CurrentBlue Cross Blue Shield - TexasPolicy CPCPO43

Lactation Support Services Coding and Reimbursement

Defines appropriate coding, eligible providers, billing rules, and reimbursement guidance for lactation support services provided during antenatal, perinatal, and postpartum periods to Blue Cross Blue Shield of Texas members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyLactation Support Services Coding and Reimbursement

Policy CodePolicy CPCPO43

Change TypeNew policy

Effective DateJun 26, 2025

Next Review Date

Key ActionBill lactation visits as one claim per lactating member-baby dyad per session and submit supporting documentation when requested.

SourceLink

POLICY UPDATE CHANGES

New policy establishing coding and reimbursement guidance for lactation support services.

1.0policy version

Jun 26, 2025plan effective date

1new policy entry

Mar 14, 2025committee approval

Policy Overview

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This Blue Cross Blue Shield of Texas policy (CPCPO43) establishes coding and reimbursement guidance for lactation support services provided during the antenatal, perinatal, and postpartum periods. It defines eligible providers, acceptable service settings, and required coding rules to determine reimbursement. Coverage is subject to member plan benefits and documentation requirements, and services must be billed per the lactating member-baby dyad as outlined in the policy.

Coverage Criteria

Coverage criteria

Reimbursement eligibility depends on provider qualification, service setting, coding, and member plan benefits.

ALL of the following

Provider qualification
- Services must be provided by a qualified health care professional (physician or non-physician) with lactation training (includes physicians, registered nurses, physician assistants, nurse practitioners, and other providers acting within the scope of their license or certification).
- Independent Lactation Consultants/Counselors (e.g., Certified Lactation Counselors [CLC], International Board-Certified Lactation Consultants [IBCLC]) are non-physician qualified professionals; reimbursement for consultants not associated with a network practice may be processed as out-of-network per the member's benefit terms.
Services rendered during an inpatient stay are not eligible for separate reimbursement and should not be billed separately.
Visits are billed as one claim per lactating member-baby dyad per session; do not bill multiple family members for the same session.
Coverage and reimbursement are subject to the member's specific plan terms and applicable statutes/mandates; inclusion of a code does not guarantee payment and appropriate diagnosis codes must be included on the claim to determine eligibility.
Code-specific rules
- Non-physician providers may report 98960-98962 (self-management education and training) and HCPCS S9443 (lactation classes, non-physician, per session). S9443 is reported per session (not timed).
- Physician or other qualified providers should report the listed physician/provider CPT and HCPCS codes when acting within their scope of practice; unlisted preventive medicine code 99429 should not be used for services described in this policy.
Services may be rendered in hospital outpatient, clinic, breastfeeding center, provider office, or member home; use the appropriate place of service code when billing.
Plan may request supporting documentation; providers must submit accurate documentation and valid code combinations per HIPAA code sets and industry coding guidelines.

Coding and Billing Guidance

Non-physician lactation support codesCPT | HCPCSCovered

98960	Self-management education and training; 98960
98961	Self-management education and training; 98961
98962	Self-management education and training; 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 individual 15 min
99402	Preventive counseling individual 30 min
99403	Preventive counseling individual 45 min
99404	Preventive counseling individual 60 min
99411	Preventive counseling group 30 min
99412	Preventive counseling group 60 min
99347	Home/residence visit, established patient, level with straightforward MDM
99348	Home/residence visit, established patient, low MDM

1–10 of 12

1/2

Not to be usedCPTNot Covered

99429

Unlisted preventive medicine service

Timing and units guidance for lactation support codes

98960-98962 timingEach of CPT 98960–98962 is a timed code for up to 30 minutes; providers may bill 2 units to represent approximately 1 hour of total time.

S9443 session billingHCPCS S9443 is a per-session (non‑timed) code for lactation classes/non‑physician provider; no additional units may be billed for time increments.

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

Place-of-service and claim rulesBill using appropriate place-of-service and include required diagnosis codes to determine eligibility; services during an inpatient stay are not separately reimbursable.

Provider Actions and Billing Rules

Documentation Required

Documentation and Reimbursement Disclaimer

The plan may request supporting documentation to substantiate services billed. Failure to provide adequate documentation or to follow coding and billing policies may affect claims processing and reimbursement. Inclusion of a code in this policy does not guarantee payment under the member's benefit.

Billing Rule

Billing per Dyad and Coverage Dependency

Lactation visits involve the lactating member-baby dyad and are considered one patient. Providers should bill one claim per session for the dyad. Coverage and payment for lactation services are subject to the member's specific plan benefits and terms; appropriate diagnosis code(s) must be included on the claim to determine eligibility.

Bill one claim per session for the lactating member-baby dyad
Include appropriate diagnosis code(s) on the claim
Coverage depends on the member's plan benefits

Definitions

Lactation support — definition and scope

DefinitionEducation, counseling, or behavioral interventions to improve breastfeeding outcomes, including promoting breastfeeding, helping with latch and positioning, counseling on returning to work or school, and managing lactation problems.

Typical servicesMay include promoting breastfeeding, assisting with latch/positioning, managing lactation crises, and coordination with other health care providers.

Preventive statusLactation support services may qualify as preventive services; refer to the Preventive Services policy for additional details.

Independent Lactation Consultant / Counselor — definition and reimbursement note

DefinitionNon-physician qualified health care professionals such as Certified Lactation Counselors (CLC) and International Board-Certified Lactation Consultants (IBCLC) who provide professional lactation counseling and management.

Eligibility for reimbursementIndependent consultants affiliated with a network practice or holding recognized certifications (CLC, IBCLC) may be eligible for reimbursement per member benefit terms; out-of-network consultants may be processed per the member's coverage.

Scope of practiceThese professionals have specialized lactation training and certification; IBCLCs have formal clinical training and must meet continuing education requirements.

Lactating member‑baby dyad — billing definition

DefinitionThe lactating member and baby participating together in a visit are considered one patient (the member‑baby dyad) and the visit should be billed on one claim per session.

Billing implicationDo not bill multiple family members for the same session on the same day; for members with multiples, report additional time spent caring for the dyad as appropriate.

Claim submissionOne claim per session should represent the dyad encounter and include applicable diagnosis codes and place-of-service information to determine reimbursement eligibility.