1. Explain how to create a breastfeeding friendly office.
2. Identify different types of certifications in the field of lactation. Compare the amount of training required, the cost and the advantages/ disadvantages of each.
3. Discuss the benefits and challenges of incorporating lactation services into a pediatric practice and a PNP schedule.
4. Discuss how to bill and get reimbursed for lactation services as a Nurse Practitioner.
• Recertified by continuing education credits after 5 years and by retaking the exam every 10 years (required).
• Post Masters PNP certification in 1996
• Developed Lactation Consultant Service within a large pediatric group practice in 2003. Currently 5 of 7 PNPs are IBCLCs. We had 1700 newborns in 2017, LCs saw about 75% for first visit (1275) and saw an additional 765 Lactation visits.
• Establish a written breastfeeding friendly office policy• Train all staff – providers, nurses, assistants, phone triage protocols• Schedule newborn visits with someone trained in lactation who can observe a feeding• Office posters/ pictures of breastfeeding mothers• Access to references about medications and breastfeeding. • Know community resources for referral.• Provide parent handouts on common problems, or have information available on your web
site.• No free formula samples; keep formula and bottles in a closed closest. No advertising for
formula companies via pens, posters, calendars.• “Breastfeeding Welcome Here” in patient waiting areas; also provide privacy for nursing if
desired.• Provide services for tongue tie or know local referral sources.• Monitor breastfeeding initiation and duration rates.
Evaluation of a Office Protocol to Increase Exclusivity of Breastfeeding by
Corriveau, et.al. Published in Pediatrics in 2013.• Multicultural, suburban/ rural area of Virginia• Implemented the ABM clinical protocol for providing BF services in peds primary care clinic (including staff training, written policies, on site lactation consultant)
• All BF newborns scheduled with RN/ IBCLC at same time as initial appt – extended visit (up to 1 hour), LC followed by medical provider exam.
• 757 mother‐infant pairs; retrospective design. Data collection in hospital, newborn visit, 2, 4 and 6 mo checks
• Results: statistically significant increase in exclusive BF rates from preintervention group to postintervention group at all 5 timepoints.
Integrating routine Lactation Consultant support into a Pediatric practice. Witt, et al. Published in Breastfeeding Medicine, 2012.
• 2012, Ann Witt, Breastfeeding Medicine– Suburban Pediatric practice in Cleveland, 350 newborns a year– Sample 350 patients. Retrospective study compared 166 in 2007 (before LC) and 184 in
2009 (after intervention)– Hired IBCLC (RN) to see all initial newborn visits, 45‐60 min; followed by discussion with
a physician who spent an average of 5 minutes in the room evaluating the patient and discussing the treatment plan. This was reimbursed as a general medical visit, billed under the provider.
– IBCLC f/u visits (more than 45% had multiple visits) and phone calls prn– Non‐formula feeding went up by 10‐15% at all time points from 2 to 9 months. – In‐person, early BF support can increase both short and long term duration– Changed the culture of infant feeding in the practice. The message to parents: we feel
that BF is so important to your baby’s health that we will do everything we can to help you through the challenges.
How to integrate a Lactation Consultant in an Outpatient Clinic environment. Lukac, et al. Published in Journal of Human
Lactation, 2006.
• Urban teaching hospital in Charlotte, NC – hired IBCLC to staff the outpatient clinics. Primary role – in person visits with nursing dyads in the clinic. Secondary role – education of patients and staff.
• Some LC visits prescheduled for problems or concerns, others general newborn visits – assist with latch and positioning, educated about milk production, provided with supplies/ referrals as needed. f/u by phone or visit within a week.
• Random chart review of 30 patients seen by LC and 30 not seen. 23% not seen were BF for 4‐6 mos; 53% seen, BF for same length of time. Plan to do more detailed data collection/ monitoring.
• There are a myriad of lactation training programs, with various titles for the people who complete them. There is not a requirement to be a health care professional prior to IBCLC certification. As in the above studies, an RN who is certified as an IBCLC is not a licensed provider, so still needs to see patients in conjunction with an NP or MD. An NP who is certified as an IBCLC is the best!
www.lactationtraining.comSince 1993, based in Maryland, Vergie Hughes, RN, MS, IBCLC90 hour course, online access X 12 mos (average 4‐6 mos to complete) $975.00OR Phase 1 (45 hours) ‐ $645.00 and Phase 2 (45 hours) ‐ $595.00 (each has 12 mos access online)LEARCC approved (Lactation Education Accreditation & Approval Review Committee)Certified Breastfeeding Specialist (CBS)(also a clinical internship program for clinical hours)
www.centerforbreastfeeding.org1993, nonprofit research and education institution which includes the Center for Breastfeeding. Largest national provider of lactation education for healthcare providers. Karin Cadwell, PhD, RN, CLC, IBCLCCertified Lactation Counselor (CLC) approved by Academy of Lactation Policy and Practice (ALPP); LEARCC approved5 day in person course (45 hours), offered all over US, approximately 100 classes per year; COST $625.00. Exam on final day of course, 6‐8 wks for results.
Washington State, Director Molly Pessl, RN, BSN, IBCLC
5 day in person course “Foundations for Best Practice in Lactation Care” $959.00 or online for 12 mos $650.00Certified Lactation Educator (CLE)Valid 5 years, not official, no renewal
A. In any well visit the clinician is expected to spend time addressing routine feeding issues. When additional time is required, there are 2 ways of addressing the issue:
1. Spend the extra time to address the problem immediately. Bill using the 99213‐99215 codes appended with the modifier 25 (not all insurers will pay for a modified code)2. Schedule a f/u visit and bill using the office visit codes and appropriate diagnoses codes. The reason for f/u must be clearly noted in the preceding well visit note.
B) You can bill for care provided for the mother, often as a new patient, IN ADDITION to billing for the baby, if history, exam, diagnosis and treatment are done for her.
C) As a consultation if the mother or baby is specifically referred to you for lactation services.
Billing based on timeFor follow‐up and sick visits if > 50% of time is spent in counseling, education or coordination of care. Must document total face to face time and time spent on counseling or coordination of care on the record.New Patient 99203 26‐37 minutes
99204 38‐52 minutes99205 53+ minutes
Established Patient 99213 13‐20 min99214 21‐32 min99215 33+ minutes
EHR Documentation• Lactation Template that includes mother and baby assessment• Birth history transfers as does family history/ social history• Maternal health history: thyroid issues, breast surgery, other major
surgery or chronic illness, maternal meds/ supplements, prior BF history• Current complaint/ Feeding issues• WEIGHTS:
– Birth weight– Last weight (date)– Today’s weight (naked)– Today’s weight (diapered)– Post feeding weight– Weight gain
EHR documentation (continued)• Output past 24 hours – # of wet diapers, # of stools/ color• Spit up – yes/ no, amount• Infant Assessment: current state – asleep, awake/alert, fussy, frantic• Notes about breastfeeding observation/ feeding effectiveness• Interventions/ Education• Return appt/ follow‐up• Coding (generally level IV or V)• ___minutes were spent in face to face care of which more than 50% was
spent in counseling and discussing the diagnosis, benefits/ drawbacks/ side effects of treatment, anticipatory guidance and future care plans.
• Lab orders – TCB, Serum bilirubin• Procedures – Silver Nitrate to Umbilicus, Frenotomy – note about consent
• American Academy of Pediatrics (2012). Breastfeeding and the Use of Human Milk. Pediatrics. 129(3), pp 827‐841.
• American Academy of Pediatrics (2010). Supporting Breastfeeding and Lactation: The Primary Care Pediatrician’s Guide to Getting Paid. http://www2.aap.org/breastfeeding/files/pdf/coding.pdf.
• Busch, D.W., Logan, K.L., Wilkinson, A. (2014). Clinical Practice Breastfeeding Recommendations for Primary Care: Applying a Tri‐Core Breastfeeding Conceptual Model. Journal of Pediatric Health Care. 28(6). Pp. 486‐496.
• Centers for Disease Control and Prevention (2016). Breastfeeding Report Card of 2016. Atlanta, VA: Government Printing office. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard.htm.
• Corriveau, S.K., Drake, E.E., Kellams, A.L., Rovnyak, V.G. (2013). Evaluation of an Office Protocol to Increase Exclusivity of Breastfeeding. Pediatrics, 131, pp 942‐950.
• Farver, M.C. (2016). A Model for Outpatient Lactation Care. MedCrave Online Journal of Women’s Health 2(2).
• Geraghty, S.R., Riddle, S.W., Shaikh, U. (2009). The Breastfeeding Mother and the Pediatrician. Journal of Human Lactation. 24(3), pp 335‐339.
• Grawey, A.E., Marinelli, K.A., Holmes, A.V. and the Academy of Breastfeeding Medicine. (2013). ABM Clinical Protocol #14: Breastfeeding‐Friendly Physician’s Office: Optimizing Care for Infants and Children, revised 2013. Academy of Breastfeeding Medicine, 8(2).
• Lukac, M., Riley, J.K., Humphrey, A.D. (2006). How to Integrate a Lactation Consultant in an Outpatient Clinic Environment. Journal of Human Lactation. 22(1). Pp 99‐103.
• Meek, J.Y., Hatcher, A.J. and AAP Section on Breastfeeding. (2017). The Breastfeeding‐Friendly Pediatric Office Practice. Pediatrics, 139. pp e1‐e9.
• Mueller, K. (2015). Implementation of a Lactation Support Program in a Primary Care Pediatric Practice. ICAN: Infant, Child & Adolescent Nutrition. 7 (6), pp 323‐327.
• Thurman, S. E, Allen, P. J. (2008). Integrating Lactation Consultants into Primary Health Care Services: Are Lactation Consultants Affecting Breastfeeding Success? Pediatric Nursing, 34(5), pp 419‐425.
• Willis, S.A. (2003). The Pediatric Nurse Practitioner as Lactation Consultant. Journal of Pediatric Health Care 17(6), pp 335‐337.
• Witt, A.M., Smith, S., Mason, M.J., Flocke, S.A. (2012) Integrating routine lactation consultant support into a pediatric practice. Breastfeeding Medicine. 7(1), pp 38‐42.
• Wolynn, T. L. (2011). Breastfeeding – So Easy Even a Doctor Can Support It. Breastfeeding Medicine 6(5), pp 345‐347.
• US Department of Health and Human Services (2011). The Surgeon General’s Call to Action to Support Breastfeeding. Washington DC; US Department of Health and Human Services, Office of the Surgeon General.
