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CO HCPF Lactation Support Services Billing Manual — Billing Information

BillingInformation

activein force · 2026-07-26 – presentas-observed

RefertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageundertheGeneralProviderInformationdrop-downforgeneralinformation.

ThetermThird-PartyLiability(TPL)describescircumstanceswhenaHealthFirstColoradomemberhashealthinsuranceorotherpotentialresources-inadditiontotheHealthFirstColoradoprogram-thatmaypayformedicalservices.

Anestimated10%ofHealthFirstColoradomembershaveotherhealthinsuranceresourcesavailabletopayformedicalexpenses.

WhilemostbenefitsrequireaprocessbywhichMedicaidwouldbethepayeroflastresortbecauseFederalregulationsrequirethatallavailablehealthinsurancebenefitsbeusedbeforeHealthFirstColoradoconsiderspayment,ThirdPartyLiability(TPL)editswillbeautomaticallybypassedforbothcommercialinsuranceandMedicarewhenclaimsaresubmittedbythefollowingprovidertypes:

PT70-LactationConsultant

PT72-Lactation/DoulaProfessionalGroup

PT79–Doula

FormoreinformationonTPL,pleasevisitthegeneralproviderbillingmanualsectionthatdiscussestheserulesingreaterdepth.

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LactationSupportServicesarebilledusingasingleHealthcareCommonProcedureCodingSystem(HCPCS)procedurecode(S9443),one(1)oftwo(2)modifiercodesindicatingindividual(U1)orgroupsettings(U2)andone(1)ofeight(8)modifiercodes(U3,U4,U5,U6,U7,U8,U9,UA)toindicatethenumberofminutesspentprovidingdirectcontactservicestothemember.Addanadditionalmodifiercodeifservicesaredeliveredviatelemedicine(FQ,FR,93,95),asshowninthetablesbelow.RefertothecurrentFeeScheduleforratesPriorauthorizationrequestsarenotrequired.Therearenoamount,durationorscopelimitationsfortheLactationSupportServicesbenefit.AppropriatediagnosiscodesmustbeutilizedwhenbillingforLactationSupportServices(e.g.,Z39.1:encounterforcareandexaminationofalactatingmother,O92.70:unspecifieddisordersoflactation).Ifbillingaclaimforabreastfeedingchild,useachildlactation-relatedcode(e.g.,R63.31:pediatricfeedingdifficulty,P92.5:neonatalfeedingdifficultiesatbreast).Servicesforthelactatingmemberandchildmustbebilledonone(1)claim.Boththelactatingmemberandthebreastfeedingchildmustnothaveclaimssubmittedforthesameserviceandthesamedateofservice.Theprovidershouldbilltheclaimundertheeligiblememberforwhomthevisitwasscheduled,ormostcloselyalignswiththeprovider’sscopeofpractice.Forexample,apediatricianwouldbillundertheHealthFirstColoradoenrolledbreastfeedingchild,andanobstetricianwouldbillundertheHealthFirstColoradoenrolledlactatingmember.

WhenbillingforLactationSupportServicesfortwins,multipleinfantsortandembreastfeeding,providershavetwooptions:

Billforextendedtimespentwiththelactatingmember;OR

Billseparatelyfortimespentwitheachbreastfeedingchild.Providerswillneedtoensuretobillfordistinctandseparateidentifiableamountsoftimeforeachpediatricmember.

Alactationsupportproviderwhorendersservicestomorethanone(1)memberatatimemustbillappropriatelyusingtheapprovedgroupsessionmodifierU2.Thegroupsessionmustbeaninstructor-ledbreastfeedingeducationgroup.NotallparticipantsinthegroupneedtobemembersofHealthFirstColorado,butaclaimforpaymentmayonlybesubmittedforeachenrolledHealthFirstColoradomemberwhoreceivedservicesinthegroupsession.SuchclaimsmustbecodedusingS9443withtheU2modifier.

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ProcedureCode

Description

FirstPositionModifier

SecondPositionModifier

S9443

LactationSupportServices

Telemedicineservicedeliveryisallowed.

U1=individualsession

U2=groupsession

U3=8-22minutes

U4=23-37minutes

U5=38-52minutes

U6=53-67minutes

U7=68-82minutes

U8=83-97minutes

U9=98-112minutes

UA=113-127minutes

Example:Amemberreceivedatotalof90minutesofindividualin-personLactationSupportServicesonagivendateofservice.TheprovidershouldreportS9443withtheU1modifiertoindicateindividualsettingandtheU8modifiertoindicate90minutesofdirectmembercontactservicesprovided.

ImportantNotesonS9443

AlthoughtheformaldefinitionofHCPCSprocedurecodeS9443is“Lactationclasses,non-physicianprovider,persession,”theDepartmentinstructsproviderstousethisprocedurecodeunderthedirectiondetailedinthisbillingmanual.Keydifferencesare:

ThisprocedurecodeshouldbereportedforLactationSupportServicesbyanyeligibleprovider,includingphysicians,ratherthanjust“non-physicians.”

ModifierCodesforTelemedicineServiceDeliveryforS9443

Description

Theservicewasfurnishedusingaudio-onlycommunicationtechnology.

Thesupervisingpractitionerwaspresentthroughtwo-wayaudio/videocommunicationtechnology.

Synchronoustelemedicineservicewasrenderedviatelephoneorotherreal-timeinteractiveaudio-onlytelecommunicationssystem.

Synchronoustelemedicineservicewasrenderedviareal-timeinteractiveaudioandvideotelecommunicationssystem.

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Providersreportthecodeforthetimespentindirectmembertreatment.Pre-andpost-deliveryservicesarenottobecountedindeterminingthetreatmentservicetime.Inotherwords,thetimecountedas"intra-servicecare"beginswhenthelactationproviderisdirectlyworkingwiththemembertodelivertreatmentservices.Record-keepingdocumentationandtraveltimeisnotreimbursable.Timespentforpreparation,reportwriting,processingofclaims,ordocumentationregardingbillingorserviceprovisionisnotreimbursable.

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Whenmultipleservices,includinglactationsupport,areprovidedduringasinglevisit,providersshouldnotbillforoverlappingtimespentondifferentactivities.Eachbilledprocedurecodemustcorrespondtoadistinctandseparatelyidentifiableamountoftimeandworkforeachservice.Forexample,ifduringavisitbothpreventivemedicineservicesandLactationSupportServicesareprovided,theprovidermaybilleachcodeonlyifthetimespentoneachisseparatelyidentifiableanddoesnotoverlap.

NCCIProcedure-To-Procedure(PTP)andMedicallyUnlikelyEdits(MUE)mayapplytocertaincombinationsofprocedurecodes.VisittheCentersforMedicare&MedicaidServices(CMS)NCCIwebpageforacompletelistofimpactedcodes,guidanceonbypassmodifieruses,andgeneralinformation.BacktoTop

LactationSupportServicesareprovidedaspreventativeservicesandrequirearecommendationbyaphysicianorotherlicensedpractitionerofthehealingartsactingwithintheirscopeofpracticeinaccordancewith42CFR440.130(c).

Thelactatingindividual-childdyadrequiresarecommendationonfilefromaphysicianorotherlicensedpractitionerofthehealingarts.ThisrecommendationauthorizesLactationSupportServicesfrompregnancythroughthedurationofbreastfeeding.Therecommendationcancomefromthelicensedhealthcareproviderofeitherthelactatingindividualorthechild.

Physician–PT05/65

Osteopath–PT26

PhysicianAssistant–PT39

AdvancedPracticeNurse–PT41

NurseMidwife–PT22

CertifiedMidwife(CM)–PT80

CertifiedProfessionalMidwife(CPM)/DirectEntryMidwife(DEM)-PT69

Non-PhysicianPractitioner-Individual–PT24

TherecommendingproviderindicatedontheclaimmustbeactivelyenrolledwithHealthFirstColorado(42CFR455.410(b)).Theclaimwillbedeniediftheindicatedproviderisnotactivelyenrolled.ReferencetheOrdering,Prescribing,andReferringClaimProjectIdentifierforfurtherdetails.

Ifalicensedproviderlistedinthismanualrendersaserviceundertheirownorderingauthority,thenthatrenderinglicensedprovider'sNPInumbershouldbeplacedintheapplicableOPRfieldontheclaim.ThisdoesnotapplytoprovidersenrolledasIBCLC,CLCandCLEs.

ProfessionalClaims

Paperclaimsusefield17.b.

Electronicsubmissionsuseloop2420withqualifierDK(Ordering),DN(Referring)orDQ(Supervising).

ClaimssubmittedthroughtheProviderWebPortalusethe“ReferringProvider”field.

InstitutionalClaims

TheAttendingProviderfield(#76)ortheOtherIDfields(#78or#79)forbothpaperandelectronicclaims.

ProvidersmayrefertotheirapplicableUB-04billingmanualsforguidanceonhoweachfieldisused.

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Theprovidermustmaintaindocumentationinaccordancewith10CCR2505-108.130.2thatcomplieswithstateandfederalregulations.Theprovidermustretainrecordsthatspecificallyrecordthedatesandprecisetimesatwhichdirectservicesprovidedtoamemberbeganandended,amongothergeneralrequirementsfordocumentation.Thesetimestampsarecriticalforvalidatingthesecondpositionmodifierbilled.

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LactationSupportServicesarenotincludedinHealthFirstColoradophysicalhealthmanagedcareplans.LactationSupportServicesarestillcoveredbenefitsformembersenrolledinthoseplansas“wrap-around”benefitsoftheplan.

AllclaimsforLactationSupportServicesshouldbebilledtotheDepartment’sFiscalAgent,GainwellTechnologies,evenifthememberisattributedtoaHealthFirstColoradophysicalhealthmanagedcareplan.

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LactationSupportServicesprovidedatanOutpatientHospitalarereportedontheinstitutionalclaimtypeandarereimbursedaspartofthehospital'sEAPGpayment.

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ProfessionalservicesprovidedbyaLactationSupportServicesproviderassociatedwithnewborndeliveriesandimmediatepostnatalbreastfeedingsupportcareforthelactatingindividualarepartofthehospital’sfacilityAllPatientRefined-DiagnosisRelatedGroup(APR-DRG)paymentandtheFreestandingBirthCenter’sdeliverypayment.SuchcircumstancesarenoteligibleforbillingthroughtheLactationSupportServicesbenefit.PlaceofServicecodes21(InpatientHospital)and25(FreestandingBirthCenter)arenotavailableforbillinguse.HCPCScodesforLactationSupportServicescannotbebilledfordatesonorduringthedatespanofthedeliveryandinpatientstay.RefertotheObstetricalCareBillingManual.

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ProvidersmayprovideLactationSupportServicesinavarietyofsettings,includingthemember’shome,clinics,providerofficesorviatelehealth.ThevisitsettingshouldbeindicatedontheclaimusingthePlaceofServicecode.AfulllistofallowableplacesofserviceforLactationSupportServicesisindicatedbelow.

LactationSupportServicescanbeprovidedviatelemedicinewithPlaceofServicecodes02or10.TelehealthservicesmustadheretotheTelemedicineBillingManual.

OfficialdescriptorsofthePlaceofServicecanbefoundontheCentersforMedicareandMedicaidServices(CMS)website.

ThefollowingPlaceofServicecodesareallowed:

AllowedPlaceofServiceCode

Description(short)

TelehealthProvidedOtherthaninPatient’sHome

HomelessShelter

TelehealthProvidedinPatient’sHome

Office

Home

MobileUnit

OffCampus-OutpatientHospital

UrgentCareFacility

OnCampus-OutpatientHospital

IndependentClinic

FederallyQualifiedHealthCenter

PublicHealthClinic

RuralHealthClinic

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ContacttheProviderServicesCallCenterwithbillinginquiries.ContacttheDepartment’sLactationSupportServicespolicyspecialistatHCPF_MaternalChildHealth@state.co.usforallotherinquiries.BacktoTop

Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: f1297c2d6afe9f41e666dca0f1544185ff9ae5a43d144672c7e51602b7f3a23e

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