CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP043

Lactation Support Services

Defines appropriate coding, billing, provider qualifications, locations, and reimbursement guidance for lactation support services for members and their infants under Blue Cross Blue Shield - Oklahoma plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLactation Support Services

Policy CodePolicy CPCP043

Change TypeNew policy (version 1.0)

Effective DateJune 26, 2025

Next Review Date

Key ActionBill one claim per lactation session for the lactating member-baby dyad and include required documentation when requested.

SourceLink

POLICY UPDATE CHANGES

New enterprise policy establishing coding and payment guidance for lactation support services.

1.0policy version

Jun 26, 2025plan effective date

CPCP043policy number

98960-98962, S9443, G0513-4, 99401-99404, 99411-99412, 99347-99350codes referenced

Coverage and Billing Criteria

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Coverage is dependent on the member’s plan benefits and applicable statutes; lactation support services may qualify as preventive services.

Services must be billed for the lactating member-baby dyad; providers should bill one claim per lactation session and include appropriate diagnosis code(s) to determine reimbursement.

ALL of the following

Qualified providers include physicians, registered nurses, physician assistants, nurse practitioners, and other licensed or certified providers with lactation training (examples: IBCLC, CLC).
Independent Lactation Consultants/Counselors (CLC or IBCLC) are non-physician qualified health care professionals; if not associated with the plan network, claims may be processed as out-of-network per the member’s benefits.

Services rendered during an inpatient hospital or facility stay are not eligible for separate reimbursement and should not be billed separately.

ALL of the following

Non-physician qualified health care professionals may report CPT codes 98960-98962 for individual self-management education/training and HCPCS S9443 for lactation classes (non-physician) as recognized by the Plan.
Physicians or qualified providers acting within their scope may report prolonged preventive service add-ons G0513-G0514, preventive counseling CPT codes 99401-99404 (individual) and 99411-99412 (group), and home visit codes 99347-99350 as appropriate; these codes are not eligible when submitted by non-physician providers.
Unlisted preventive medicine code 99429 should not be reported for services described in this policy.

ALL of the following

CPT 98960-98962 are timed codes that cover up to 30 minutes per unit; two units may be billed to represent approximately one hour of service.
HCPCS S9443 is not a timed code; additional units for the same session are not permitted.

ALL of the following

Billing for multiple family members in the same session on the same day is not eligible for reimbursement.
For lactating members with multiples, providers may report additional time spent caring for the dyad as appropriate (report additional time rather than billing separate family-member claims).

Documentation and reimbursement note: The Plan may request supporting documentation; inclusion of a code on a claim does not guarantee reimbursement.

Codes, Unitization, and Timed Services

Non-physician lactation service codesCPT | HCPCSCovered

98960-98962	Self-management education/training (non-physician timed codes for individual education/counseling)
S9443	Lactation classes, non-physician provider, per session

Physician/provider codesCPT | HCPCSCovered

G0513-G0514	Prolonged preventive services (add-on first 30 min and each additional 30 min)
99401-99404	Preventive counseling individual 15-60 min
99411-99412	Preventive counseling group 30-60 min
99347-99350	Home/residence visits, various complexity and time

Non-physician timed service duration

Unit lengthCPT codes 98960-98962 are timed codes covering up to 30 minutes per unit.

Typical billing for 1 hourTwo units of 98960-98962 may be billed to represent approximately 1 hour of service (2 units ≈ 1 hour).

Use by non-physiciansNon-physician qualified health care professionals may use 98960-98962 for individual education/counseling services.

S9443 unitization

Code statusHCPCS code S9443 is recognized by the Plan for preventive lactation support services by non-physician providers.

Unitization ruleS9443 is not a timed code; no additional units may be billed for S9443.

Typical useS9443 is reported per session for lactation classes or group education by non-physician providers.

Documentation, Network Status, and Reimbursement Actions

Documentation Required

Plan may request supporting documentation; code inclusion not a guarantee of payment

The plan reserves the right to request supporting documentation for lactation services; inclusion of a code in this policy does not guarantee reimbursement. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Provide documentation when requested to support medical necessity and coding.
Understand that presence of a listed code alone is not authorization for payment.

Billing Rule

Independent lactation consultants may be processed as out-of-network

Independent lactation consultants or counselors who are not part of the Plan's network may have their claims processed as out-of-network according to the member's individual benefits; confirm network status and member benefit terms prior to billing.

Verify whether the lactation consultant is associated with a network practice before submitting claims.
If the consultant is independent and not in-network, expect out-of-network processing per member benefits.

Key Definitions

Lactation support — definition

DefinitionLactation support includes education, counseling, or behavioral interventions to improve breastfeeding outcomes (e.g., promoting breastfeeding, helping with latch and positioning, managing lactation problems, counseling on return to work/school).

ScopeServices may be provided during antenatal, perinatal, and postpartum periods and may qualify as preventive services.

Examples of servicesActivities include assisting with latch/positioning, managing lactation crises, counseling, and coordination with other health care providers.

Lactating Member-Baby Dyad — billing convention

Dyad conceptLactation visits depend on the lactating member-baby dyad and require participation of both the lactating member and the infant.

Single patient billingThe dyad is considered one patient; visits should be billed on one claim per session.

Multiple family membersBilling for multiple family members in the same session on the same day is not eligible for reimbursement; for multiples, report additional time for the dyad as appropriate.

Qualified Health Care Professional — eligible providers

Included professionalsQualified health care professionals include physicians, registered nurses (RNs), physician assistants (PAs), and nurse practitioners (NPs) with lactation training.

Lactation specialistsCertified Lactation Counselors (CLC) and International Board-Certified Lactation Consultants (IBCLC) are recognized non-physician qualified professionals for reimbursement when applicable.

Scope and settingServices must be provided within the provider's scope of license or certification; services rendered during an inpatient stay are not separately billable.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLactation Support Services

Policy CodePolicy CPCP043

Change TypeNew policy (version 1.0)

Effective DateJune 26, 2025

Next Review Date

Key ActionBill one claim per lactation session for the lactating member-baby dyad and include required documentation when requested.

SourceLink

On This Page

OpenPayer

Lactation Support Services

Coverage and Billing Criteria

Codes, Unitization, and Timed Services

Documentation, Network Status, and Reimbursement Actions

Key Definitions

Policy Changes and Effective Dates