IBCLC Coding, Documentation and Billing for In-Network IBCLCs      Time to Get Paid!

 Medicaid Billing and the RN, IBCLC

Medicaid Billing & RN, IBCLCs

First off, since the IBCLC credential is not a licensed one yet unless you are in Rhode Island or Georgia. Medicaid only recognizes licensed providers such as a Physician, Nurse Practitioner, Certified Nurse Midwife or Physician's Assistant. We are certified but not licensed. Insurance companies, especially those who are calling for IBCLCs to become In-Network providers, are private companies that can allow any providers or procedure codes they deem appropriate for our type of services and these private companies require just the credential of IBCLC.  
Medicare and Medicaid are government programs and coverage of procedure codes and services are narrower in the scope of reimbursement and require expanded credentials. Many IBCLCs who also hold a state license in another specialty may see Medicaid moms in a pediatric office now and use basic office visit codes to cover the lactation service they provide in the office setting. These are called “incident to” as the services are to patients of the doctor and are done in the same office space.

“Incident to” services are also relevant to services supervised by certain non-physician

practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse

midwives, or clinical psychologists. These services are subject to the same requirements as

physician-supervised services. Remember that “incident services” supervised by non-physician

practitioners are reimbursed at 85 percent of the physician fee schedule.” *

*  http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

Currently those of you that hold multiple credentials will be more marketable in areas that serve this patient population.  Many RN, IBCLCs and NP, IBCLCS are utilized for patient care in pediatric, family practice and OB office settings, but do not normally use any coding specific to lactation. That is starting to change.

Small steps are being made with Medicaid. The Center for Medicaid Services issued a brief to all states encouraging coverage of lactation services. New York State has stepped up and I’m sure more states will follow soon. Google your state medicaid office and the words lactation.

A procedure code for PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER is available for use. Does it apply to a typical comprehensive lactation consultation, NO, but it can apply as a “counseling session” or you can now hold a “lactation class” and bill each Medicaid mom individually so it is a great start.

New York State: Effective April 1, 2013, a separate Medicaid payment will be available for separate and distinct breastfeeding services provided by professionals who are certified as IBCLCs credentialed by the IBLCE:

  • Physicians
  • Nurse Practitioners (NPs)
  • Midwives (MWs)
  • Physician Assistants (PAs)
  • Registered Nurses (RNs)

Lactation consultants in this program are expected to practice within the scope of practice that is appropriate to their respective discipline, as defined by the Office of the Professions, New York State Education Department.

Billing Medicaid Fee-for-Service

  • Lactation counseling services may be billed directly to Medicaid by physicians, nurse practitioners, or midwives who are IBCLCs (S9445 and S9446). A physician who employs an IBCLC physician assistant or registered nurse may bill Medicaid for lactation counseling provided by these health care professionals (S9445 and S9446).
  • Modifier "AF" (specialty physician), along with the appropriate "S" code from Table 1, must be reported on a claim when the physician is the provider of service.

Table 1:


Code Description

Benefit Limitations



The initial lactation counseling session should be a minimum of 45
minutes. Follow up session(s) should be a minimum of 30 minutes.

Three sessions within  a 12-month period  immediately following delivery.



Up to a maximum of eight participants in
a group session.60 minute minimum 
session length. One prenatal and 
one postpartum class per recipient 
per pregnancy.


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