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Please Use Our Templates to Help Establish a CMS Code for Lactation Consultant Services  
Dear USLCA Members and Friends:

I am writing to you with an urgent request.

Many IBCLCs - perhaps you yourself -  have trouble billing for their services, in part because there is currently no billing code that adequately describes the services we provide. As you may be aware, this past January, the USLCA submitted an application to the Centers for Medicare and Medicaid Services (CMS) for a new Health Care Common Procedure Coding System (HCPCS) code to describe lactation consultant services performed by IBCLCs.   We sought this code in order to facilitate billing.

Unfortunately, CMS' preliminary decision, released today, is not to create a HCPCS code for IBCLC services because, according to CMS, there is no program operating need to create such a code.  The text of CMS' decision is copied below for your reference.

But all is not lost.  As the applicant, the USLCA has the right to make a presentation at CMS' May 29th meeting to discuss this preliminary decision.  We also have the opportunity to provide written materials that support this presentation, provided that such materials are received by CMS by May 15th. 

We need to demonstrate during this presentation that there is, in fact, a programmatic need for the new code. We need to show that insurers are having difficulty processing claims for IBCLC services given the absence of an appropriate code.  Ideally, we would be able to support this assertion with letters written by insurers.  Therefore, we urge that you reach out to any insurers to whom you submit claims and request that they write a letter to this effect and submit it to CMS no later than May 15th.

To assist you in this process, we have prepared two documents for you to use:  (1) Click Here ( to Insurers 5_2_13.doc) for the text of the email you should send to insurers requesting their assistance; and (2) Click Here ( Insurer Letter 5_2_13.docx) for a draft letter to attach to that email that the insurers can complete, sign, and send to CMS.

Please do not hesitate to contact us if you have any questions.  Your assistance with this urgent request is greatly appreciated.

Best regards,

Marsha Walker, RN, IBCLC
Director of Public Policy
U.S. Lactation Consultant Association



Request to establish a Level II HCPCS code to identify individualized lactation assessment and management services provided by International Board Certified Lactation Consultants (IBCLCs). Applicant's suggested language: "individualized lactation assessment and intervention visit furnished by an International Board Certified Lactation Consultant; each 15 minutes".

According to the applicant, several evaluation and management CPT codes describe general services similar in structure to individualized IBCLC services, but are not specific to lactation and do not describe higher intensity individualized services including evaluation and intervention components (e.g., that a lactation "class" would lack). This is an existing service not adequately described by current HCPCS codes. A HCPCS code is needed to enable IBCLCs to bill for the service and to facilitate coverage and reimbursement of the service. IBCLCs are the only health professionals certified in lactation management.

Preliminary Decision:
A national program operating need was not identified by Medicare, Medicaid or the private insurance sector to establish a Level II HCPCS code to identify this professional service. CMS refers the applicant to the American Medical Association (AMA) editorial process for establishing Current Procedural Terminology (CPT) codes.

Medicare Payment:
There would be no payment for these items and services under level II of the HCPCS.

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