My name is Barb Roseborough and I'm a nurse, educator, and "old"
(figuratively speaking, natch!) LLLeader.  I've been lurking on Lactnet for
a while in digest form and I've also been a subscriber to the perinatal
nursing list.

Recently, I was/am involved in setting up a Lactation Center at our facility
(a 500-bed health center in northwestern Pennsylvania).  We do about 1800+
deliveries a year and over half of those moms initiate breastfeeding.  There
are two IBCLCs associated with our facility:  one works full-time on our
postpartum floor; the other part-time in the Lactation Center.  Both do
consults; 48-hour post-discharge follow-up phone calls; take calls from a
breastfeeding warm-line; and teach prenatal breastfeeding (basic and
working) classes (and, of course, "other duties as assigned").  The
Lactation Center also has a retail business (since we are a non-profit
hospital, this service is provided under the auspices of our auxiliary-run
gift shop).

We do not do pump rentals.  Several years ago our facility gave up its DME
license, something about conflict-of-interest since we joined with several
other institutions to form a separate entity that, among other things,
handled DME.  (However, I recently learned that a DME license in the
commonwealth of PA is nothing more than a registration that costs $25.00 per
year.  Our financial folks are currently investigating whether or not our
little outpatient service could have its own DME license!)

Moms who come to us for consults are registered as outpatients, but since we
do not bill insurance companies, services are rendered in a "self-pay"
fashion.  We have been giving moms a copy of the "Lactation Superbill" with
a "tip sheet" for submitting to their insurance carriers.  We've only been
open since May and haven't had much feedback in terms of whether or not the
moms have had any reimbursement.  We did, however, have one formed directly
returned to us from an insurance provider, asking us to fill in the CPT
codes.  We had merely been filling in the ICD-9/diagnoses codes.  (To make a
long story short, we must have misplaced whatever instructions for use that
came with the superbill and duplicates are being sent to us.)

Here's the rub:  our health system's coding expert is raising some, albeit
friendly (she's a grandma and personally thinks our service is a great
idea), issues about how we function re: charges, billing, coding, etc.,
etc., etc.  I respect her knowledge and, in the light of Corporate
Compliance and the "f" word (fraud, folks!), she suggested I ask a few
questions of others in the Lactation Center business!  Please feel free to
respond to me privately since I don't want to clog up the list with issues
that may not be pertinent to the majority ([log in to unmask]).  If you can
relate to anything that I've rambled on about so far (if you have some
solutions, all the better!), please respond.  Perhaps the following
questions might add to the discussion:

1.   Do any of you bill insurance carriers directly?  What success, if any,
have
      you had?

2.   What code are you using for your services?   All the CPT codes, our
expert
      tells me, that are on the lactation superbill are PHYSICIAN codes.
And
      they may not be used without an MD or an APN physically present who
      must also see the patient.  She says there is a number -- 99211 -- for
a
      nurse to use, but it's not on the superbill.  Do any of you use 99211?
Our
      IBCLCs happen to be nurses;  what code do those of you who are not
      nurses use?

3.   If you are billing, do you break your charges down according to
      time/complexity of services?  What criteria do you use?  (We currently

      charge according to the time spent with the IBCLC;  breaks down into
      quarter-our increments.  Our expert says that is not allowable under
      the 99211 code.)

4.   Do any of you use the 99212-15 codes?  Or any others?

5.   Are you getting written consults/referrals from physicians?

6.   How do you handle self-referrals?

I have to add here that there is concern about the use of the words
"consult" and "referral" among coders.  Here's how they're seen (this is
"physician" in nature -- which is how the code system is structured):
        consult - advise me how to treat my patient
        referral - here is my patient - treat her as you think best
Adams, W.  (August 1998).  The proverbial quandary:  Consult or referral?
    AAPC News.

I've probably bored you with the length of this inquiry, but HELP!  Just one
more question!

7.   Do any of you know of/use any different coding guidelines for lactation

      consultants?


Again, please feel free to respond to me privately.  And, in advance, thank
you, thank you!

Barb Roseborough, MSN, RN
[log in to unmask]

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