Primary Care Coding Alert

You can bill more than 99211 for this service

You could be losing out when your office provides lactation counseling, but coding experts say you'll boost reimbursement if you zero in on who performs the service.

"In a family practice, a registered nurse (RN), a licensed practical nurse (LPN), an International Board Certified Lactation Consultant (IBCLC) or a family physician (FP) could perform lactation counseling," says Marsha Walker, RN, IBCLC, IBCLC Association past-president.

Because CPT doesn't contain a code for lactation counseling, you have to use office visit codes for the service. Coding experts recommend billing based on the following three guidelines:

1. Use 99211 for Nurse Counseling

For breast-feeding encounters that involve a nurse only, CPT restricts you to coding a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ... typically 5 minutes are spent performing or supervising these services). If a nurse provides lactation counseling for mothers who have difficulty breast feeding or as a regular post-hospital service, you should report 99211 for the visit, says Cindy Godley, CCS-P, a family practice coding specialist for the Navy in Washington, D.C. Regardless of how long the nurse spends, you may not report a higher-level E/M service.

In Godley's practice, an RN weighs the baby, and then a lactation nurse discusses lactation supervision with the mother. "The nurse usually spends 15 total minutes on the visit," Godley says. Since an RN provides the service, you still have to use 99211 for the office visit, she says.

2. Bill NP Services Based on Time

You may recoup higher-level office visits when a nurse practitioner (NP) provides lactation counseling. NPs can use the full scale of E/M codes, says Richard H. Tuck, MD, FAAP, a nationally recognized speaker on coding, compliance and reimbursement. "They can report 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family), if justified," Tuck says.

Because counseling dominates the visit, you should report the appropriate level of E/M service based on time. For instance, if the NP spends 15 minutes counseling the mother on proper feeding and the importance of breast milk, you should report 99213 (... physicians typically spend 15 minutes face-to-face with the patient and/or family) for the visit.

3. Report 99212+ for Direct FP Involvement

When your FP spends face-to-face time with the patient, you should report more than 99211. "If a nurse does the counseling, you can only code 99211," Walker says. "To code any higher than that, the FP must step into the room." And that "step into the room" is key: If the nurse briefs the FP, and he approves the setup, that is enough to report 99212 or higher, Walker says.