Supporting Breastfeeding and Lactation
Contents
1. Other specified follow up exam V67 59 When the original reason for visit has resolved Report CD 9 ClM codes through September 30 2015 Current Procedural Terminology 2013 American Medical Association All Rights Reserved Feeding problems ICD 10 CM P92 01 Bilious vomiting of newborn P92 09 Other vomiting of newborn P92 1 Regurgitation and rumination of newborn P92 2 Slow feeding of newborn P92 3 Underfeeding of newborn P92 5 Neonatal difficulty in feeding at breast P92 8 Other feeding problems of newborn P92 9 Feeding problem of newborn unspecified R11 10 Vomiting unspecified gt 28 days old R11 12 Projectile vomiting gt 28 days old R11 14 Bilious vomiting gt 28 days old Jaundice P59 0 Neonatal jaundice associated with preterm delivery P59 3 Neonatal jaundice from breast milk inhibitor P59 8 Neonatal jaundice from other specified causes P59 9 Neonatal jaundice unspecified Weight and hydration P74 1 Dehydration of newborn P74 2 Disturbances of sodium balance of newborn P74 3 Disturbances of potassium balance of newborn P92 6 Failure to thrive in newborn R62 51 Failure to thrive in child over 28 days old R63 4 Abnormal weight loss R63 5 Abnormal weight gain R63 6 Underweight Infant distress R68 11 Excessive crying of infant baby R68 12 Fussy infant baby R10 83 Colic Gl issues R19 4 Change in bowel habit R19 5 Other fecal abnormalities R19 7 Diarrhea unspecified R19 8 Other spe2. interstitial 675 24 Feeding problem infant gt 28 days b Breast engorgement ductal 676 24 Vomiting infant gt 28 days 87 03 Burning pains hyperesthesia 782 0 Jaundice Ectopic or axillary breast tissue 757 6 Iki Galactocele 676 84 Breastmilk jaundice 774 39 ves Neonatal adie unspecified 774 6 Other specified nipple breast anomaly 757 6 Preterm jaundice i 774 2 Other specified nipple breast infection 675 84 N Nipple infection 675 04 Weight and hydration Nipple cracks or fissures 676 14 Dehydration neonatal 775 5 Nipple sore 676 34 Failure to thrive newborn 779 34 Retracted nipple postpartum 676 04 Weight loss 783 21 Impetigo staph nipple 684 Underweight 783 22 Candidiasis nipple or breast 112 89 ae na a FTT infant gt 28 days T Constitutional normal weight gain As well as all the diagnoses associated SiR aa sleep cycle hanes with size and maturity atigue Infant distress Lactation Agalactia failure to lactate 676 44 Fussy infant baby 780 91 eae Excessive crying infant 780 92 pee see ae i li i inal di 789 7 mene Cone Pr Metal RES ee Other specified disorders of lactation 676 84 Gl issues Supervision of lactation V24 1 Abnormal stools 787 7 Diarrhea 787 91 Change in bowel habits 787 99 Other Mouth Other specified follow up exam V67 59 ou When the original reason for visit has resolved Ankyloglossia 750 0 High arched palate 750 26 ICD 9 CM Codes 630 679 are only for use on the maternal record Other
3. health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years The practice can also under specific circumstances charge for services provided by nurses and such allied health professionals as lactation consultants health educators and nutritionists using a variety of codes This fact discusses Options for billing the three to five day visit Billing for extra time spent at well baby visits Use of time based coding Billing for consults Billing for care provided for the mother Billing for allied health professional services Commonly reported ICD 9 CM for use before Oct 1 2014 and CD 10 CM codes for use on or after Oct 1 2015 8 Codes for breast pump NOoh WON gt Unless restricted by their state or payers scope of practice limitations This pamphlet does NOT discuss the detailed important and specific guidelines affecting decisions about billing for nurse practitioners and physician assistants i e whether credentialed and billed under their own names vs billing for their services incident to physician care and thus billed under the physician s name That topic is beyond the scope of this pamphlet However all physicians employing such allied health care providers need to be aware of and understand the applicable billing rules and apply them carefully whether billing for feeding problems or for any other medical services i
4. they incorporate more breastfeeding support into their practices Billing for problems with breastfeeding and lactation is just like billing for any other pediatric problem Pediatricians and other billable licensed practitioners nurse practitioners and physician assistants may e Use current Current Procedural Terminology CPT codes e Use current ICD 9 CM codes e Code based on time if greater than 50 of time is spent in counseling education or coordination of care The three to five day visit The AAP recommends 123 this visit e to assess jaundice in ALL infants regardless of feeding method e to address other early feeding issues For breastfeeding infants the purpose of this visit is e to assess weight hydration and jaundice and e to address the ability of the infant to e Use modifier 25 appended to a separately reported office or other outpatient service to bill for extended time spent on feeding problems at a well baby visit e Bill for care provided for the mother often as a new patient in addition to billing for the baby if history exam diagnosis and treatment are done for her e Anew patient is one who has not received any professional face to face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code s from the physician qualified health care professional or another physician qualified
5. 14 or 99215 using time as the controlling minimum of 3 qualified health care professionals in factor based on face to face time spent on attendance counseling and coordination of care e To bill for participation by non physician qualified health care professionals use 99366 for meetings of 30 minutes or more American Academy of Pediatrics Subcommittee on Hyperbilirubinemia Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation Pediatrics 2004 114 297 316 American Academy of Pediatrics Committee on Practice and Ambulatory Medicine Recommendations for Preventive Pediatric Health Care Pediatrics 2000 105 645 3American Academy of Pediatrics Committee on Fetus and Newborn Hospital stay for healthy term newborns Pediatrics 2010 125 2 405 409 published ahead of print January 25 2010 doi 10 1542 peds 2009 3119 Current Procedural Terminology 2013 American Medical Association All Rights Reserved Codes for Breast Pumps HCPCS Codes E0602 Breast pump manual any type E0603 Breast pump electric AC and or DC any type E0604 Breast pump hospital grade electric AC and or DC any type Commonly Reported Diagnosis Codes Baby Feeding problems ICD 9 CM Mother Feeding problems slow feeding newborn 779 31 Breast amp Nipple issues ICD 9 CM Bilious vorniting in newborn 779 32 Abscess breast Mastitis infective 675 14 Other vomiting in newborn 779 33 Blocked milk duct Mastitis
6. 8 1 2014 Supporting Breastfeeding and Lactation The Primary Care Pediatrician s Guide to Getting Paid Affordable Care Act The Affordable Care Act ACA has two major provisions affecting breastfeeding 1 coverage of comprehensive lactation support and counseling and 2 costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding These provisions however are typically linked to maternal benefits under the insurance plans and therefore coverage may be dependent upon submitting claims under the mother s name If pediatric providers plan to provide these services and expect the claims to be adjudicated with benefits covered under ACA provisions the claim may have to be submitted under the mother s name and not the baby s Check with your payers under the essential health benefits for more details Remember that services provided out of a payer s network can be subject to cost sharing Below is a link to a Section on Breastfeeding resource on ACA provisions and federal support for breastfeeding Also the section has developed a letter for payers FEDERAL SUPPORT FOR BREASTFEEDING Breastfeeding support can often be quite time intensive initially but pays off in a healthier patient population It is in your insurers best interests that you provide these services and be reimbursed appropriately This pamphlet is a guide to help pediatric practitioners get paid appropriately for their time as
7. ch 15 minutes face to face time e 96153 Health and behavior intervention group two or more patients Note you will need a group of five or six to be reimbursed for the allied health professional s time equivalently to the individual or family sessions Each 15 minutes face to face time e 96154 Health and behavior intervention family with patient present Each 15 minutes face to face time e 96155 Health and behavior intervention family without patient present Each 15 minutes face to face time Current Procedural Terminology 2013 American Medical Association All Rights Reserved Billing for phone calls and online communications Certain non face to face services codes have been updated for 2008 The updated E M codes for telephone Medical Discussion Physician Non physician and online medical discussions permit billing for both in minutes Calls Provider Calls physician services and services provided by qualified non 5 10 minutes 99441 98966 physician health care professional s Billing for these services is limited to the following ernie AAA 20967 circumstances e The telephone or online communication is with an 21 30 minutes 99443 98968 established patient or an established patient s parent or guardian NOT for NEW patients e The online codes but not the telephone codes additionally may be used for communications with Online Medical Evaluations the patient s health care provider E M services e The telepho
8. cified symptoms and signs involving the digestive system and abdomen Mouth Q38 1 Ankyloglossia Q38 5 Congenital malformations of palate high arched palate Other Z09 Encounter for follow up examination after completed treatment When the original reason for visit has resolved Mother ICD 10 CM Breast amp Nipple issues B37 89 Candidiasis breast or nipple LO1 00 Impetigo unspecified 091 02 Infection of nipple associated with the puerperium 091 03 Infection of nipple associated with lactation 091 13 Abscess of breast associated with lactation Mastitis purulent 091 23 Nonpurulent mastitis associated with lactation 092 03 Retracted nipple associated with lactation 092 13 Cracked nipple associated with lactation Q83 8 Other congenital malformations of breast ectopic or axillary breast tissue R20 3 Hyperesthesia burning Constitutional G47 23 Circadian rhythm sleep disorder irregular sleep wake type G47 9 Sleep disorder unspecified R53 83 Fatigue Lactation 092 3 Agalactia 092 4 Hypogalactia 092 5 Suppressed lactation 092 6 Galactorrhea 092 70 Unspecified disorders of lactation 092 79 Galactocele Other disorders of lactation Z39 1 Encounter for care and examination of lactating mother Excludes encounter for conditions related to O92 Other Z09 Encounter for follow up examination after completed treatment When the original reason for visit has resolved Do not use any codes liste
9. d under the mother for the baby s medical record Report CD 10 CM codes for services on or after October 1 2015 Current Procedural Terminology 2013 American Medical Association All Rights Reserved
10. e Health Behavior Assessment and Intervention codes allow the allied health professional to see the patient alone and bill for the allied health professional s face to face time A Joint visit physician and allied health professional 99212 99215 This is a physician visit which is supported and facilitated by the initial work of the allied health professional The latter begins the visit records the chief complaint documents the history establishes key physical findings observes and documents the breastfeeding encounter and counsels the patient about lactation issues related to the problem The physician can join the allied health provider baby and mother partway through the encounter and then 1 Review the history 2 Examine the infant to confirm and or add to the physical 3 Document in the chart the physician s physical findings diagnoses and plans 4 Write any necessary prescriptions With the help of the allied health provider physician time spent on history taking counseling and education will be minimized History physical and medical decision making guidelines will be used to decide the level of the visit code 99212 99215 Time based coding cannot be used for this visit because the physician will have spent relatively little time face to face with the family Time based coding is based specifically on the physician s time NOT the allied health professional s time B _ Health and Behavior Assess
11. idual state and payer limitations Current Procedural Terminology 2013 American Medical Association All Rights Reserved Billing for the Infant s Mother If the physician or other billable licensed health care provider is taking the mother s history examining her breasts and nipples observing a feeding and making a diagnosis and treatment plan for her the clinician is treating a second patient This may change the visit with the baby into two separate and identifiable visits with two different patients two patients two visits two records two bills and two co pays Remember under the ACA provisions in order to not incur cost sharing these services may need to be submitted under the mom and not the baby e Depending on the mother s insurance you may need to get a request from her primary care health care provider e Can be billed either as a new patient 99201 99205 or if you have a request and will make a written report back to the requesting source as a consult 99241 99245 Billing for services by allied health providers who are neither nurse practitioners nor physician s assistants Services provided by an allied health professional who is not a billable and credentialed nurse practitioner or physician s assistant e g a nurse health educator or lactation consultant can be billed two ways A The allied health professional s time can be used to make the physician s time more productive B Th
12. itates extra time beyond routine well visit feeding counseling then the 99212 99215 codes appended with the modifier 25 may be reported in addition to the preventive medicine service code Furthermore the problem based note will require that all required key components of appropriate time based billing is documented for the code selected Current Procedural Terminology 2013 American Medical Association All Rights Reserved Both visits are then reported appending the modifier 25 to the problem based visit code For example using an established patient 8 to 28 days old you would report 99391 V20 32 99212 25 779 31 Note Some payers do not pay for both E M services on the same date Billing for any clinician s visit based on time Because breastfeeding visits are dominated by counseling and education they can be time intensive The CPT guidelines allow for a visit to be billed based on time rather than by meeting the E M requirements for elements of history physical and decision making if 1 More than 50 of the practitioner s face to face time with the patient has been spent on counseling patient education or coordination of care 2 You must document on the chart a Your total face to face time with the patient and or the patient s family b Time spent in counseling or coordination of care and this must be gt 50 of total c Abrief description of what was discussed should be one or more diagno
13. ment and Intervention codes After a breastfeeding or any other health problem has been established by the physician a qualified nonphysician health care professional may see the patient to identify the psychological behavioral emotional cognitive and social factors important to the prevention treatment or management of physical health problems The focus in on the biopsychosocial factors important to physical health problems and treatments the AMA s CPT manual 2014 page 591 The following conditions apply 1 These require a medical condition e g feeding problem or low weight gain previously diagnosed by the physician at an earlier date 2 These health and behavior visits may not be reported on the same day as any other E M service 3 These visits are not for generalized preventive counseling or risk factor reduction 4 These are billable in 15 minute time increments based on the allied health professional s time they are not for use by physicians or other billable licensed health care provider If honored by the insurer these codes are well reimbursed and are a good way to pay for your office lactation consultant who is not otherwise licensed or credentialed for billing Codes e 96150 Initial health and behavior assessment clinical interview behavioral observations health questionnaires etc Each 15 minutes face to face time e 96151 Reassessment e 96152 Health and behavior intervention individual Ea
14. n the pediatric office 1 Maintain hydration AND 2 Sustain growth and activity AND 3 Increase and maintain maternal production This assessment usually includes 1 History Infant feeding sleep and activity patterns urine and stool output maternal lactogenesis comfort and confidence 2 Exam Weight and exam for dehydration sleepiness and level of jaundice Current Procedural Terminology 2013 American Medical Association All Rights Reserved 3 If indicated observation of a feeding including weights before and after feeding 4 Testing interventions and counseling if indicated The visit may be billed as either e a first routine well visit OR e a follow up visit for a problem noted earlier Billing as a well visit If the infant s previous record does not document a feeding problem and no other health problem has been identified then this first office visit should be coded and billed as an established patient well child visit e CPT code 99391 e ICD 9 CMV20 32 and any other indicated diagnosis codes eg for jaundice or feeding problem In any well visit the clinician is expected to spend time addressing routine feeding issues When unusual time beyond the usual is required there are two ways of billing for this extra time When extra time is required If a feeding problem exists which requires more than an ordinary amount of time to address the physician may depending on the circumstances cho
15. ne or online service does NOT e provided to an established patient or guardian originate from a related E M service or procedure e using the internet or similar electronic for that patient within the previous 7 days communications network e The telephone E M codes may NOT be used if the e not originating from a related E M service in the call leads to a face to face E M service or previous 7 days may be billed regardless of procedure within the next 24 hours or the soonest length using codes available appointment The online E M codes do e 99444 for services provided by a physician not carry this restriction e 98969 for services provided by a qualified non Note Not all insurers reimburse for these codes physician health care professional Telephone Calls Provided the criteria above are met telephone calls may be billed using the following codes Billing for Interdisciplinary Team Conferences The codes for billing for participation in interdisciplinary To bill for participation in team meetings of 30 minutes or medical team conferences attended by other health more when the patient or family is NOT present professionals have been updated for 2008 e 99367 participation by physician e 99368 participation by non physician qualified To bill for participation in team meetings when the patient health care professional or family is present e Physicians continue to use regular E M codes e g To bill for codes 99366 99368 there must be a 992
16. nutes is closer to 40 minutes 99215 rather than 25 minutes 99214 you would report a 99215 Your chart documentation must include the three elements described above total physician face to face time total time spent counseling and a description of that counseling Consultations The physician or individually credentialed nurse practitioner or physician s assistant may also bill the initial feeding evaluation as a requested consultation if the following guidelines are met A requested consultation 99241 99245 requires the 3 Rs documentation on chart of 1 Request whether verbal or written from another physician even within the practice or other appropriate source can be a lactation consultant or even a La Leche League leader is documented and the original request is to gather your advice or opinion This cannot be a transfer of care Render the service requested Report back to requesting source Note must be a written report Billing for codes 99241 99245 may be based either on key components or time on Follow up visits will be billed as established patients 99212 99215 An allied health car provider cannot bill a consult under the incident to billing options Only a nurse practitioner or physician s assistant who has been credentialed individually by an insurance company may bill for either of these types of consults under that provider s own name Note This is subject to indiv
17. or billable licensed health care provider e g NP or PA Use office follow up codes 99212 99215 and appropriate CD 9 CM codes e If the feeding problem persists use an CD 9 CM such as 779 31 774 6 783 21 etc e f however the feeding problem has resolved use instead ICD 9 CM code V67 59 just as you would for a follow up resolved otitis media 2 Nurse visit with possible triage to physician or other billable licensed health care provider This is a weight check and quick screen for feeding sleep and stool patterns It is only billable to the nurse as a 99211 if it is NOT triaged to the doctor Triage based on adequacy of feeding a If this visit demonstrates that good feeding has been established the physician does not need to see the patient to bill for a limited nurse s visit with CPT code 99211 and ICD 9 CM code V67 59 b If nurse s weight check visit reveals persistent problems you do NOT bill for the nurse visit but instead triage back to pediatrician or other billable health care practitioner NP or PA immediately for a problem visit billable as a follow up visit 99212 99215 Billing for extra time spent on feeding problems at any well baby visit A separate note is optimally written on a separate page or on the same page with a line separating the two notes the well visit note and the problem based note If at a well visit a significant separately identifiable diagnosable feeding problem necess
18. ose one or both of the following options as clinically appropriate e Prefer to spend extra time at this visit to address the problem immediately This may then be billed separately using the 99212 99215 codes appended with the modifier 25 following the guidelines described on the next page e Schedule a follow up visit for example within a few days or at one to two weeks of age That follow up visit would then be billable using the office follow up codes 99211 99215 related to that feeding problem diagnosis Coding and billing as a follow up visit For this to be billed as a follow up visit the reason for follow up must be clearly established on the preceding health or hospital record The earlier chart must document the unresolved problem that requires a follow up visit An appropriate diagnosis code e g newborn feeding problem 779 31 or jaundice 774 6 must be included with the hospital or birth center s discharge diagnoses to establish the reason for the follow up visit Alternatively telephone chart notes document that since discharge a new problem exists Examples of early problems requiring follow up include but are not limited to Jaundice Infrequent and or dark stools Ability to transfer milk not established Infrequent breastfeeding Weight loss exceeds 7 Breastfed infant being fed formula Options for coding and billing as a follow up visit 1 Schedule routinely with physician
19. sis or impressions prognosis risks benefits of management options instructions for management and follow up compliance issues risk factor reduction patient and family education a checklist on your encounter form will make this easier for all time based visits not just those about breastfeeding issues You can bill for time for most routine E M codes eg 99212 99215 when counseling education or coordination of care dominate a visit otherwise not meeting customary guidelines for history physical and medical decision making It should be noted that time based billing cannot be used with the preventive medicine service codes since their CPT code descriptors do not contain typical times Also note that typical times are not threshold times and you do not need to reach the time listed in a specific code in order to report it but must be closer to that time then the time listed in the code below The CPT E M quidelines for billing based on time New Established Outpatient Patient Time Patient Time Consult _Time 99202 20 99212 10 99241 15 99203 30 99213 15 99242 30 99204 45 99214 25 99243 40 99205 60 99215 40 99244 60 99245 80 For example if you spent 35 minutes face to face with an established baby and mother of which greater than18 minutes were spent counseling about feeding issues you could bill with CPT code 99215 ignoring the usual history exam and medical decision making requirements for a 99215 Since 35 mi
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