CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lactation consultations — Coverage and billing

Policy governs coverage and billing for lactation consultation services provided to members who plan to breastfeed and encounter breastfeeding difficulties; applies to Medicare Advantage and Commercial products administered by BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLactation consultations — Coverage and billing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionSubmit claims for lactation consultation services on a single claim listing the mother as the patient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1unit allowed per date of service for CPT 98960

98960primary billed procedure code specified

ICD-10 listdiagnosis codes required for separate reimbursement

IBCLC or physicianrequired provider qualification for covered services

Coverage Criteria

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Covered with criteria

Covered when ALL of the following are met

Provider qualification: Service is provided by an International Board-Certified Lactation Consultant (RLC) or physician.

Licensure requirements for IBCLC per Rhode Island rules apply.

Procedure code: CPT 98960 is billed for the service (maximum one unit per date of service).max 1 unit per date of service

Commercial: no cost share when filed with listed ICD-10 diagnosis; Medicare Advantage: applicable cost share applies.

Diagnosis coding: A primary diagnosis from the policy's ICD-10 Diagnosis Code list is filed for separate reimbursement.primary diagnosis must be from list

If a diagnosis not on the list is used, the service will be covered but not separately reimbursed.

Claim patient: Claim must list the mother as the patient; claims submitted under an infant (ages 0-12 months) will not be considered for reimbursement.

Claims for lactation consultation services must be submitted on a single claim listing the mother as the patient.

Claims for lactation consultation services must be submitted on a single claim listing the mother as the patient. Claims submitted under an infant (ages 0–12 months) will not be considered for reimbursement. A maximum of one (1) unit for CPT code 98960 per date of service will be considered for reimbursement; when CPT 98960 is time-based, a unit is obtained when the midpoint is passed (for example, 16 minutes of face-to-face time to bill a 30-minute unit).

If CPT 98960 is filed with a primary diagnosis that is not on the policy's ICD-10 Diagnosis Code list, the service will be covered but not separately reimbursed.

Coding

Covered CPT CodesCPTCovered

98960

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

ICD-10 Diagnosis Codes for separate reimbursementICD-10

092.011-092.013 092.019 092.02-092.03 092.111-092.113 092.12-092.13 092.119 092.20 092.29 092.3 092.4-092.5 092.70 092.79 P92.1-P92.6 P92.8-P92.9

ICD-10 Diagnosis Code(s) list provided by policy

Billing unit time midpoint (CPT 98960)

Midpoint rule for CPT 98960A billing unit for CPT 98960 is obtained when the midpoint of the time period is passed (example: 16 minutes of face-to-face time to bill a 30-minute unit).

Example time threshold16 minutes required to bill one 30-minute unit (midpoint of 30 minutes).

Applies to time-based codingCPT guidelines regarding time-based codes are followed for CPT 98960 units (midpoint rule).

Impact on unit countingUnits should be counted per date of service with the midpoint rule determining whether an additional unit is billable.

Provider Actions / Billing Requirements

Prior Authorization

No prior authorization is required for lactation consultation services.

Billing Rule

Patient on Claim Requirement

Claims must be submitted with the mother listed as the patient on the claim. Claims submitted under an infant (ages 0-12 months) will not be considered for reimbursement.

Denial Risk

Claims for Infant as Patient Not Reimbursable

Claims submitted under an infant (ages 0-12 months) will not be considered for reimbursement.

Billing Rule

Billing Limit for CPT 98960

A maximum of one (1) unit for CPT Code 98960 per date of service will be considered for reimbursement.

Affected code: CPT 98960 — limit 1 unit per date of service

Background

Lactation consultations are educational services and clinical management provided to members who plan to breastfeed and encounter anatomic variations or newborn feeding problems. These services are delivered by qualified providers, such as an International Board‑Certified Lactation Consultant (IBCLC/RLC) or a physician, and focus on education, troubleshooting of breastfeeding technique, and management of lactation-related issues to support successful breastfeeding.

Definitions

IBCLC / RLC — definition

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

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

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

Ongoing requirementsIBCLCs have continuing education requirements in lactation as part of certification maintenance.