S9443 vs. 98960: Which Code Should You Use?

Q: What Is S9443?

HCPCS S9443 is defined as: Lactation classes, non-physician provider, per session. Despite its official descriptor referencing "classes," many commercial insurers and state Medicaid programs recognize S9443 as the primary code for individual lactation consultations performed by IBCLCs and other qualified non-physician providers.

Q: What Is 98960?

CPT 98960 is defined as: Education and training for patient self-management by a qualified nonphysician healthcare professional using a standardized curriculum, face-to-face with one patient, each 30 minutes. Unlike S9443, this code was not created specifically for lactation services. It is a general patient education code that some insurance companies recognize for breastfeeding education and counseling.

Q: Can You Bill Both S9443 and 98960 for the Same Visit?

Generally, no. In most situations, billing both codes for the same lactation consultation is not appropriate. Although there is no national rule that universally prohibits submitting both codes together, both codes typically describe the same underlying professional service—lactation education, counseling, and support. Billing both for the same work creates significant compliance concerns.

Q: Is There Ever a Situation Where Both Could Be Appropriate?

Possibly—but only if they represent distinct, separately identifiable services that are supported by the payer's published billing policies and your documentation. This is uncommon for routine IBCLC visits.

Q: Which Code Should You Use?

The safest approach is simple: Bill the code your patient's insurance company recognizes for lactation services. Before submitting claims: Review the payer's billing policy. Confirm which code is accepted for your provider type. Follow payer-specific modifier and documentation requirements. Avoid submitting both codes for the same counseling session unless the payer's guidance clearly supports it.

Rachael Lara
Jul 2
3 min read

One of the most common questions IBCLCs ask is whether they should bill HCPCS S9443 or CPT 98960 for a lactation consultation.

The answer is: it depends on the patient's insurance company.

Although both codes are commonly used for lactation services, they were created for different purposes and are interpreted differently by insurance companies. Understanding those differences can help you avoid claim denials, duplicate billing issues, and audit risk.

What Is S9443?

HCPCS S9443 is defined as:

Lactation classes, non-physician provider, per session.

Despite its official descriptor referencing "classes," many commercial insurers and state Medicaid programs recognize S9443 as the primary code for individual lactation consultations performed by IBCLCs and other qualified non-physician providers. Some payers have even published billing guidance specifically instructing providers to use S9443 for one-on-one lactation support.

S9443 is commonly used because it more accurately reflects the preventive breastfeeding support services provided by IBCLCs.

What Is 98960?

CPT 98960 is defined as:

Education and training for patient self-management by a qualified nonphysician healthcare professional using a standardized curriculum, face-to-face with one patient, each 30 minutes.

Unlike S9443, this code was not created specifically for lactation services. It is a general patient education code that some insurance companies recognize for breastfeeding education and counseling.

Several commercial insurers reimburse IBCLCs using 98960, while others do not recognize it for lactation services at all.

The Biggest Difference

The biggest difference is that insurance companies decide which code they recognize.

For example:

Some payers reimburse only S9443.
Some reimburse only 98960.
Some recognize both, but have specific rules about when each may be used.
Others have entirely different billing requirements.

There is no universal billing code for lactation consultations, which is why payer-specific policies are so important.

Can You Bill Both S9443 and 98960 for the Same Visit?

Generally, no.

In most situations, billing both codes for the same lactation consultation is not appropriate.

Although there is no national rule that universally prohibits submitting both codes together, both codes typically describe the same underlying professional service—lactation education, counseling, and support. Billing both for the same work creates significant compliance concerns.

Risks of Billing Both Codes

1. Duplicate Billing

If both codes represent the same counseling session, an insurance company may determine that you billed twice for the same service.

This often results in:

Claim denials
Payment reversals
Requests for refunds
Increased scrutiny of future claims

2. National Correct Coding Initiative (NCCI) Concerns

Many payers use NCCI editing or similar claim-editing software to identify overlapping services.

Even if a payer technically accepts both codes, overlapping services or overlapping time may trigger edits or denrollment rules. Time spent counseling cannot generally be counted twice toward separate billable services.

3. Audit Risk

Repeatedly billing both codes for the same encounter may raise questions during an audit.

An auditor may ask:

What separate service justified the second code?
Was there distinct documentation?
Was additional work performed beyond the lactation consultation?

If the documentation cannot clearly support two separate, independently billable services, repayment may be required.

4. Contract Compliance

Many commercial payer contracts specify which code should be used for lactation services.

Submitting an alternate code—or both codes together—may violate payer billing policies, even if the claim initially pays.

Always follow the coding guidance provided by each payer.

Is There Ever a Situation Where Both Could Be Appropriate?

Possibly—but only if they represent distinct, separately identifiable services that are supported by the payer's published billing policies and your documentation.

This is uncommon for routine IBCLC visits.

If you believe two services were performed, you should verify:

That the payer allows both codes.
That the services are not duplicative.
That documentation clearly supports each service separately.
That any required modifiers are used appropriately.

Never assume that payment means billing was correct. Claims sometimes pay initially and are later recouped during post-payment audits.

Which Code Should You Use?

The safest approach is simple:

Bill the code your patient's insurance company recognizes for lactation services.

Before submitting claims:

Review the payer's billing policy.
Confirm which code is accepted for your provider type.
Follow payer-specific modifier and documentation requirements.
Avoid submitting both codes for the same counseling session unless the payer's guidance clearly supports it.

Final Thoughts

S9443 and 98960 are both used in lactation billing, but they are not interchangeable in every situation, and they generally should not be billed together for the same lactation consultation.

The most common reason providers encounter problems with these codes is assuming that if one code is appropriate, both must be appropriate. In reality, insurance companies each establish their own reimbursement policies, and using the wrong code—or both codes together without a clear basis—can result in denials, recoupments, or unnecessary audit risk.

When in doubt, follow the payer's published billing guidance rather than relying on general coding advice. Accurate, payer-specific coding is one of the best ways to protect your practice while maximizing appropriate reimbursement.