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

 Where are you now?

Are you an employee in a doctor’s office, private practice IBCLC or both?                          
This page offers general practice management advice.  I strongly encourage you to consult with a lawyer or accountant on business matters but I can offer some information on reimbursement, marketing ideas and practice management.  Besides my previous billing experience and my current IBCLC certification, I have a bachelor’s degree in business administration with a focus on small business management and entrepreneurship. 

IBCLC as employee:

IBCLCs with multiple credentials have more options in the physician’s office. When you offer lactation services in this setting, your patient contact may be billed out under the physician’s tax ID using basic office visit procedure codes for time spent with baby.  If you become an In-Network provider yourself with Aetna or another carrier, you could create a different relationship with patients as you could now be set up as an IBCLC in the vicinity or within in the office setting. You might choose to bill now for the mother or baby or possibly both. So, for Aetna or other in-network patients, the billing departments can now bill out for expanded procedure codes designated for IBCLCs and listed in my manual.   

All insurance plans are unique, so at the time of this first printing, it is not 100% clear if the new ACA directive only applies to mom.  A pediatric office normally bills for baby but in certain circumstances of screening and counseling it is possible to bill for the mother. For example, the AAP encourages pediatricians to bill for maternal depression screening. With an IBCLC it may be appropriate to use counseling coding for the mother as patient using ICD 10 diagnosis code of Z39.1, postpartum care of the lactating mother.  

Additional Resources: This guide link is not specific to IBCLC billing, but it does explain some coding for pediatric offices.


 For a light read: this is a link to an article by Brandon, a practice administrator at a pediatric office.


Private Practice:

Home Visit vs sublease or "sharing office space" with a pediatrician, OBGYN, chiropractor, dentist, or outpatient clinic:  

Some IBCLCs love the style of a home visit. This visit style requires time for travel, consultation and paperwork. In most cases now, you can spend time with the patient but you may be reimbursed for only 60 minutes or up to 90 minutes of time spent as an In-Network provider. But you will get reimbursed for multiple visits, and Mother should not incur a copay or out of pocket cost.

If you business expands by the use of in-network patients, it may seem reasonable to switch to an office setting so you can see more visits in one day without your travel time. It may also seem reasonable to do the home visits, but limit your scope of travel to a reasonable area to maximize your time. With Aetna, you can meet with mom up to 6 times; based upon the complexity of the case,  it may be a good practice management technique to set up the follow up visit at the end of the first one. You may also have a cancellation policy for missed visits, which can only be a suggestion and it only has merit of the Mother knows you have a cancellation policy and charge. This type of charge is not billable to insurance either.

The Stark Law & tips for a sublease or office space "rental" :  

Another option is creating a separate sublease arrangement, but due to current federal and state legislation, primarily called the Stark Laws, your practice would need to appear separate and optional to the patient. There are many aspects to this law but there are also many exceptions.  The simplest way to explain it is this: if you were in the Pediatrician's office and he says to Mom that she must go now see Lactation Lisa who is leasing space from that doctor in another room,  that is violating the flavor of the law and does not offer the patient a choice. One of the Stark Law suggestions is to “provide an individual with a written list of suppliers who furnish such services in the area in which such individual resides” like a list of local IBCLCs also listing the one who happens to be in your building.

Additional Resources:  

The following is from an article in the American Medical News.com, the full article link is below:  

Expansion potential

There is potential for conflict when the renter serves a patient population that has different needs and behaves in different ways. But when that population meshes with your own, the arrangement can not only provide a financial boost to the practice, but also can make it easier for patients to access recommended care. For instance, Dr. Fuisz rents space to a podiatrist and a cardiologist, and offers her patients the option of being referred to these physicians. "It's really very convenient for patients," she said.

Such arrangements should not run afoul of various state and federal anti-kickback statutes as long as the rent paid is comparable to that for similar spaces in the area, and there is a written, signed lease lasting at least a year, experts said.

Physicians are allowed to charge a subtenant for both the cost of the actual office space and use of the common areas, but the size of the space and the time allotted need to be fixed. For example, an arrangement that allows a physician to use an office every Wednesday for eight hours, paying the same rent no matter how many patients are seen, is generally considered legal. One in which the hours vary widely or the rent is well above or below the cost of similar spaces would not.

"There are a lot of compliance issues you have to be aware of when you have a referral relationship," said David Biehl, a partner/director in the law firm Garfunkel Wild in Great Neck, N.Y., who has advised physicians on these types of deals. "The most important issue is that the cost of the space has to be at fair-market value. You cannot underpay. You cannot overpay."


This link below is “Stark Law–Frequently Asked Questions.”                                                             It is the easiest to read handout I could find.


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