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Billing Tips: Breast Pumps, Breast Pump Supplies and Banked Donor Milk

Friday, August 30, 2019

Earlier this year, TRICARE announced benefit changes for breast pumps and related supplies, and banked donor milk. To help avoid claims denials, we offer the following benefit and billing reminders. 

Breast pumps and supplies:
Breast pumps and supplies are covered beginning week 27 of pregnancy or the birth of a child if prior to 27 weeks, and for mothers who legally adopt who intend to breastfeed. For detailed benefit information, visit our Breast Pumps and Supplies Details web page.

  • A prescription is required; it must include the type of breast pump and number of weeks pregnant or age of infant.
  • New! HNFS offers a Breast Pump and Supplies Prescription Form available on our Breast Pumps web page to help ensure all criteria are met. 
  • A certificate of medical necessity is not required with the claim unless the quantity limits are exceeded.
  • When billing unlisted HCPCS codes A9900 or A9999 for breast pump supplies, include the appropriate modifier (pay attention to benefit limits, as a new prescription is required for supplies in excess of the limits below):
Supply Type Modifier Quantity Limits 
Replacement valves/membranes XG 12 every 12 months (1 unit = a set of 2 valves/membranes)
Replacement breast milk storage bags XH 90 individual bags every 30 days
Replacement nipple shields XD 2 sets (2 shields/set) every birthing event
Supplemental nursing system XN 1 every birthing event
Breast pump kit XR 1 every birthing event

 

Banked donor milk:
Banked donor milk is a covered benefit for infants who are critically ill and the mother’s milk is not available or isn’t enough. A total of 35 ounces per infant per day is covered for up to 12 months of age. For detailed benefit information visit our Milk (Banked Donor) web page.  

  • Providers must submit date ranges on the claim if requesting more than 35 ounces.
  • Dates on prescriptions should not exceed the 30 day limit; a new prescription is required every 30 days.
  • The amount and frequency of feedings should be notated on the prescription. 
  • The prescribing provider must be actively managing the infant’s care.
  • Milk quantities must be in ounces only. For example, a claim with 100 mL will deny because our automated claims system will read it as 100 oz, which exceeds the daily 35 ounce limit. 
  • If medical necessity is not indicated on the prescription, a completed coverage criteria attestation letter is needed. HNFS offers a Banked Donor Milk Coverage Criteria Attestation form available on our Milk (Banked Donor) web page, which may be submitted in lieu of clinical documentation.