Recommend reviewing preventive service and obstetric service policies of the payers to which the practice most frequently submits claims. Payer policies vary from instruction to report S9443 to bundling into the global OB (covered but not separately paid). Finding information usually requires review of the payer's reimbursement policies and contracting/credentialing policies (eg, Can the IBCLC/RN report the services under their own name and NPI or must services be reporting by a supervising physician? If reported by the physician will the lactation services be bundled?). Unless the payer's policy expressly permits reporting of 99401-99404 for services not personally-performed by a physician or other QHP whose scope of practice includes E/M services, these codes may not be applicable.
Hi Phillip
Thank you very much for this information. Our hospital is considering the CPT 99401-99404 and S9443 options at this point. I realize that payors may have specific billing/reimbursement policies, but from a strict coding perspective I am curious if others are billing both (9940x as well as S9443), or if others view billing only one or the other as appropriate.Hi Phillip
Here is some info may help you on billing lactation....
You can have billing of CPT 99241-99425 consult care as outpt. in office if MD DO NP PA provider. Ensure document properly of date when treatment starts, doc name referred on claim, and proper dx codes. Other CPT 96150,or 96040 CPT 98960, 96156-96168 ,99502 home visit if newborn still CPT 97530 97535 work breast pump patient's mother caretaker education as a QHP Lactation Consultant. Also can do CPT 99211(can be used for QHP staff too). Ensure the Lac consult give good notations /describe problem Mom and baby having and assign dx code. I d have the referring doc be the peds doctor in the office since recommending this help and list their name on claim. Dx codes can range from 091.23 , N61, I80 or with dx Z39.1 per notations. Also if baby having eating difficulties add dx code of R63.,3 or F50, or P92 if newborn status
I hope helped you.
Lady T
Thank you. We are indeed considering the preventive counseling codes (99401-99404). Can the S9443 (Lactation classes, non-physician provider, per session) be used in conjunction with the 99401-99404?
These codes are payer-specific so there's not much regulatory guidance surrounding their use. Some payers want one or the other, but what they are clear on is if there's no condition such as mastitis, use the Z39.1 as preventive care.
Hi Phillp
