reduction; and 4) Visits are billable in 15-minute increments based on IBCLC time when performed.

From chunk 62 and billing codes in chunk 61

inv-09: Service Location and Telehealth — Covered when ANY of the following site-of-service conditions are met

Covered when ANY of the following site-of-service conditions are met

Approved service locations: Services provided in hospital outpatient clinics; public agencies such as health departments; federally qualified health centers (FQHCs); rural health clinics (RHCs); private agencies; physician or medical diagnostic clinics; and physician offices are acceptable service locations. Telehealth claims should be filed with the provider's usual place of service code(s); listed CPT/HCPCS codes are telehealth-eligible where indicated.

From chunks 67, 68, 60, 61

Services that are unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as accepted medical practice are excluded from coverage, including under EPSDT for beneficiaries under 21. Additionally, Medicaid does not cover procedures, products, or services that duplicate another provider's service or are provided to beneficiaries who do not meet the eligibility or clinical criteria in Sections 2.0 and 3.0.

Group medical lactation services are specifically not covered under this policy; individual medical lactation services must be billed and documented per the policy requirements.

Routine nutrition education and supplemental foods for WIC-eligible individuals must be provided through the WIC Program and beneficiaries should be referred to WIC prior to billing Medicaid for dietary evaluation and counseling. For agencies that administer WIC, required WIC nutrition education contacts must be provided before billing Medicaid, and staff time used to provide Medicaid-reimbursable nutrition services must not be charged to WIC funds.

Visits that are generalized preventive counseling or focused on risk factor reduction are not billable under the medical lactation health and behavior codes (e.g., 96156, 96158, 96159); services billed with these codes must address a diagnosable medical condition and meet the policy's documentation and coverage requirements.

Coverage is limited to services that are individualized, specific, consistent with symptoms or a confirmed diagnosis, and not in excess of the beneficiary's needs. Services that are not individualized, inconsistent with the diagnosis, unsafe, or when a more conservative or equally effective and less costly treatment is available statewide may be considered not medically necessary and may be denied.

Services that are experimental, investigational, part of a clinical trial, or duplicate another provider's service are excluded from coverage. EPSDT does not require coverage for services that are unsafe, ineffective, or experimental/investigational.

If required WIC services have been provided but additional medical lactation services are requested, those additional services will be reimbursed only if they are medically necessary and the medical documentation supports the need.

Health and behavior codes 96156, 96158, and 96159 have reporting restrictions: if the beneficiary is seen by a physician and the IBCLC on the same date, the physician must bill the appropriate E/M code and include the IBCLC services as described; health and behavior visits (96156, 96158, 96159) may not be reported on the same date of service as an E/M when performed by the IBCLC.

Coding and Claim Guidance

Attachment A references (Claims/Billing guidance)mixed

No codes listed

Provider taxonomy/NPI specialty codes listedmixed

133V00000X	Dietician, Registered
133VN1101X	Nutrition, Gerontological
133VN1201X	Nutrition, Obesity and Weight Management
133VN1301X	Nutrition, Oncology
133VN1004X	Nutrition, Pediatric
133VN1401X	Nutrition, Pediatric Critical Care
133VN1005X	Nutrition, Renal
133VN1501X	Nutrition, Sports Dietetics
133N00000X	Nutritionist

Claim Typesmixed

Professional (CMS-1500/837P)	Claim Type
Institutional (UB-04/837I)	Claim Type

Pregnant and Postpartum Women ICD-10-CM codes (as listed/mapped)ICD-10Covered

O09.512	ICD-10-CM (listed in pregnant/postpartum mapping)
P92.2	ICD-10-CM (listed in pregnant/postpartum mapping)
O09.513	ICD-10-CM
P92.3	ICD-10-CM
O09.521	ICD-10-CM
P92.4	ICD-10-CM
O09.522	ICD-10-CM
P92.6	ICD-10-CM
O09.523	ICD-10-CM
R62.51	ICD-10-CM

1–10 of 42

1/5

Coding specificity guidanceneutral

No codes listed

Medical Lactation Service CodesCPTCovered

96156	Health and behavior assessment or intervention, each 15 minutes (Medical Lactation Services) — Telehealth Eligible
96158	Health and behavior intervention, each 15 minutes (Medical Lactation Services) — Telehealth Eligible
96159	Health and behavior intervention family, each 15 minutes (Medical Lactation Services) — Telehealth Eligible

Dietary Evaluation and Counseling CodesCPTCovered

97802	Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face; 15 minutes — Telehealth Eligible
97803	Medical Nutrition Therapy; re-assessment and intervention, individual, face-to-face; 15 minutes — Telehealth Eligible

FQHC/RHC BillingHCPCSCovered

T1015

Clinic visit/encounter, all inclusive (FQHC/RHC)

Revenue CodesRevenue

RC 942

Hospital outpatient clinic revenue code for dietary evaluation and counseling

Referenced ICD-10 Diagnosis CodesICD-10

multiple ICD-10 codes

Numerous diagnosis codes listed for pregnant/postpartum women and infants receiving lactation services (see document chunks for full listing)

inv-28: Age threshold for EPSDT expanded coverage

EPSDT age thresholdBeneficiaries under 21 years of age are eligible for EPSDT-expanded coverage

Statutory basis42 U.S.C. § 1396d(r) (1905(r) of the Social Security Act) requires coverage for medically necessary services for beneficiaries under 21

ScopeCovers services medically necessary to correct or ameliorate a health problem identified through screening or evaluation

inv-29: Pregnancy obesity BMI thresholds

Provider Actions, Documentation & Prior Authorization

Prior Authorization

EPSDT and Prior Approval

If the service requires prior approval under policy, that requirement remains in effect for beneficiaries under 21; EPSDT does not waive prior approval. Providers must document medical necessity and EPSDT criteria when applicable. Prior approval may still be required per policy guidance and NCTracks resources.

Providers must verify beneficiary eligibility at each visit and ensure documentation justifies EPSDT exception when applicable.

Note

Prior Approval Not Required for These Services

Medicaid shall not require prior approval for Dietary Evaluation and Counseling and Medical Lactation Services.

Background

Dietary evaluation and counseling provide individualized nutrition guidance tied to the beneficiary's diagnosis and treatment, and medical lactation services offer clinical lactation assessment and interventions to support breastfeeding when there is a diagnosable medical need. Coverage requires that services be medically necessary, individualized, and safely furnished; for infants and breastfeeding dyads, medical lactation evaluation may be covered when a medical feeding condition (for example, poor latch or low weight gain) is diagnosed by a physician, NP, PA, or CNM. EPSDT requires coverage of medically necessary services for beneficiaries under 21 to correct or ameliorate health problems, but excludes services that are unsafe, ineffective, or experimental.

Definitions and Indications

inv-50: EPSDT definition and summary

Definition of EPSDTEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT) requires the state Medicaid agency to cover medically necessary services for beneficiaries under 21 to correct or ameliorate health problems identified through screening or evaluation

PurposeTo provide most medical or remedial care a child needs to improve/maintain health, compensate for a health problem, prevent worsening, or prevent additional problems

Exclusions within EPSDTEPSDT does not require coverage of services that are unsafe, ineffective, experimental/investigational, or not medical in nature

inv-51: Medicaid beneficiaries under 21 years of age - indications

Covered indications (selected)Inappropriate growth or weight gain, nutritional anemia, eating/feeding disorders causing medical conditions, physical conditions affecting growth/feeding, chronic infections with nutritional components

Revision History & Implementation

Policy Summary

PayerAlliance Health

PolicyDietary Evaluation and Counseling and Medical Lactation Services

Policy CodePolicy 1-I

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument medical necessity (and for beneficiaries under 21, demonstrate EPSDT criteria) when providing dietary evaluation, counseling, or medical lactation services.

SourceLink

On This Page

Children diagnosis flexibility: Children 0-20 years of age are not limited to a specific diagnosis for these services.

Pre-pregnancy/postpartum obesity threshold

BMI greater than 30 in same woman pre-pregnancy and postpartum

Early pregnancy threshold (6 weeks)BMI greater than 35 at 6 weeks of pregnancy

Later pregnancy threshold (12 weeks)BMI greater than 30 at 12 weeks of pregnancy

inv-30: Severe maternal anemia threshold

Severe maternal anemia thresholdHemoglobin (HgB) less than 10 m/dL or Hematocrit (Hct) less than 30%

ContextUsed as an indication for dietary evaluation and counseling when pregnancy is threatened by conditions where nutrition is critical

PopulationApplies to pregnant women (coverage includes postpartum follow-up if condition persists or develops early postpartum)

inv-31: Children age coverage (0-20 years not limited to diagnosis)

Children age coverageChildren 0-20 years of age are eligible and are not limited to a specific diagnosis for dietary evaluation and counseling

EPSDT overlapChildren under 21 also qualify under EPSDT when nutrition therapy is a critical component of management

Related noteSee qualifying pediatric indications for examples of covered conditions (inappropriate growth, nutritional anemia, feeding disorders, chronic conditions, etc.)

Denial Risk

Coverage Requires No Equally Effective, More Conservative or Less Costly Statewide Treatment

All services must be individualized, specific, consistent with the beneficiary's symptoms or confirmed diagnosis, not in excess of needs, and provided only when no equally effective and more conservative or less costly statewide treatment exists. Services may be denied if an equally effective conservative or less costly statewide treatment is available.

Documentation Required

Documentation of Medical Necessity and EPSDT

Providers must document medical necessity for every billed service. Documentation should support how the service corrects, ameliorates, or treats the diagnosed condition and, for beneficiaries under 21, how EPSDT criteria are met.

Include rationale linking clinical findings to the service requested.
Include evidence that less invasive options were considered if applicable.

Denial Risk

Denial Risk — Non‑Individualized or Inconsistent Services

Failure to individualize services, provide documentation consistent with the diagnosis, or providing services that are excessive or primarily for convenience can trigger claim denials.

Services that duplicate another provider's service or are experimental/investigational are not covered.
Providers must verify beneficiary eligibility prior to billing.

Billing Rule

Billing Noncompliance May Cause Denial

Claims that do not follow National Uniform Billing (UB-04) or National Coding Guidelines (CPT/HCPCS) may be denied. Institutional claims must follow the National Uniform Billing Guidelines; all claims must comply with National Coding Guidelines.

Bill professional claims on CMS-1500/837P and institutional claims on UB-04/837I as directed.
Do not bill services to both WIC and Medicaid for the same staff time when WIC-administered services were provided.

Billing Rule

Coding Specificity Requirement

Providers shall report the most specific CPT/HCPCS code that accurately and completely describes the service. If no specific code exists, report the appropriate unlisted procedure or service code. Failure to report the most specific code or an appropriate unlisted code may result in denial.

Use current edition CPT, HCPCS, and UB-04 Data Specifications Manual in effect at date of service.
Report unlisted procedure codes when no specific code exists.

Documentation Required

Required Documentation — Dietary Evaluation and Counseling

Required documentation for Dietary Evaluation and Counseling includes review of medical management and psychosocial history; assessment of living conditions related to nutrition; diagnostic nutritional assessment (labs/anthropometrics, dietary analysis, nutrient‑drug interaction assessment, feeding skills); development of an individualized nutrition care plan (nutrition/calorie recommendations, therapeutic diet calculations, referrals); counseling on nutrition management; consultation with the beneficiary's primary care provider; and education on reading food labels.

Maintain an order or referral from the beneficiary's primary care or specialty provider.
Record date of service, presenting problem, summary of required nutrition service components, and the qualified nutritionist's signature.

Documentation Required

Required Documentation — Medical Lactation Services

Required documentation for Medical Lactation Services includes review of infant medical management and psychosocial history; a diagnostic lactation assessment (feeding history, urine/stool output, infant weight measured in person, skin and hydration assessment, alertness); review/consultation of pertinent infant labs/radiology; observation of feeding with pre‑ and post‑weights if indicated; referrals for additional testing/treatment as needed; and communication of findings to the infant's primary care provider.

Maintain an order or referral from the beneficiary's primary care or specialty provider.
Record date of service, presenting problem, summary of required lactation service components, and the signature of the qualified IBCLC, MD, CNM, NP or PA providing the service.
Infant weight cannot be obtained via telephone or audio/video; in‑person measurement required when weight is part of the assessment.

Documentation Required

Required Clinical Documentation and Coding

Clinical documentation and coding requirements: a qualifying medical condition must be diagnosed by an MD, NP, PA, or CNM. If an IBCLC and a physician see the beneficiary on the same date, the physician must bill using the appropriate E/M code and include services provided by the IBCLC; health and behavior codes 96156/96158/96159 may not be reported the same date as an E/M service. Visits billed under IBCLC time are reported in 15‑minute increments (one unit) based on the IBCLC's time when performed. Federally qualified health centers and rural health clinics use HCPCS T1015. Hospital outpatient clinics use RC 942 for dietary services.

Ensure coding follows the listed CPT codes for dietary and lactation services (e.g., 97802, 97803; 96156, 96158, 96159) and facility‑specific billing instructions.
Do not report health and behavior codes 96156/96158/96159 on the same date as an E/M service.
When both physician and IBCLC are seen same date, sequence and bill per guidance: physician E/M must include IBCLC services as appropriate.

ExamplesCystic fibrosis, cerebral palsy, necrotizing enterocolitis, chronic cardiac disease, cancer, metabolic disorders

RequirementNutrition therapy must be a critical component of medical management for coverage

inv-52: Pregnant and postpartum women - indications

Covered pregnancy/postpartum indications (selected)Severe anemia, preconception underweight, inadequate gestational weight gain, intrauterine growth retardation, multiple gestation, substance use, metabolic and chronic medical disorders

Obesity-specific thresholdsObesity covered when BMI thresholds in policy are met (see BMI criteria)

Postpartum coveragePostpartum women needing follow-up for conditions that threatened pregnancy or who develop such conditions early postpartum are eligible

inv-53: Medical lactation services - infant indications

Infant indications for medical lactation servicesLatch-on difficulties, prematurity, multiple birth, special-needs infant affecting feeding, jaundice, dehydration with difficulty gaining weight, inadequate weight gain or inappropriate weight loss

Condition for coverageMedical lactation services covered when infant has a chronic, episodic, or acute condition for which lactation services are a critical component of medical management

Service elementsServices include individualized assessment and counseling for the breastfeeding dyad

inv-54: EPSDT exception to policy limitations

EPSDT exception to policy limitsFor beneficiaries under 21, EPSDT allows exceptions to policy limitations when services are medically necessary to correct or ameliorate a health problem identified through screening or evaluation

Prior approval noteIf a service requires prior approval, that requirement still applies even for beneficiaries under 21 (see Subsection 2.2.1)

Exclusions still applyEPSDT does not require coverage of services that are unsafe, ineffective, experimental/investigational, or not medical in nature

inv-55: Medical lactation services — IBCLC-provided service billing units and requirement for underlying medical condition

IBCLC billing unitsIBCLC-provided medical lactation services are billable in 15-minute increments (1 unit per 15 minutes)

Provider requirementA qualifying medical condition must be diagnosed by a physician, NP, PA, or CNM for IBCLC services to be covered

Billing relationshipPhysicians, NPs, PAs, CNMs may bill for IBCLC services under employment or by including services in their office visit codes; if seen same date by physician and IBCLC, the physician must bill the appropriate E/M code and health and behavior codes may not be reported on same date as an E/M by the IBCLC