Insurance Codes for Doulas

Medical billing is a very complex arena. Whole departments are dedicated to it for many medical providers.

For many years doulas have made the mistaken assumption that there is a CPT code that applies to doulas. Sources citing this code can be found that date as far back as 1998.

For nearly 20 years, doulas have been wrong.

CPT code 99499 is the code that many assume is the “doula code” but it is not. The code is for “other evaluation and management services”. It is used in the context of a licensed medical professional providing evaluation and management services. This code is used when services are provided for which no other specific code applies.

Not for services provided by a doula.

Most of the Evaluation and Management codes refer to physician-provided services. Office visits, hospital observation, ER services, critical care services, nursing home services, etc. 99499 is the one used when one of the existing codes from 99201–99499 cannot be used.

“Other Evaluation and Management Services” is the actual definition of the code. At some point, someone tacked on “labor support” to try and make this code specific to doulas. I’m sure this was done with the best of intentions. Yet the fact remains, it was not correct.

While it has been interpreted that way for far too long, is not a code created for doulas.

It never was a code intended for doulas.

There is NO CPT code for labor or postpartum doula services.

Some insurance companies have overlooked this in the past. In spite of the misuse of the 99499 code, some clients were reimbursed.

In 2014, Kelly Townsend a doula and doula trainer in Arizona tried to get doulas their own insurance codes.

When new codes are established, it is common to look to the specific fields that the code is requested for. In the case of labor and postpartum support, the American Congress of Obstetricians and Gynecologists and the American Academy of Family Physicians were consulted.

Both ACOG and the AFP came out strongly against the request. Among the reasons cited is the lack of licensure among doulas. The full reply is included in the quote below.

If a doula is using the old codes she is doing so (likely unknowingly) fraudulently. The codes that have been used for years are not doula codes and have never been doula codes. They are medical codes for evaluation and management services. Services provided by a licensed medical care provider when no other code is available for the specific services rendered.

From Kelly Townsend on the topic of trying to apply for a doula specific CPT code:

So I received back some feedback today about our application for a CPT code that would allow us to bill insurance.

 

Most wanted a more detailed description of what a doula does, which I have sent to Penny Simkin for her help.

 

The most concerning is the message from ACOG and American Family Physicians, which I will post here. Your counter arguments are very welcome. The hearing is Feb 6-8 of this year (2014).

 

“ACOG Comments –

Does not meet:

• Performed by many across the US

• Performed with frequency of intended use

• Consistent with current medical practice

• Literature of the utility of doulas is limited in the peer reviewed literature.

• The specialty does not support this code change

• Not performed by many across the US, not consistent with current clinical practice.

 

While ACOG appreciates the value that a doula can provide to maternity care, ACOG does not support a CPT code for the services of a doula. These services are oftentimes provided by lay persons of variable training and experience within a facility, state, and region.

 

Question #18 in the CCP states that doulas provide “non-cliincal measures.”

Per CPT, “a “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional services. These professionals are distinct from “clinical staff.”

 

A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but does not individually”

In 2014 the hearings concluded. The official response was that doulas will not be given CPT codes. It was suggested that if doulas wish to pursue obtaining CPT codes in the future, licensure should be considered as the next and first step towards that goal.

To reiterate, while insurance companies have reimbursed in the past, we now know that using the 99499 code is indeed insurance fraud as we are not licensed providers. DONA asked their doulas to stop filling out 3rd party paperwork for their clients using the 99499 CPT code prior to 2014.

Doulas who continue to promote and use CPT codes on documentation provided to clients who wish to submit for reimbursement to their insurance companies are committing insurance fraud. It is a misrepresentation of the doula to the insurance company as a qualified medical professional, which we most certainly are not.

This puts both the client and the doula at risk of legal action.

So what is a doula and client to do?

Submit a detailed receipt outlining the cost and care given. Some refer to this as a “superbill.” Some doulas have found it helpful to have clients submit their request for reimbursement along with a copy of a prescription from their provider for doula care.

We have the best luck with helping clients get reimbursed when they have flex spending accounts or health savings accounts. Those who reimburse their subscribers for doula care, do so without the need for insurance codes.

Additionally, beware of the doula who is also a lactation professional who offers to bill for labor support services under lactation management. This is also insurance fraud yet it is a practice that some are using in order to help clients get coverage for doula care.