Question LACTATION COUNSELING

[ELITEMED1]

I need some clarification on compliant documentation for a particular group. Current workflow is patient comes into the office with infant, sees IBCLC for lactation counseling/guidance. During the visit the MD talks with the patient, reviews the notes by the IBCLC- all via telemedicine. The MD then attests the services, the education provided, the plan, and indicates the dx codes.
I have educated the provider and non QHCP that the MD must attest and sign for their own medical eval/services and the IBCLC's services before I can properly code and for the notes to be compliant.
My ask:
1. Shouldn't there be two claims (one for mom, one for baby) for lactation counseling?
2. If medical concerns are addressed, that would create a third claim from the MD?
a. If no additional medical concerns, the MD services would be telehealth codes. Correct? Still a third claim.
3. Since the MD is attesting the IBCLC services, the claim can be billed under the MD. Correct?
If all this is incorrect, please advise with the proper workflow.
I want to ensure proper documentation and compliant billing. If anyone could assist, it would be much appreciated. Thank you,
Michelle

 

[Pam Warren]

Under the Affordable Care Act, lactation services are part of the preventive care benefit where there is no cost-sharing for mom. This is billed under mom only (in what circumstance could we ever counsel a newborn?). We bill preventive counseling services 99401-99404, depending on how much documented time was spent with mom. These are not evaluation and management services, and billing them as such is inappropriate. We submit this with Z39.1 (encounter for lactating mom), because an RN may not ever diagnose a medical condition, and generally a nurse provides this service. Any medical issues that are treated for mom (such as blocked ducts, mastitis) cannot be billed by a nurse, so the MD would have to address those. Any issues that the baby has (failure to thrive, tongue tied), are billed under the baby, usually as an E&M or as part of the well check. Generally, lactation services are provided by lactation nurses, incident-to a physician's professional services, meaning that there has had to have been a previous visit with the MD, and accompanying plan of care (for counseling, if appropriate), and the MD would need to be in the suite. Best practice indicates that the MD cosigns the note, but there is absolutely no CMS guidance surrounding this. However, since the doc's name is on the claim, it's recommended. In a provider-based practice, you would additionally need an order.

 

[ELITEMED1]

Yes. I totally get that an infant can't be counseled. I see how me listing it as such was wrong. The way this group is providing services is little unique to what I am used to. Is that the patient is coming into the office, being treated by the IBCLC and then MD is then called and performs an audio/visual visit with the patient and reviews the care plan with the patient and the IBCLC. I communicated that the MD must attest the counseling services and sign the note. If there are any medical issues that need to be addressed then she will need to fully document the note just as she would if she was in office. I personally don't like the fact that they have the MD doing this when they have an NP onsite that is able to go in the room and perform a complete E&M with the additional preventive counseling services. I did create a coding and documentation guideline for them that did indicate an order would need to be added.

To summarize recommended and a compliant workflow: NP or MD must see patient in office, order lactation counseling by RN/IBCLC on site. Bill all services under mother, unless medical issues need to be addressed for infant- separate note/billing for infant. Typical CPT codes E&M OV and PCS 99401-99404.

Correct?