CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lactation Consultations Payment Policy

Defines payment policy for lactation consultation services rendered by International Board Certified Lactation Consultants (IBCLC/RLC) or physicians, including required CPT code, applicable ICD-10 diagnosis codes, and billing/time guidance. Notes coverage interplay with home care per diem and PPACA preventive services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLactation Consultations Payment Policy

Policy CodePolicy N/A

Change Typeclarified

Effective DateApr 1, 2017

Next Review Date

Key ActionFile claims for lactation consultations with CPT 98960 and a qualifying primary ICD-10 diagnosis, document IBCLC/RLC or physician provision, and do not bill separately when services are part of a Home Care Agency per diem.

SourceLink

POLICY UPDATE CHANGES

Policy last updated on 2019-09-03; no material clinical policy statement changes indicated in document.

1Required CPT code

26Listed ICD-10 diagnosis codes

0Prior authorization required

1Provider types eligible (IBCLC/RLC or physician)

Policy overview

Background: Lactation consultations refer to educational services and clinical management provided to women planning to breastfeed who encounter anatomic or newborn feeding problems. These services are typically delivered by an International Board Certified Lactation Consultant (IBCLC), also called a Registered Lactation Consultant (RLC), who is a certified health professional with specialized lactation education, clinical training, board certification, and continuing education requirements. Rhode Island licensing rules specify qualifications for licensure as a lactation consultant (see R23-13.6-LAC).

Scope summary and payment policy (effective 04/01/2017, status CURRENT, last reviewed 09/03/2019): Coverage is allowed when services are provided by an IBCLC/RLC or a physician, the claim is filed with CPT code 98960, and the primary diagnosis on the claim is one of the listed ICD-10 codes. When services are furnished by a Home Care Agency they are included in the home care per diem and are not separately payable. Lactation consultations fall under PPACA preventive services for women (breastfeeding support) with no cost sharing when delivered by a network provider. Claims should follow CPT time-based coding guidelines.

Key metadata

effective date2017-04-01

last review2019-09-03

next review

statusCURRENT

scope_summaryDefines payment policy for lactation consultation services rendered by International Board Certified Lactation Consultants (IBCLC/RLC) or physicians, including required CPT code, applicable ICD-10 diagnosis codes, and billing/time guidance. Notes coverage interplay with home care per diem and PPACA preventive services.

policy_numberN/A

provider types eligibleIBCLC/RLC or physician

Coverage criteria

Coverage / Provider and Diagnosis Requirements

Lactation consultations are covered when ALL of the following are met:

Provider: Service is provided by an International Board Certified Lactation Consultant (IBCLC/RLC) or a physician
Confirm and document IBCLC/RLC certification or physician provision as applicable (Rhode Island licensing qualifications referenced).
Billing Code: Claim is filed with CPT code 98960Follow CPT time midpoint rule: a 30-minute unit is obtained when the midpoint is passed (example: 16 minutes of face-to-face time required to bill one 30-minute unit).
Diagnosis: Primary diagnosis on the claim is one of the listed ICD-10 codesICD-10 codes: O92.011, O92.012, O92.013, O92.019, O92.02, O92.03, O92.111, O92.112, O92.113, O92.12, O92.13, O92.20, O92.29, O92.3, O92.4, O92.5, O92.70, O92.79, P92.1, P92.2, P92.3, P92.4, P92.5, P92.8, P92.9

Home care exception

Bundling: Services provided by a Home Care Agency are covered as part of the home care per diem (i.e., not separately payable)
Do not bill lactation consultations separately when provided under a home care per diem.

Codes & billingable items

Required CPT for lactation consultation billingCPTCovered

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient each 30 minutes; individual patient

Applicable ICD-10 primary diagnosis codes (covered when billed with CPT 98960)ICD-10Covered

O92.011
O92.012
O92.013
O92.019
O92.02
O92.03
O92.111
O92.112
O92.113
O92.12

1–10 of 25

1/3

Billing guidance: Use CPT time-based coding rules for 98960 — a unit (30-minute) is obtained when the midpoint is passed; for example, 16 minutes of face-to-face time meets the threshold to bill one 30-minute unit, per CPT time-based coding guidelines.

Required provider actions & documentation

Billing Rule

Use CPT 98960 with qualifying diagnosis

File claims for lactation consultations with CPT code 98960 and an applicable primary ICD-10 diagnosis from the policy list. Follow CPT time-based coding guidelines: a 30-minute unit is counted when the midpoint is passed (example: 16 minutes face-to-face required to bill one 30-minute unit).

Affected CPT code: 98960
CPT time midpoint rule: a unit is obtained when the midpoint is passed (e.g., 16 minutes for one 30-minute unit)

Documentation Required

Provider qualification documentation

Confirm and document that the lactation consultation was provided by an International Board Certified Lactation Consultant (IBCLC/RLC) or a physician. Reference Rhode Island licensing/certification rules for IBCLC qualifications when documenting provider credentials.

Billing Rule

Home care per diem bundling

Lactation consultations delivered by a Home Care Agency are considered included in the home care per diem and must not be billed separately.

Document revision history

2019-11Provider Update

Provider Update published November 2019

2017-06Provider Update

Provider Update published June 2017

2016-09Provider Update

Provider Update published September 2016

2019-09-03Policy updateLatest

Policy last updated on 2019-09-03; no material clinical policy statement changes indicated