Ob-Gyn Coding Alert

Question: I am trying to figure out if 99404 can be used to bill for lactation services provided at my hospital as an outpatient service (facility charge vs. office). Also, can this be billed by the registered nurse (RN) providing the lactation services or does a physician need to be present?

Minnesota Subscriber

Answer: The Affordable Care Act, which is still in place, states that payers must cover, at no cost to the patient, “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.” The problem is the law does not define what comprehensive support means, who qualifies as a trained provider, nor how to bill for it. So basically, this is payer dependent.

Also, you have to know if this is a class, whether the RN is qualified to teach under state regulations, and so on. For instance, only a provider who can be paid directly and is giving individual lactation services for a particular patient can bill 99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes). This level of service would not fly if the RN was providing the service, nor if she was teaching more than one patient.

Another option (if this RN qualifies under the payer rules as a nonphysician provider (NPP) rather than clinical staff) is 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 (could include caregiver/family) each 30 minutes; individual patient) for self- management. Also, you have S9443 (Lactation classes, non-physician provider, per session) for lactation classes by a nonphysician. Again, check with your payers on this. If these classes are associated with the delivery in any way, the facility fee will be bundled for sure, but the provider might be able to bill.