Effective Date: January 1, 2021
Last Updated: March 27, 2022

Purpose:

This policy provides reimbursement guidelines for breast pumps, breast pump supplies and lactation counseling.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Policy:

Horizon NJ Health will cover certain breastfeeding equipment and services consistent with the New Jersey Breastfeeding Support Law at N.J.S.A. § 30:4D-6o in accordance with, and subject to, the following policy.

Breast Pumps:

Horizon NJ Health will consider for reimbursement either one (1) purchased manual breast pump (HCPCS code E0602) OR one (1) purchased electric breast pump (HCPCS code E0603) per birth event. Hands-free single-user electric pump coverage is intended to support members with disabilities and should be billed using E0603 appended with modifier -SC.

Horizon NJ Health will only consider a hospital grade pump (HCPCS code E0604) with a prior authorization and if the pump is a rental unit appended with modifier –RR. Only one (1) hospital grade pump is allowed per birth event. Note: Medical records must support the need for a hospital grade pump. A letter of medical necessity and/or the physician order may be requested on a post-service basis.

Breast Pump Supplies:

Horizon NJ Health shall consider for reimbursement one (1) breast pump supply kit per birth event.

Lactation Counseling:

In-person lactation counseling and lactation consultation will be considered for reimbursement by non-physician providers using HCPCS code S9443 (Lactation classes, non-physician provider, per session). The provider must be a nurse practitioner, physician assistant or nurse midwife in order to be considered for reimbursement. Practitioners billing for this service outside of specialties family practice, pediatrics or OB/GYN shall not be reimbursed.

In-person group lactation counseling classes will be considered for reimbursement by non-physician providers using HCPCS code S9446 (Patient education, not otherwise classified, non-physician provider, group, per session). The provider must be a nurse practitioner, physician assistant or nurse midwife in order to be considered for reimbursement. Practitioners billing for this service outside of specialties family practice, pediatrics or OB/GYN shall not be reimbursed.

Telephonic lactation assistance will be considered for reimbursement using CPT codes 99441 (Telephone evaluation and management service by a physician or other qualified health care professional, 5-10 minutes of medical discussion), 99442 (Telephone evaluation and management service by a physician or other qualified health care professional, 11-20 minutes of medical discussion) and 99443 (Telephone evaluation and management service by a physician or other qualified health care professional, 21-30 minutes of medical discussion). Practitioners billing for this service outside of specialties family practice, pediatrics or OB/GYN shall not be reimbursed.

Diagnosis Codes Requirements:

All claims for breast pumps (E0602, E0603 and E0604), breast pump supplies (A4281, A4282, A4283, A4284, A4285, A4286 and K1005) and lactation counseling (S9443, S9446, 99441, 99442 and 99443) must have one of the following diagnosis codes:

O09.00, O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, O09.13, O09.211, O09.212, O09.213, O09.219, O09.291, O09.292, O09.293, O09.299, O09.30, O09.31, O09.32. O09.33. O09.40, O09.41, O09.42, O09.43, O09.511, O09.512, O09.513, O09.519, O09.521, O09.522, O09.523, O09.529, O09.611, O09.612, O09.613, O09.619, O09.621, O09.622, O09.623, O09.629, O09.70, O09.71, O09.72, O09.73, O09.811, O09.812, O09.813, O09.819, O09.821, O09.822, O09.823, O09.829, O09.891, O09.892, O09.893, O09.899, O09.90, O09.91, O09.92, O09.93, O36.80X0, O36.80X1, O36.80X2, O36.80X3, O36.80X4, O36.80X5, O36.80X9, O91.011, O91.012, O91.013, O91.019, O91.02, O91.03, O91.11, O91.111, O91.112, O91.113, O91.119, O91.12, O91.13, O91.2, O91.21, O91.211, O91.212, O91.213, O91.219, O91.22, O91.23, O92.011, O92.012, O92.013, O92.019, O92.02, O92.03, O92.111, O92.112, O92.113, O92.119, O92.12, O92.13, O92.20, O92.29, O92.3, O92.4, O92.5, O92.6, O92.70, O92.79, P92.5, Z13.0, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z39.0, Z39.1 or Z39.2.

Procedure:

Horizon NJ Health will not consider for reimbursement claims for more than one (1) manual breast pump (HCPCS code E0602) or one (1) electric breast pump (HCPCS code E0603) per birth event. Any manual or electric pump billed within the same birth event as the original pump shall not be considered for reimbursement.

Horizon NJ Health will not consider for reimbursement hospital grade pumps (HCPCS code E0604) that do not have a prior authorization.

Horizon NJ Health will not consider for reimbursement hospital grade pumps (HCPCS code E0604) that are not rentals appended with modifier -RR.

Horizon NJ Health will not consider for reimbursement breast pump supplies that exceed one (1) breast pump kit per birth event.

Horizon NJ Health will not consider for reimbursement lactation counseling or consultation (HCPCS codes S9443 and S9446) when billed by someone other than a nurse practitioner, physician assistant or nurse midwife.

Horizon NJ Health will not consider for reimbursement lactation counseling and assistance (HCPCS codes S9443, S9446, 99441, 99442 and 99443) when billed by someone outside of the specialties of family practice, pediatrics or OB/GYN.

Horizon NJ Health will not consider for reimbursement breast pumps, breast pump supplies or lactation counseling when the code is not billed with one of the diagnosis codes outlined in this policy.

Resources:

New Jersey Breastfeeding Support Law, N.J.S.A. § 30:4D-6o.

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

History: