New Coverage of Medical Lactation Services

As noted in the August 2017 Special Medicaid Bulletin, Clinical Coverage Policy (CCP) 1-I, Dietary Evaluation and Consultation, has been revised. The revisions, which became effective August 1, 2017, add Medical Lactation Services to CCP 1-I, in addition to updated ICD 10 codes in the dietary section of the policy. The new title for policy CCP 1-I is Dietary Evaluation and Consultation and Medical Lactation Services.

The Medical Lactation Services covered in CCP 1-I include lactation evaluation and breastfeeding counseling when the breastfeeding infant has a chronic, episodic, or acute condition for which medical lactation services are a critical component of medical management.

Medical Lactation procedure codes require modifier SC when billed for a Medicaid beneficiary under the age of three years. The initial lactation assessment (96150-SC) is allowed only once per beneficiary lifetime. Lactation Assessment Services (any combination of 96150-96152 with modifier SC) are limited to a total of six units per single date of service. In addition, Lactation Assessment Services (any combination of 96150-96152 with modifier SC) are limited to a total of 36 units per beneficiary lifetime. Lifetime Medical Lactation Services are tracked and viewable on the recipient service limit record in NCTracks so providers can see how many units are available to bill. Medical Lactation Services can be billed on professional and Health Department claims. For FQHC and RHC, the service is included in their Core service, so although they can provide the service, they will not actually bill the medical lactation consultation codes.

The revised CCP 1-I policy can be found on the Clinical Coverage Policies page of the N.C. Division of Medical Assistance website. Refer to Attachment A, Sections C and E of CCP 1-I for specific information on billing for medical lactation services.