Lactation & Patient Responsibility
The Affordable Care Act Provisions of the ACA have a big impact on how we are able to bill for lactation as well as other additional services. Some provisions increase coverage and others cut down the likelihood of patient responsibility for these services.
So what does the ACA do for birth centers? Plans cannot discriminate against any type of licensed medical provider if the state licenses midwives, insurance plans must reimburse them. Plans are required to cover maternity and newborn care as part of the required Essential Health Benefits. Plans are required to cover preventative care 100% no patient responsibility. But grandfathered plans are not required to comply with any of these three provisions.
But what s a grandfathered plan? Per HealthCare.gov, Grandfathered plans are those that were in existence on March 23, 2010 and haven t been changed in ways that substantially cut benefits or increase costs for consumers. Grandfathered plans are not required to comply with a number of the provisions of the ACA. This doesn t mean that every grandfathered plan fails to comply with these provisions they just aren t required to. Grandfathered plans will remain grandfathered until such time as they make certain changes to the plan there is no end date or time limit on being grandfathered.
Know the Benefits Because there s such a gap between what grandfathered plans may cover and what other plans are required to cover, you ll want to bill differently for grandfathered plans. So you must know the patient s benefits. We ll talk about two different billing situations: 1. Billing for grandfathered plans with no maternity care. 2. How to bill for maximum reimbursement with all plans.
Defining Preventative Care
Define Preventative A preventative visit is the opposite of a problem visit making sure a problem doesn t occur in the future, rather than treating an existing problem. Some procedure codes are implicitly preventative: preventative counseling, weight management, smoking cessation counseling, etc. Some codes, like office visit codes, can indicate either preventative or problem care. But what really defines preventative care is the use of preventative diagnosis codes.
Preventative Procedures Code(s) Description 99381-99397 Preventative Medicine (by age) 99401-99404 Preventative Medicine Counseling (by service level) 99406-99407 Smoking and Tobacco Cessation Counseling S9449 S9470 S9443 S9442 Weight Management Classes Nutritional Counseling Lactation Classes Child Birth Education Classes
What about E/M codes? You may sometimes be unable to bill a preventative procedure code because of restrictions on your contract or Medicaid reimbursement schedule. In these cases, you can bill a normal evaluation and management code with a preventative diagnosis code. Code(s) Description 99201-99215 Office Visits (by new/established and service level) 99345-99350 Home Visits (by new/established and service level) For more information on determining service level, visit the Evaluation and Management Services Guide at cms.gov.
Preventative Diagnoses In the new ICD-10 system, many preventative diagnosis codes start with Z: Factors influencing health status and contact with health services (Z00-Z99) ICD-9 ICD-10 Description V70.0 Z00.0_ Routine General Medical Exam V72.31 Z01.41_ Routine Gynecological Exam V22.0-V22.1 Z34._ Normal Pregnancy V24.1 Z39.1 Care and Examination of Lactating Mother V78._ Z13.0 Screening for Blood Diseases or Disorders V82.71 Z13.71 Screening for Genetic Disease Carrier Status
Why Preventative Care? Proper use of preventative care billing is key to maximum ACA reimbursement. Though grandfathered plans are not required to cover preventive care 100%, they are likely to pay something for it, and many won t pay anything for maternity care. So for grandfathered plans you ll want to bill part of maternity care as preventative visits. And for non-grandfathered plans, you can bill extra preventative visits outside of global care.
Working Global
Defining Global Care To bill outside of or instead of global care, we ll want a clear understanding of what s included. Global care is: Standard prenatal care. Routine in-house labs (some contracts may vary). Labor and delivery. Standard postpartum care.
Global Breakdown For grandfathered plans that don t cover maternity care, don t bill globally for care break it down into its components. Bill preventative visits for prenatal care. Use E/M or preventative codes for the visits. Use preventative and screening diagnoses as the primary whenever appropriate. Bill for labor and delivery. This will be denied as non-covered, but at least it s only a portion. Bill preventative visits for postpartum care. Bill as for prenatal care.
Outside of Global For plans that do comply with all ACA provisions, you can bill extra preventive care outside of global. To determine what can be billed separately, think non-routine and outside the belly. STD Screening Drug and Alcohol Counseling Nutritional Counseling But be careful not to get greedy with billing these extras make sure that every time you bill a separate visit, the preventative care component was truly the focus of the visit. Don t bill a smoking cessation visit when it was really just a routine prenatal where you talked for a minute or two about the patient quitting smoking.
And Now Let s Talk Lactation
Billing for Lactation Services Lactation services are a prime example of non-routine, preventative postpartum care. This is a good preventative service to recoup some money for postpartum care of a patient with no maternity coverage. And it s an opportunity to bill outside of global for patients who do have maternity coverage. Use proper E/M or preventative medicine codes and applicable diagnosis codes. If there is a lactation problem, your patient may be subject to a copay, which we ll talk about further on.
Bill for Two! If both mom and baby receive care during a lactation visit, you can bill for both. This isn t always the case though make sure you bill for whoever receives significant care. Did mom receive care for 75% of the visit? She should probably be billed. But you might bill baby for a lower level code as well. Did mom receive care for 95% of the visit? You probably shouldn t bill for baby. Preventative medicine procedures codes (99401-99404) are great for lactation visits for both mom and baby. But use E/M codes (99211-99214) if the patient has no preventative coverage or it was a problem visit.
Lactation Diagnoses ICD-9 ICD-10 Description V24.1 Z39.1 Care and Examination of Lactating Mother 783.22 R63.6 Slow Weight Gain/Underweight 750.0 Q38.1 Tongue Tied/Ankyloglossia 779.31 P92._ Feeding Difficulty, Newborn 783.3 R63.3 Feeding Difficulty, Infant 676.34 O92.20 Disorder of Breast, Postpartum 675.2_ O91.2_ Nonpurulent Mastitis 611.71 N64.4 Breast Pain 676.04 O92.0_ Retracted Nipple, Postpartum
The End of Visits
Preventative care is here to stay! Preventative care is not limited by age or times per year. But be careful with your codes! The diagnosis code will make or break you. It decides how much the insurance pays and what ends up being the patient s responsibility.
Patient Responsibility
Not the end of Copays Many patients will come in expecting a visits that is covered 100%. But a preventative care visit can easily turn into a problem visit. Be clear with your patients when you provide treatment for a problem or condition that the visit is no longer preventative, and it may be subject to a copay, coinsurance, or deductible. Grandfathered plans may also have patient responsibility for preventative care or not cover preventative care. If the plan doesn t cover preventative care, make sure to bill E/M codes rather than preventative medicine codes. It may not be covered 100%, but at least there will be coverage!
Non-covered Services You may also want to discuss non-covered services with patients. This is particularly important with patients whose grandfathered plans do not cover maternity care. For Medicaid patients, you could find that some services, like lactation support, are not covered. In such situations, you can issue an ABN to the patient, informing her that the cost of services will be her responsibility. Payable Non-payable
Utilizing an ABN An Advance Beneficiary Notice of non-coverage (ABN) is a document Medicare and Medicaid requires providers to issue to patients before rendering services that are usually covered by Medicaid or Medicare but are likely to be denied as not medically necessary because of the diagnosis codes used. You may also choose (but are not required) to use an ABN before rendering services that are consistently denied by Medicaid or Medicare.
Routine Notice Prohibition The Routine Notice Prohibition on ABNs is simply a provision to ensure that providers aren t using ABNs all the time for no reason. To comply, you must ensure that you have reasonable evidence to believe and support that a service would not be covered by Medicaid. Just don t issue ABNs on a routine basis without occasionally checking that the services for which you issue ABNs are still non-covered.
Lactation Services CMS$150ABN Regularly denied as non-covered Example The ABN tells the patient that she will either need to pay for the services out-of-pocket or choose not to receive them.
but Cautious
Use Opportunities Wisely The ACA provides some great opportunities to increase reimbursement, but always be careful of overuse and misuse. Know your codes, and use them properly. For example, if it wasn t an annual visit, don t use an annual visit code just to make the visit appear preventative. Use appropriate codes for lactation and other preventative services, and if the insurance company doesn t cover them as preventative services, argue with them. Always keep good records to support your coding.
Lactation Billing & Patient Responsibility Presented by Marnie Cabezas-Skorupa Executive Director, Midwife s Billing Service, Inc.