Rule 5160-8-42 | Lactation consultation services.
(A) Scope and definitions.
(1) This rule sets forth provisions governing payment for professional, non-institutional lactation consulting services.
(2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human lactation.
(3) "International Board Certified Lactation Consultant" (IBCLC) is a professional member of the healthcare team who has earned and maintains the credential which identifies knowledge and expertise in breastfeeding management and care. This includes insight, skills, and knowledge to identify complex breastfeeding problems and to educate, promote, and facilitate an optimal breastfeeding experience and environment.
(1) Rendering providers. The following eligible providers may render a lactation consultation service:
(a) A physician.
(b) A physician assistant.
(c) An advanced practice registered nurse.
(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for lactation consultation services on behalf of a rendering provider:
(a) A physician;
(b) A physician assistant;
(c) An advanced practice registered nurse;
(d) A professional medical group;
(e) A federally qualified health center (FQHC);
(f) A rural health clinic (RHC); or
(g) An ambulatory health care clinic;
(C) Coverage. Payment may be made for the following lactation consultation services:
(1) Providing evidence-based information to assist the client to make decisions regarding infant feeding.
(2) Performing comprehensive maternal, child and feeding assessments.
(3) Developing and implementing an individualized feeding plan.
(4) Providing evidence-based information regarding use, during breastfeeding and human lactation, of medications (over-the-counter and prescription), alcohol, tobacco and addictive drugs, and herbs or supplements, and their potential impact on milk production and child safety.
(5) Providing support and encouragement to successfully meet breastfeeding goals.
(6) Supporting access to other well-care services for mothers and infants, including connections to other services and supports including WIC, primary and pediatric care, and home visiting.
(D) Allowances and limitations
(1) Payment may be made for lactation consulting services when the following criteria are met:
(a) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;
(b) The service is performed at the order of a practitioner in accordance with rule 5160-1-17 of the Administrative Code;
(c) The individual is not currently receiving nurse home visiting services in accordance with rule 5160-21-05 of the Administrative Code;
(2) Payment may be made for lactation consulting services performed by a registered nurse who holds a current IBCLC credential, when performed under the supervision of a physician, physician assistant or an advanced practice registered nurse.
(3) No additional payment is made for lactation consulting services rendered to the same individual on the same date of service as medical nutrition therapy.
(E) Claims payment.
(1) Payment for a covered lactation consultation service is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.
(2) Payment for a covered lactation consultation service provided by an FQHC or RHC is paid in accordance with Chapter 5160-28 of the Administrative Code.
(3) Payment for a covered lactation consultation service provided in a hospital is paid in accordance with Chapter 5160-2 of the Administrative Code.
(4) Payment for lactation pumps and supplies is made in accordance with rule 5160-10-25 of the Administrative Code.
Last updated January 3, 2022 at 9:49 AM