Pediatric Coding Alert

Provider credentials key to accurate billing.

Giving Mom the best possible advice about breastfeeding her infant isn’t only one of the most important services your pediatrician can provide for newborns — it’s now also the law.

“Breastfeeding counseling is now a required service for most insurance plans since the passage of the Affordable Care Act,” Laurie Bouzarelos, MHA, CPC-A, contracting and chart auditing specialist at Physician’s Ally Inc. of Littleton, Colorado, reminds coders.

But the service can raise plenty of questions when it comes to billing and coding. That’s why we’ve pulled together three of the most asked questions and answered them for you.

Question: Can we bill for lactation services if there is no breastfeeding problem?

Answer: Should your pediatrician provide lactation services at the newborn’s first visit, you would bill for it with 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year), or 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), using time to determine the appropriate level, as counseling will take up more than 50 percent of the encounter.

Question: But what if someone other than our pediatrician provides lactation services?

Answer: This is where coding and billing gets a little tricky, as the issue of credentialing comes into play. Lactation certifications are numerous and include such titles as certified lactation educator (CLE), certified lactation counselor (CLC), and lactation consultant, also known as an International Board Certified Lactation Consultant, or IBCLC.

Each one varies in their scope of practice. “An IBCLC, for example, has a much broader scope of practice and can work with more challenging situations and complicated cases,” according to Natalie O’Connor, LPN, LMT, CLC, a certified lactation counselor with Twelve Corners Pediatrics in Rochester, NY.

However, “there is no requirement for an IBCLC to be a qualified healthcare provider [QHP]. If they are not a licensed provider, they have to work with a physician, a nurse practitioner [NP] or a physician assistant [PA],” cautions Bouzarelos. This means CLEs, CLCs, and IBCLCs who are not QHPs must operate under incident-to rules, and “work in tandem with the pediatrician and be mindful of the doctor’s plan, helping the provider with a feeding plan and following up with Mom to build on and supplement their visit,” according to O’Connor.

A number of other services are also appropriate for lactation counseling, including

• S9443 (Lactation classes, non-physician provider, per session)
• 99341-99344/99347-99350 (Home visit for the evaluation and management of a new/established patient …)
• 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …) (Source: uslca.org/wp-content/uploads/2013/01/Suggestions-for-Billing-Codes-for-IBCLCs.pdf).

Coding caution 1: With the exception of S9443, all of these services must be performed by, or incident-to, a QHP. If you bill under incident-to rules, in addition to following a provider’s course of treatment, CLEs, CLCs, or IBCLCs have to perform the services “in the presence of the physician, or a qualified member of the physician’s practice, if they are not a QHP,” Bouzarelos warns (see, for example, the CMS incident-to rules found at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.

pdf). Consequently, “a nurse practitioner or a physician assistant who is also an IBCLC and contracted and credentialed with payers is the ideal staffing arrangement for a pediatric practice,” Bouzarelos believes.

Question: What kind of problems might you have to code when Mom tries to breastfeed?

Answer: “The issues that we see most often with breastfeeding are problems with the latch and the milk supply,” O’Connor notes. This means that you should have a number of diagnosis codes ready after encounters with breastfeeding moms and infants.

A poor latch, for example, can be associated with conditions of the nipple, including O92.13 (Cracked nipple associated with lactation), O91.03 (Infection of nipple associated with lactation), O91.13 (Abscess of breast associated with lactation), and even O91.23 (Nonpurulent mastitis associated with lactation). Sore nipples can also lead to a fungal infection known as candiasis, or breast and nipple thrush (BNT), which you would code with B37.89 (Other sites of candidiasis).

From the infant’s side, poor latch can also be a result ofQ38.1 (Ankyloglossia). If that’s the case, your provider might decide to perform a frenotomy, which you would document with 41010 (Incision of lingual frenum (frenotomy)).

Additionally, there are a number of codes you could report for problematic milk production, including O92.3 (Agalactia), which is the end, either partial or complete, of milk flow in a healthy mother before the normal end of the lactation period; O92.4 (Hypogalactia), which is a reduced or low milk supply; and O92.5 (Suppressed lactation). All of these could lead to preliminary diagnoses of P92.5 (Neonatal difficulty in feeding at breast), R63.4 (Abnormal weight loss), or R68.12 (Fussy infant (baby)) in the child.

Don’t forget: “Remember to use Z39.1 [Encounter for care and examination of lactating mother] to document most of these encounters,” Bouzarelos reminds coders. But if your pediatrician documented any of O92.- codes, you won’t be able to, as the lactation disorder codes are an Excludes1 for Z39.