Us vs. Them – my solution to the IBCLC versus CLC debate (at least here in New Mexico)

The us versus them of IBCLCs and CLCs has been going on for years. I admit that I felt the same way many IBCLCs do about CLCs too. It is hard to see someone take a one week course and see themselves as equal, but I also don’t feel that is how most CLCs are. All lactation care providers have been continuously undervalued in healthcare and not given credit for their expertise. Not all breastfeeding dyads need the level of care an IBCLC can and does provide though. Many families simply need encouragement and education about the normal course of breastfeeding, including normal newborn behavior, which CLCs are well equipped to provide and should be providing. Even minor corrections in positioning and latch are well within the scope of a CLC. After careful consideration, and heated conversations (thank you to my friend and ally Lissa for challenging me to look at this issue through a health equity lens), I believe that the biggest issue in the minds of many IBCLCs is that there is no current place for CLCs in our healthcare system in regard to the currently used Current Procedural Terminology (CPT) codes and billing. I believe CLCs do have a place in our healthcare system, and I believe I have a solution.

CLCs are counselors, they are well equipped for counseling and should be reimbursed. CLCs know normal and know to refer when things are not normal. As IBCLCs we should embrace this and network with our community CLCs and support them.

The rest of this discussion gets in to some of the nitty gritty of billing and coding, which while not fun is part of this solution. So try to stay with me! I know when I starting looking at all of these codes and terms when I first started I felt like my head was going to explode!

via GIPHY

If we look at the Evaluation & Management CPT codes for new patients (99201-99205) they have criteria that need to be met to be used for billing (per the American Medical Association and the DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services). IBCLCs generally bill using 99203 as we easily meet the criteria of: history, chief complaint, a review of 2-9 body systems as part of our assessment (most commonly 5; including psychiatric, endocrine, integumentary, GI, and musculoskeletal), and low to moderately complex decision making. 99203 can be used as a time-based code as well. It is generally recognized as a 30min code and at least half the time needs to be spent discussing the current problem and relevant history. This is well within our scope and standard of practice.

A CLC is trained in normal and is not making moderately complex medical decisions, but they can meet the criteria for 99201, which only requires the chief complaint to be documented. 99201 as a time-based code is considered 5min. This is excellent way to value the care that CLCs provide to families with normal breastfeeding and need support through the process in the early days.

We tie these codes with counseling time-based codes (99401-99404) using modifier 25, (significant, separately identifiable evaluation and management [E/M] service by the same provider on the same day of the procedure or other service). These counseling codes are 15min increments, 99401 being 15min through 99404 being 60min. Counseling codes are modified using modifier 33, for preventative services. The Affordable Care Act (ACA) classifies lactation care as preventative and we should code accordingly.

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As a member of the Lactation Care Provider Practice Act Committee, I was the first IBCLC in New Mexico to be issued a license.

Licensure in New Mexico, my beautiful state, went live on February 26, 2019. I was issued the first license that day, and am now a New Mexico Licensed Lactation Care Provider (LLCP). The purpose of licensure was to provide a way for Medicaid to provide reimbursement. Per the federal regulations, Medicaid cannot pay non-licensed providers, so we introduced HB 138 The Lactation Care Provider Practice Act in 2017, which incredibly was signed in to law that same session. In New Mexico we chose to license both IBCLCs and CLCs. Our state is incredibly rural and we approach things a bit differently than other states in order to provide adequate access to care, and this was one example of how we do that. After our bill was signed, the next task was writing the regulations for the law, which I was a major part of. Our law tasked the New Mexico Board of Nursing with the oversight of Licensed Lactation Care Providers, and the regulations can be viewed here (part 11 Lactation Care Providers).

If we look at the current New Mexico Medicaid fee schedule, both IBCLCs and CLCs should be paid for their time spent counseling families, and in New Mexico the published Medicaid rates for a 50min CLC visit using 99201 and 99403 would be $62.76 ($35.18 + $27.58 = $62.76). An IBCLC on the other hand, typically sees more complex problems and would bill (and document for) 99203 and 99402 for a 60min visit, the rate would be $118.59 ($93.52 + $25.07 = $118.59). Counseling rates are paid the same for all, but IBCLCs are paid for their expertise in the new patient E&M code.

This same concept applies to follow-up E&M CPT codes (99211-99215). IBCLCs commonly use 99212 and 99213 (more commonly 99212, a problem focused visit versus expanded problem focused visit), depending on the complexity. A CLC can easily meet the criteria for 99211, which again is only chief complaint and doesn’t require further documentation.

If we look at follow-up codes, a CLC would typically bill 99211 and 99403 for a 50min follow-up visit for a rate of $45.49 ($17.91 + $27.58 = $45.49), whereas an IBCLC would bill 99212 and 99403 for a 55min follow-up for a rate of $64.47 ($36.89 + $27.58 = $64.47). Again, IBCLCs are paid more for the evaluation and management, as they can document and meet advanced criteria. This also creates a system where IBCLCs can work to correct complex problems and then refer to CLCs in the community when families no longer need complex care and rather need support of the normal (and corrected) course of breastfeeding. IBCLCs and CLCs should be working together to provide our communities the best support available.

This looks specifically at Medicaid, which in my state is the largest provider of healthcare for young families. More than 80% of babies in New Mexico are covered by Medicaid, so there has been a HUGE gap in coverage for these families. Outpatient hospital clinics simply cannot see all of these families, and they cannot afford private practice lactation providers, so many were left only with non-clinical options, which while amazing cannot fill in all of the gaps.

We do not need to have an us versus them mentality. Rather, we should be looking at this as a health equity issue. We should have CLCs as the first responders out in the community, seeing families in the first week of life and triaging them to a higher level of lactation care if needed, and otherwise supporting them along their breastfeeding journey. In my rural state, access to IBCLCs is limited. I have seen families from 2-3hrs away at times, and if there had been a CLC in their community, maybe I could have worked with that CLC and helped these families earlier. Also, most IBCLCs are white women, like myself, and in my state white women are the minority. Having more, Spanish-speaking women of color available to support their peers is incredibly important. Becoming an IBCLC is not easy, but training women to support their community is and that is what we should be doing. As IBCLCs we should welcome CLCs to our community and see them as referral sources. CLCs are also able to make our job easier by seeing those families in the early days and “stabilizing” them and referring them to us when things are not normal. We all know rule number one of lactation care is Feed the Baby! CLCs in our community can help be sure infants are fed, and we can be there to be sure that issues are addressed and breastfeeding goals are met, when we work together. We need villages when we have a baby, and IBCLCs and CLCs all have a place in that village.

I am in no way affiliated with The Healthy Children Project, Inc. Center for Breastfeeding and have no financial interest in the Certified Lactation Counselor program. My only interest in finding a way for us to all work together is that CLCs are eligible for licensure in New Mexico. This system of CLCs as first responders and as an integral part of our maternal child health care program is simply my vision for a healthier New Mexico, and how I can see increasing our exclusive breastfeeding rates, as well as our breastfeeding duration. I can see this translating to other states as well. I understand the long held feelings of IBCLCs and the need to not undermine our credential, and I hope IBCLCs can see how I believe this type of system in fact elevates and protects our credential as the higher level of care.

New Mexico Medicaid has not recognized Licensed Lactation Care Providers yet, so this is still a vision, but I am hopeful and will update as this all moves forward.

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