Pediatric Coding Alert

Question: Is there a code we can use for lactation counseling when the service is provided by a trained lactation consultant?

Pearsall Pediatrics
Houston, TX

Answer: There is no specific code for lactation counseling. If the pediatrician or nurse practitioner does the counseling, you can use the office-visit codes (99201-99205 for new patients, 99212-99215 for established patients). The diagnosis code, regardless of who is doing the counseling, will usually be 783.3 (symptoms concerning nutrition, metabolism, and development; feeding difficulties and mismanagement) or 779.3 (other and ill-defined conditions originating in the perinatal period; feeding problems in newborn).

One of the problems, however, is that many pediatricians and nurse practitioners dont have time to provide breastfeeding education and counseling. And if they have their nurses do it, they lose both waysthe nurse is tied up for half an hour, and there is no way to bill for the procedure. True, the nurse could bill a 99211, but the $20 or so is a small return for the half-hour spent counseling. Furthermore, these visits are frequently in combination with a pediatrician visit, which would throw out the 99211 altogether.

For nurse counseling, often the best solution is to have the pediatrician involved minimally in the encounter, coming in to be briefed by the lactation counselor, examining the baby to make sure there arent any medical problems, and then leaving. The typical code used for this session is 99213, although it also could be a 99212 depending on the level of exam and other components. Remember that only the physician time and effort countsthe nurses time in this scenario does not contribute to the E/M level selected.

Many lactation counselors are able to pick up problems during this first breastfeeding education session, which usually occurs at the first weight check. For example, the lactation consultant may notice a possible fractured clavicle, or a submucous cleft, which had been missed. In these cases, the pediatrician would take a primary role in the visit, which would no longer be a feeding problem alone. Some practices always involve the pediatrician in breastfeeding counseling. If, for example, the mother is talking to the nurse and asks a question about breastfeeding, the nurse will get the pediatrician.

Another option is to have a certified lactation consultant on staff have the consultant apply for providership from the insurance companies.

Since some plans will pay for these services if provided by a certified lactation consultant, particularly if the pediatrician backs up her application with a letter explaining why the services are necessary and attesting to the effectiveness of the work, this is one option. However, most plans will not pay for open-ended services: They will limit it to one [...]