CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lactation consultations

Policy governing coverage of lactation consultation services provided to breastfeeding women, including who may provide the service and applicable coding and diagnosis requirements for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLactation consultations

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionFile claims using CPT 98960 with a primary diagnosis from the listed ICD-10 codes and ensure services are provided by an IBCLC or physician.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

98960CPT to bill

IBCLC or physicianRequired provider

No prior authPrior auth

PPACAPreventive benefit

Coverage Criteria for Lactation Consultations

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Provider: Service is provided by an International Board-Certified Lactation Consultant (IBCLC/RLC) or a physician

Services provided by a Home Care Agency are covered as part of the home care per diem

Coding: Claim is filed with CPT 98960

Time-based CPT guidelines apply; a unit is obtained when the midpoint is passed (e.g., 16 minutes required to bill one 30-minute unit)

Diagnosis: A primary diagnosis is one of the ICD-10 codes listed in the policy (see ICD-10 list)

ICD-10 codes listed in policy include 092.011-092.013, 092.019, 092.02-092.03, 092.111-092.113, 092.12-092.13, 092.20, 092.29, 092.3, 092.4-092.5, 092.70, 092.79, P92.1-P92.5, P92.8-P92.9

Benefit coverage may vary by group and contract; PPACA preventive services may apply with no cost when delivered by a network provider

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable office visit or preventive services benefits

Benefits for lactation consultations may vary by group and contract. Refer to the member's Benefit Booklet, Evidence of Coverage or Subscriber Agreement and the employer contract to determine applicable office visit or preventive services benefits. The policy notes that lactation consultations can be a PPACA preventive service and may be covered with no cost-share when delivered by a network provider.

If services are determined to be not medically necessary or are non-covered benefits under the member's plan, those services may not be billed to the member unless the provider has informed the member in advance and the member has agreed in writing to pay for the services. For member-specific benefit or eligibility questions, contact the provider call center or review the subscriber agreement and employer contract.

Coding and Billing

Covered CPT CodesCPTCovered

98960

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

Covered ICD-10 Diagnosis CodesICD-10Covered

092.011-092.013 092.019 092.02-092.03 092.111-092.113 092.12-092.13 092.20 092.29 092.3 092.4-092.5 092.70 092.79	Listed ICD-10 diagnosis codes (as provided in policy)
P92.1-P92.5 P92.8-P92.9	Listed ICD-10 diagnosis codes (as provided in policy)

inv-06: Billing unit timing

Billing unit ruleA unit is obtained when the midpoint is passed (example: 16 minutes of face-to-face time required to bill one 30-minute unit)

Time-based CPT guidanceCPT coding guidelines regarding time-based codes are followed for CPT 98960

Example applicationBill one unit of 98960 when at least 16 minutes of individualized, face-to-face education/training have occurred

Provider Actions and Billing Requirements

Prior Authorization

Not applicable: No prior authorization is required for lactation consultations.

Note

Reserved

Billing Rule

Claim submission

Claims must be filed using CPT code 98960 with a primary diagnosis from the ICD-10 list provided in the policy. Follow CPT time-based coding guidelines: a unit is obtained when the midpoint is passed (e.g., 16 minutes of face-to-face time needed to bill one 30-minute unit).

CPT: 98960 - Education and training for patient self-management by a qualified, nonphysician health care professional, each 30 minutes; individual
ICD-10: See ICD-10 diagnosis codes list in policy (P92.1-P92.5, P92.8-P92.9, and listed 092.* codes)

Documentation Required

Provider credential requirement

Services must be provided by an International Board-Certified Lactation Consultant (IBCLC/RLC) or a physician. Services provided by other provider types may not be covered. Note: Services provided by a Home Care Agency are covered as part of the home care per diem.

Background

An International Board-Certified Lactation Consultant (IBCLC), also referred to as a Registered Lactation Consultant (RLC), is a health professional who completes accredited lactation education, clinical training and an international certification exam to specialize in clinical management of breastfeeding. Lactation consultations address breastfeeding support and management of breastfeeding difficulties related to anatomic variations and newborn feeding problems. Covered services must be provided by an IBCLC (RLC) or a physician as specified in the policy.

Definitions

inv-12: IBCLC / RLC definition

DefinitionInternational Board-Certified Lactation Consultant (IBCLC) — a health care professional who specializes in the clinical management of breastfeeding with extensive formal lactation education and clinical training, who has passed an international certification exam

Alternate titleMay also be called a Registered Lactation Consultant (RLC)

Scope of servicesProvides educational services and clinical management to women who plan to breastfeed but encounter difficulties due to anatomic variations or newborn feeding problems

Licensure qualifications (RI)To be licensed in Rhode Island, applicants must complete an accredited academic and practical lactation program, be at least 18 years old, and pass the IBCLC board certification exam