Why We Don't Bill 99404 for Most Telehealth Lactation Visits

And why TRICARE is the exception—not the rule.

One of the most common questions we receive is:

"Why don't you bill 99404 for telehealth lactation visits?"

The answer is simple:

Because billing should follow the payer's published policy—not just what happens to pay.

While some billing companies routinely submit 99404 for commercial telehealth lactation visits, we generally do not. The one major exception is TRICARE, which has a unique breastfeeding benefit that specifically reimburses preventive counseling codes 99401–99404 for covered lactation counseling, including qualifying telehealth visits.

What Is CPT 99404?

CPT 99404 describes:

Preventive medicine counseling and/or risk factor reduction intervention, approximately 60 minutes.

It is a preventive counseling code—not a code created specifically for lactation services.

Whether it can be billed depends on both the CPT definition and the individual payer's reimbursement policy.

Why We Don't Use It for Most Commercial Telehealth Claims

Many commercial insurers have specific lists of services they recognize for telehealth reimbursement. Simply adding a telehealth modifier or billing with POS 10 does not make every CPT code payable via telehealth.

If a payer has not identified 99404 as an eligible telehealth service for your provider type or benefit, receiving payment does not necessarily mean the claim complied with the payer's policy.

Claims are frequently processed through automated systems. A claim can pay today and still be reviewed months later during a post-payment audit.

That's not a risk we're willing to take with our clients' practices.

TRICARE Is Different

TRICARE has created a dedicated breastfeeding counseling benefit.

Under its published policy, TRICARE reimburses individual breastfeeding counseling using CPT codes 99401–99404, including qualifying remote counseling sessions that meet TRICARE's telehealth requirements. It also allows qualified IBCLCs participating in the demonstration program to provide these services under their own NPIs.

Because TRICARE has clearly published this reimbursement pathway, using 99404 for eligible TRICARE lactation counseling is supported by policy.

That does not mean the same approach should be copied to Aetna, Cigna, UnitedHealthcare, Blue Cross, or other commercial payers.

"It Pays" Is Not a Billing Strategy

One of the biggest misconceptions in medical billing is:

"My billing company says it pays."

Payment is not proof that a claim was coded correctly.

A compliant billing strategy should answer these questions:

• Does the CPT code accurately describe the service?

• Is the provider eligible to report the code?

• Does the payer recognize the code in this setting?

• Does the documentation support the service billed?

If the answer to any of those questions is "no," payment alone does not eliminate audit risk.

Our Philosophy

At SunShyn, we don't choose CPT codes based on which one reimburses the most.

We choose codes based on:

• CPT definitions,

• payer-specific reimbursement policies,

• provider eligibility,

• published guidance,

• and documentation that can withstand an audit.

Sometimes that means reimbursement is lower than a more aggressive coding strategy.

We're comfortable with that.

Because protecting a provider from future recoupments is just as important as getting today's claim paid.

The Bottom Line

TRICARE is an excellent example of why every payer must be billed according to its own published policies.

Just because one insurer specifically authorizes 99404 for telehealth lactation counseling does not mean every commercial insurer does.

The safest billing strategy is not the one that pays the fastest.

It's the one you can confidently defend if an auditor asks, "Why did you bill this code?"