Insurance Coverage and Virtual Lactation


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As a private practice lactation consultant, it’s been important for me to understand how to help my clients access insurance coverage or reimbursement for my services. In the United States, where I practice, this process is so murky that explaining how it all works required an entire book.

Now that so many lactation consultants are incorporating virtual consults into their services, questions are coming up about how to get tele-lactation covered by insurance (for in-network providers) and reimbursed out-of-network. In this article, I’ll cover the most common questions I’ve seen and point you to more in-depth resources so that you can be as informed as you possibly can be.

Just looking for a quick list of commonly used codes for virtual lactation?

Will in-network insurance cover lactation services provided virtually?

For Aetna, the only nationwide payer to credential IBCLCs without a medical license, the short answer is yes. Other payer’s guidelines vary state-to-state, and Medicaid is still not covering lactation care without a license.

On Aetna’s COVID-19 FAQ page, you can find this information about Telehealth:

For the next 90 days, until June 4, 2020, Aetna will waive member cost sharing for any covered telemedicine visit – regardless of diagnosis.

Additionally, Aetna specifies that this is not limited to care directly related to COVID-19, but for all services, and that participating providers are also allowed to use non-HIPAA compliant platforms such as Skype or FaceTime. (We’re still not allowed to do consults on TikTok, sad to say.) The page also makes it clear that providers will be paid in full for services, meaning that when Aetna waives the cost-sharing it means that amount is paid to you directly, instead of Aetna asking the family to pay it to you.

Aetna specifies that you may only bill for synchronous services. That means that when billing based on time, you may only include time when you were directly connected to the client via a two-way video platform. You may not count time spent watching videos at other times, and you may not include care provided by telephone.

If you’ve been in-network with Aetna for any amount of time, you know that they tell their members that they get 6 visits with a lactation consultant covered. Often this means clients are coming to us and saying things like, “They said I get 6 free visits!”

When you look at the Aetna Benefit Guidance Statement for Routine Preventive Services (dated March 2020, available through your provider portal on Availity), you will see that they specify they will cover up to 6 uses of S9443 (lactation class, 1 unit) along with related evaluation and management or preventive codes. After that they will deny S9443 and apply cost-sharing to the rest of the codes.

So when Aetna says that they are waiving cost-sharing for telehealth, that implies that you may be able to do more than 6 visits with your clients with no cost-sharing. It’s unclear whether or not S9443 will get paid for these visits, but it seems clear that Aetna should not be applying the E&M codes to the deductible, or charging the client any coinsurance.

You may want to explore offering your clients shorter, more frequent consults, since theoretically until June 4th there seem to be no limitations on using E&M codes with lactation diagnosis codes. Be prepared to spend time on the phone with Aetna if they do apply cost-sharing, or hire a biller to handle this for you. Always make sure you clients understand that they are responsible for any cost-sharing applied to their claims for your services.

Can my clients submit superbills for virtual lactation care?

The vague wording of the Affordable Care Act means that virtual lactation care isn’t specifically excluded. Here’s what the ACA mandates:

Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth.

In my own practice, and among my colleagues, however, implementation of the ACA has been spotty at best. Clients do have a hard time accessing reimbursement for lactation care, even when they’ve gotten preauthorization and you’ve provided the required documentation.

That doesn’t mean it’s not worthy trying. Families will still need to be proactive about pressing their insurance companies for reimbursement, but given that so much of healthcare has moved online because of COVID-19, families may be able to leverage that to their advantage. You should only submit a superbill for synchronous services and make sure to keep documentation to back up the codes you’re using.

What codes should I use?

There are no codes specific to virtual lactation care, so you will start with the codes that fit the services you are providing.

Diagnosis codes will remain the same; there is no reason to use a different diagnosis code just because services are provided virtually.

Procedure codes are chosen based on the type of service provided. The Crash Course explains the different types of codes that can apply to lactation services, either for in-network or for out-of-network.

Per Aetna’s policy on Telemedicine and Direct Patient Contact (dated April 2021, available through your provider portal in Availity) preventive codes 99401-99404 are not included on the “List of Eligible CPT/HCPCs for two-way, synchronous.” This is consistent with the AMA’s most recent coding manual, which specifically states that 99401-99404 may NOT be used for virtual lactation.

Aetna is currently including the home visit E&M codes on its list of codes allowed for lactation. With any codes you use for Aetna, make sure they’re also on the Benefit Guidance Statement for Routine Preventive Services.

For location (or “place of service”), you have two options:

  • 02 means “Telehealth,” which clearly applies. However, this may be limited by the payer to services which they have designated as Telehealth services, vs services that are typically provided in-person and are only being provided virtually because of COVID-19.

  • 11 means “office or other outpatient” which can apply to virtual care, since “other outpatient” basically means it didn’t happen in the hospital or in the client’s home. By using this location code, you’re saying that you provided an office-based service to the client, and you’ll be using the modifier as explained in the next section to tell the payer that you used Telehealth.

The AAP guidelines allow for the use of either place of service code.

Best practices: use Code 02.

There are two possible modifiers for telehealth, which would be added to the procedure codes:

  • GT: “Via interactive audio and video telecommunication systems”

  • 95: “Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”

The AAP guidelines specify using mod 95 unless the payer specifically requests GT. Aetna has specified that mod GT be used for in-network claims.

Conclusion

As always, nothing with the insurance companies is straightforward or clear. However, by knowing your codes and how to document your usage of them, you will be able to bill for your services ethically and effectively. For more information, check out these resources:

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