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Breast Pump Coding Under Health Care Reform

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 designated certain services as preventive benefits when provided by in-network providers.  These services are available with no cost-sharing to group and individual members on non-grandfathered health plans as of August 1, 2012, or upon their subsequent renewal date. 

As part of this mandate, Blue Cross and Blue Shield of North Carolina (BCBSNC) provides benefits for breast pumps for eligible, lactating mothers under a member’s durable medical equipment (DME) benefits.  This particular mandate does not apply to State Health Plan or Federal Employee Program members, so please check their respective benefits for specific information, as needed.

In order for members to receive 100 percent coverage for a breast pump, please ensure the following:

  • Claims for breast pumps (E0602 for manual and E0603 for electric) must indicate v24.1 as the primary diagnosis code.
  • Breast pumps must be purchased from in-network DME providers.  Edgepark (1-800-321-0591, 8 a.m. to 5 p.m. EST) carries breast pumps, or the member can use Find a Doctor online to find another in-network DME provider.
  • Members will not be reimbursed if they purchase a breast pump at a retail location.
  • Hospital-grade breast pumps will not be covered.
  • Benefits for breast pumps and related supplies that are included with the breast pump (i.e., initial tubing, shields, and bottles) are only available after delivery.
  • Ongoing supplies, such as replacement tubing, nursing bras, or creams are not covered.
  • Only one manual or electric breast pump purchase per delivery will be covered.

Eligible Claims Filed With Different Diagnosis Codes

We have recently found that some claims for eligible breast pumps were denied between August 1, 2012, and February 4, 2013, due to the incorrect diagnosis code being used when filed.  We will be reconsidering those claims for payment, so no action is required on your part if this impacts your office.

However, if claims filed with dates of service on or after February 5, 2013, do not show v24.1 as the primary diagnosis code, the claim will deny due to the incorrect diagnosis code being used.  You will need to submit a corrected claim once you receive the initial denial from BCBSNC.

If your BCBSNC patients have questions about their DME benefits, please refer them to the toll-free number listed on their BCBSNC ID card for assistance. 

If you have questions, please contact the Provider Blue LineSM at 1.800.214.4844.