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"My insurance says I get 6 free visits!"

Did your insurance rep tell you that you get 6 free or “covered” visits?

Let’s dive deeper into what this means in reality…

You might think that when you have a visit with a lactation consultant, who takes your insurance, that she submits the same bill she would otherwise give to you and your insurance just pays for the visit. Well, that’s not really how it works. Submitting a claim to your insurance company is tricky, and insurance companies keep changing things up making it even trickier.

When I submit a claim, I have to use CPT codes on a special form. There are literally thousands of codes! Thankfully, as a lactation consultant, there are only a few codes that I can use. At least one code is a “diagnosis code” which tells the insurance company what you are being seen for. I then use “procedure codes” and “Evaluation and Management codes” to tell them what was done during the visit and how much time was spent.

I submit claims for both mother and baby. If I only submitted for mother, I would get paid so little that I could not do home visits at all. With the additional payment for baby, I get close to what I would normally charge for a home visit. In an office visit situation, it might be more viable to submit for just the mother, but my clients and I really like the home visit situation, so I file a claim for both.

What your insurance company means when they say that you get 6 visits is that you get 6 of a specific code paid for. That code is s9443 and it’s a “breastfeeding class” code. BCBSAZ will pay me $9.18 for that code. Yup, 9 bucks. Aetna is a bit more generous at $71.50. Neither of these numbers creates a sustainable payment for my services, nor do they represent the time I spend with clients at 60-120 minutes.

It’s important to note here that your six s9443 codes could get used up if you did any online classes that were “covered”, or a prenatal visit. There are even digital guides/books that are purchased with insurance “coverage” that could use your covered codes.

In addition to the s9443 code, I must use other codes that are time based in order to get paid for my time and expertise. 99344 or 99349 are the codes I use to represent my “evaluation and management” time and these codes also indicate that I am doing a home visit with either a new or established family.

I also submit s9443 (the breastfeeding class) for babies (although BCBSAZ won’t pay this code for a baby boy - this is a mystery). This means that 2 of your “covered codes” are being used at one visit. If you have twins, then 3 of them are being used. In addition, I use a 99403 code to represent my “evaluation and management” time with the baby.

Sometimes I use additional codes for “extra time” if a visit runs long, or a supplies code if I gave you any breastfeeding supplies during the visit. I may also use a code for depression screening. But in general, I use the same codes for every claim.

When your claim is processed, your insurance company may apply some of the codes to patient responsibility in the form of a copay, coinsurance, or deductible. In this case, you may receive an invoice from me for the amount applied to patient responsibility. Based on the structure of your particular plan, this all falls under the umbrella of “covered”.

You may have heard that your insurance company has to cover your lactation visits according to the Affordable Care Act. This is true. And they really should, according to the ACA, cover all preventive services at no cost to you. This is federal law. However, they don’t. Some companies never have, and some companies used to, but don’t anymore. What some companies will cover, six times, is that one code – s9443. At least for now.

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