CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP043

Lactation Support Services — Coding and Payment Guidance

Defines appropriate coding, billing, provider qualifications, and reimbursement guidance for lactation support services provided to the lactating member–baby dyad under Blue Cross Blue Shield of New Mexico plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLactation Support Services — Coding and Payment Guidance

Policy CodePolicy CPCP043

Change TypeNo material changes

Effective DateJun 26, 2025

Next Review Date

Key ActionSubmit accurate documentation upon request; claims are subject to review and inclusion of a code does not guarantee reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1new policy (version 1.0)

CPT 98960-98962, G0513-G0514, 99401-99404, 99411-99412, 99347-99350, S9443primary codes listed for lactation services

One claim per sessionbilling rule for lactation dyad

Not billable inpatientfacility/inpatient billing restriction

Preventivemay qualify as preventive; refer to CPCP006

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Coverage Criteria

Coverage criteria for lactation support

Covered when ALL of the following conditions are met:

Coverage and payment are subject to the member's plan benefits and applicable laws and regulations; inclusion of a code in this policy does not guarantee reimbursement.

Refer to member plan benefits and CPCP006 for preventive coverage determinations.

Services are provided to the lactating member–baby dyad and billed as one claim per lactation session.

Providers should only bill one claim per session.

Appropriate diagnosis code(s) are included on the claim to determine eligible reimbursement.

Supporting documentation is available upon request and must be provided; the plan may request records and claims are subject to review and coding edits.

Inclusion of a code does not guarantee reimbursement; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Services are furnished in a setting that permits separate billing (outpatient, home, clinic, hospital outpatient, breastfeeding center); services rendered during an inpatient stay are not separately billable.

Coding and Billing

Non-physician lactation supportCPTCovered

98960	Self Mgmt Educ/Train 1 Patient
98961	98961
98962	98962
S9443	Lactation classes, non-physician provider, per session

Physician/provider codesCPTCovered

G0513	Prolonged preventive service; first 30 minutes
G0514	Prolonged preventive service; each additional 30 minutes
99401	Preventive Counseling Indiv 15 min
99402	Preventive Counseling Indiv 30 min
99403	Preventive Counseling Indiv 45 min
99404	Preventive Counseling Indiv 60 min
99411	Preventive Counseling Group 30 min
99412	Preventive Counseling Group 60 min
99347	Home/Res Vst Est SF MDM 20
99348	Home/Res Vst Est Low MDM 30

1–10 of 12

1/2

Timed unit guidance for 98960-98962

Timed CPT codes 98960-98962May be billed with multiple units (example: 2 units for 1 hour of time).

HCPCS S9443 unit ruleS9443 is not a timed code; only one unit per session may be billed.

Scope of S9443Recognized by the Plan for preventive lactation support services when provided by a non-physician qualified health care professional (e.g., CLC, IBCLC).

Provider Actions and Billing Requirements

Documentation Required

Documentation and claim review

Providers must submit accurate and complete documentation for all services rendered. Claims are subject to coding edits and review against benefit terms, provider contracts, clinical payment and coding policies, and automated coding logic. Upon request, the plan may require supporting documentation; providers are urged to supply additional records promptly to avoid delays or denials.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG, etc.).
Claims may be subject to Uniform Billing, NCCI, and other industry-standard coding edits.
Failure to provide requested documentation or to adhere to coding/billing policies may impact claims processing and reimbursement.

Note

Network status impacts

Network status affects how claims from independent lactation consultants/counselors are processed. Independent Lactation Consultants and/or Counselors (e.g., CLC, IBCLC) who are not part of the payer's network may have claims processed as out-of-network per the member's individual benefits.

Definitions

Lactation dyad definition

Definition of the dyadThe lactating member and baby are considered one patient for billing; one claim should be submitted per session.

Participation requirementVisits require participation of both the lactating member and the baby to qualify as a dyad encounter.

Billing limitationBilling multiple family members for the same session on the same day is not eligible—one claim per session for the dyad.

Qualified personnel for lactation support

Physicians and advanced practice cliniciansPhysicians, nurse practitioners (NPs), and physician assistants (PAs) with lactation training may provide services within scope of their license.

Registered nursesRegistered nurses (RNs) with specific lactation training may provide lactation support services within scope of practice.