One of the most common questions we hear from IBCLCs is: "My local Blue Cross Blue Shield plan won't credential me. A company says they can get me paid anyway. Should I sign?" Before you do, it's important to understand how Blue Cross Blue Shield claims generally work. Blue Cross Blue Shield Is Not One Insurance Company Many providers think BCBS is a single nationwide insurer. It isn't. The Blue Cross Blue Shield system consists of independent, locally operated companies. Each plan establishes its own provider credentialing policies, participation requirements, reimbursement rules, and covered services within its service area. That means an IBCLC who is eligible to participate with one BCBS plan may not be eligible under another. Claims Follow the Provider's Local BCBS Plan When services are furnished, reimbursement is generally determined according to the rules of the provider's local Blue Cross Blue Shield plan, even when the member is insured through a different Blue plan. The BlueCard program is designed to route claims between Blue plans while allowing the local plan's provider participation and reimbursement rules to be applied where appropriate. For IBCLCs, this means the first question is usually: Does my local BCBS plan recognize and reimburse my provider type? If the answer is no, that raises an important question. How Is Another Company Getting Paid? If your local BCBS plan does not credential or reimburse your provider type directly, and another company tells you they can "get you paid," ask them to explain exactly how that works. Questions worth asking include: Under whose NPI is the claim submitted? Under whose tax identification number (TIN) is the claim billed? Who is the rendering provider on the claim? Who holds the BCBS contract? Is there a delegated network or other contractual arrangement? How does the billing model comply with the applicable payer's billing policies? Will I have access to my claims, remittance advice, and explanations of benefits? A reputable company should be able to answer these questions clearly and transparently. If You Don't Understand the Billing Model, Ask More Questions Healthcare billing is heavily regulated. Practices should understand exactly how their claims are being submitted and why the payer recognizes that billing arrangement. If someone tells you: "Don't worry—we have a special way of getting these claims paid." Ask for an explanation. You should understand: Why the payer accepts the claims. Which provider is actually billing. Whether you remain responsible for the documentation. Whether the arrangement complies with the payer's provider agreement and billing requirements. If the explanation isn't clear, don't be afraid to seek advice from a healthcare attorney or qualified compliance professional before signing a contract. Transparency Protects Everyone There are legitimate business models that help providers navigate insurance reimbursement. There are also arrangements that are poorly explained, leaving providers uncertain about who is actually billing for their services or why claims are being paid. As the rendering provider, your professional reputation and your documentation are tied to those claims. You should never feel uncomfortable asking questions about how your services are billed. The Bottom Line If your local BCBS plan does not currently credential or reimburse your provider type, be wary of anyone offering a simple solution. If they can't clearly explain how their billing process works, it should raise concerns. That doesn't automatically mean the arrangement is improper—but it does mean you should understand exactly how the claims are being submitted, who is billing them, what contractual authority supports the arrangement, and whether the billing model complies with the applicable payer's requirements. The best billing partner is one that is completely transparent—not only about what they do, but about how they do it.

As reimbursement for lactation services continues to evolve, more IBCLC practices are asking the same question: "Should we hire a physician so we can bill everything incident to them?" At first glance, it sounds like a smart business strategy. Many practice owners assume they can hire a physician to provide a small amount of oversight—perhaps a few telehealth visits each week—and then bill all lactation services under that physician for higher reimbursement. Unfortunately, incident-to billing is far more complicated than that. For many lactation practices, it can actually create more administrative work, increase compliance responsibilities, and in some cases reduce overall revenue. Understanding Incident-To Billing Incident-to billing allows certain services furnished by auxiliary personnel to be billed under a supervising physician or other eligible practitioner when all applicable payer requirements are met. Although the concept originated with Medicare, commercial insurers frequently have their own policies, which may differ substantially from Medicare and from one another. Incident-to billing is not simply a billing method—it represents a particular model of care delivery. Depending on the payer, requirements may include: The supervising provider establishes the patient's plan of care. Ongoing involvement by the supervising provider in the patient's treatment. The required level of supervision. Documentation demonstrating compliance with the payer's requirements. Compliance with federal guidance and the payer's contractual billing policies. Simply hiring a physician—or another licensed medical provider—does not automatically create a compliant incident-to billing arrangement. Hiring a Physician Doesn't Automatically Increase Reimbursement One of the most common misconceptions is: "We'll just hire a physician to oversee our IBCLCs and bill everything under them." Incident-to billing is not intended to allow a physician to simply "lend" their billing credentials to services they were not appropriately involved in under the applicable payer's rules. A physician who only performs occasional telehealth visits or has minimal involvement in the patient's care may not satisfy the requirements established by many payers for incident-to billing. Practices considering this model often discover they must redesign their entire clinical workflow so physician participation is meaningfully integrated into patient care—not simply added for billing purposes. Nurse Practitioners Are Not a Shortcut Some practices assume hiring a nurse practitioner creates an easier path. However, employing a nurse practitioner alone does not automatically satisfy incident-to requirements. Whether services may be billed under another provider depends on the payer's rules, the required supervision, the established plan of care, and other billing requirements. Practices should never assume services furnished by an IBCLC can be billed under another provider without confirming that all applicable payer requirements are satisfied. The Coding Challenge Even if an incident-to model is properly established, coding often becomes the next obstacle. Many commercial insurers recognize HCPCS S9443 (Lactation Classes, Non-Physician Provider, Per Session) as the primary code for lactation counseling provided by qualified non-physician providers. The description itself specifies "non-physician provider." When practices move to a physician-based billing model, they frequently rely on physician evaluation, counseling, or time-based codes instead of S9443, depending on the payer's policies. For many practices, this results in lower reimbursement than anticipated. One Appointment, Two Patients Lactation care is unique because one appointment frequently involves two patients. The mother receives care. The infant receives care. There is still only one clinical encounter and one block of billable time. A 90-minute lactation consultation is not two separate 90-minute visits simply because two claims are submitted. When billing time-based services, the available time generally must be allocated between the mother and infant based on the services actually provided. Reporting the full visit duration on both claims may create duplicate billing concerns. Instead of increasing reimbursement, practices often discover that the available reimbursement from time-based codes must effectively be divided between two patients. When IBCLCs Can Bill Directly, Think Carefully Before Changing Models Many commercial insurers already recognize qualified IBCLCs as reimbursable providers for lactation counseling. When a payer has an established reimbursement pathway for IBCLCs, practices should carefully evaluate whether changing to an incident-to model provides a legitimate clinical or operational advantage. Incident-to billing is intended to reflect how care is actually delivered—not simply to obtain a different reimbursement rate. If the primary reason for changing the billing provider is higher reimbursement rather than because the services genuinely satisfy the payer's incident-to requirements, the practice should proceed cautiously. Payers expect the billed provider, coding, and documentation to accurately represent the care that was furnished and to comply with the payer's billing rules. Claims that fail to meet those requirements may be denied, recouped, or become the subject of an audit. More Complexity Doesn't Always Mean More Revenue Ironically, hiring a physician solely to improve reimbursement may produce the opposite outcome. Practices may encounter: Lower reimbursement than payer policies recognizing S9443. Physician salary or contract expenses. Increased documentation requirements. Greater supervision obligations. More administrative complexity. Additional compliance responsibilities. Greater audit exposure if incident-to requirements are not fully met. The practice assumes greater operational responsibility while potentially collecting less for the same patient visit. A Practical Alternative: The Hybrid Practice Model For many IBCLC practices, the simplest and most sustainable approach is a hybrid model. Practices contract with insurers that credential and reimburse qualified IBCLCs directly. For insurers that do not offer a practical reimbursement pathway, the practice may choose to remain private pay and provide patients with a superbill when appropriate so they can pursue any available out-of-network reimbursement or submit documentation to their health plan. This approach offers several advantages: The claim accurately reflects the provider who delivered the care. Practices avoid restructuring their workflow solely to fit an incident-to billing model. Administrative complexity is reduced. Compliance risks associated with inappropriate billing arrangements may be minimized. Practices maintain greater control over their reimbursement and operations. It also provides transparency about where access barriers exist. The Affordable Care Act requires most non-grandfathered health plans to cover comprehensive breastfeeding support, counseling, and equipment as preventive services, although implementation varies among plans and payers. When patients discover they cannot reasonably access an in-network IBCLC or must pay out of pocket because their health plan lacks a practical reimbursement pathway, they often contact their insurer, employer, or state insurance regulator to ask why. Patient feedback has historically been an important driver of improvements in insurance coverage and provider network policies. Clear communication about available reimbursement options and existing coverage limitations helps patients advocate for the access they expect under their health plan. The Bottom Line Incident-to billing has an appropriate role in healthcare, but it is not a universal solution for lactation practices. When a payer already recognizes IBCLCs as qualified providers, restructuring an entire practice around incident-to billing may create additional complexity without delivering the financial advantages many practices expect. For many IBCLC practices, participating with insurers that reimburse IBCLCs directly while maintaining a transparent private-pay option for plans that do not, offers a simpler, more sustainable path. It allows billing to reflect the care being delivered accurately, supports compliance with payer requirements, and gives patients clear information about their coverage and reimbursement options. The best billing strategy is not necessarily the one that promises the highest reimbursement. It is the one that accurately reflects the services provided, complies with payer requirements, and supports long-term access to high-quality lactation care.

On its face, New York's proposed Senate Bill S1670 / Assembly Bill A4677 is exciting news for breastfeeding families. The legislation would require many health insurance plans to provide coverage for outpatient lactation services, helping more families access the breastfeeding support they need. As someone who has spent years working in lactation billing and insurance credentialing, I strongly support expanding access to quality lactation care. However, after reviewing the bill as currently written, I have concerns about how it may affect the very patients it is intended to help. The Goal Is Excellent There is no question that increasing insurance coverage for lactation services is a positive step. Breastfeeding support has been shown to improve maternal and infant health outcomes, and removing financial barriers can help families receive care earlier when challenges arise. If implemented successfully, this legislation could allow thousands of additional New York families to utilize their insurance benefits for lactation support. The Practical Concern The current language of the bill defines an eligible lactation consultant as a healthcare professional licensed under Title VIII of New York Education Law who also holds the International Board Certified Lactation Consultant (IBCLC) credential. At first glance, that may not seem significant. In practice, however, it could have a substantial impact on provider availability. Who Actually Provides Lactation Care? Many people assume physicians and nurse practitioners provide most outpatient lactation care. That is not the reality. While physicians and nurse practitioners can certainly earn the IBCLC credential, they represent only a very small portion of the lactation workforce. Most outpatient lactation care is provided by: Registered Nurses (RNs) who are also IBCLCs Independent IBCLCs whose primary professional credential is the IBCLC Very few private lactation practices are owned by physicians or nurse practitioners who also maintain an IBCLC credential. Independent IBCLCs are often the providers families rely on for timely appointments, home visits, and specialized breastfeeding support. Why This Matters If implementation of the bill ultimately limits insurance participation to providers who meet the bill's current eligibility language, many experienced IBCLCs could find themselves unable to participate in insurance networks. That would not simply affect providers. It would affect patients. Families could experience: Longer wait times Fewer in-network providers Increased travel distances Less provider choice Delays in receiving care during the most critical days after birth These challenges are especially concerning in rural and underserved communities, where lactation providers are already in short supply. More Coverage Doesn't Always Mean More Access Insurance coverage is only one piece of healthcare access. Patients also need enough qualified providers who can actually accept that insurance. If a benefit exists on paper but there are too few eligible providers available, families may still struggle to receive timely care. A Better Path Forward This legislation has tremendous potential. With thoughtful implementation, New York could become a leader in improving access to lactation care. As lawmakers continue reviewing this proposal, I encourage them to consider the composition of today's lactation workforce and ensure that qualified IBCLCs are not unintentionally excluded from participating in insurance networks. Expanding insurance coverage should also expand patient choice—not reduce it. The Bottom Line I applaud New York's efforts to improve insurance coverage for lactation services. My concern is not with the goal of the legislation. My concern is ensuring that, once implemented, families can actually find qualified providers to use those new benefits. Insurance coverage only improves access if patients have providers available to see them. As this legislation moves forward, I hope lawmakers, insurers, and the lactation community continue working together to ensure the final result supports both patients and the professionals who provide their care. This article reflects my interpretation of the proposed legislation as currently written and is intended for educational discussion. The bill may be amended before enactment, and its final implementation will ultimately depend on the enacted language, regulatory guidance, and insurer policies.

The Affordable Care Act expanded access to breastfeeding support—but it did not eliminate every patient's financial responsibility. One of the biggest misconceptions in lactation billing is the belief that: "Breastfeeding services should always be 100% covered, so patients should never receive a bill." While that would certainly make life easier for both providers and patients, it simply isn't how health insurance works. In fact, failing to collect a patient's required financial responsibility can create compliance issues for participating providers. What the Affordable Care Act Actually Requires The Affordable Care Act (ACA) requires most non-grandfathered health plans to cover breastfeeding support, counseling, and equipment as preventive services without cost-sharing when the services meet the plan's preventive benefit requirements and are provided in accordance with the plan's coverage rules. That does not mean: Every lactation-related CPT or HCPCS code is covered. Every provider is considered in-network. Every visit is preventive. Every insurance plan covers unlimited visits. Every claim is paid at 100%. Coverage depends on numerous factors, including the patient's benefit plan, the provider's network status, the codes billed, medical necessity requirements when applicable, and the payer's policies. Patient Responsibility Is Determined by the Health Plan When an insurance company processes a claim, it issues an Explanation of Benefits (EOB) that identifies: The allowed amount The insurance payment Any deductible Any coinsurance Any copayment Any non-covered charges The patient's financial responsibility For participating providers, that assigned patient responsibility is generally established by the payer under the provider's contract. Why Participating Providers Can't Simply Ignore Patient Responsibility Many provider agreements require participating providers to make a good-faith effort to collect the patient's assigned deductible, copayment, or coinsurance unless another law, contract provision, or documented financial assistance policy applies. Routinely waiving patient responsibility without a legitimate reason can raise concerns because it may: Conflict with payer participation agreements. Result in inaccurate representations of the actual charge for services. Create inconsistent billing practices. Lead to questions during payer audits. This is why we routinely encourage providers to correct billing practices when patient responsibility is being ignored. Compassion and Compliance Can Coexist Every provider wants to help families access care. If a patient is experiencing financial hardship, there are compliant ways to help, such as: Written financial hardship policies Payment plans Prompt-pay discounts when permitted Charity care programs Other assistance that complies with payer contracts and applicable laws Those decisions should be made through a consistent policy—not by automatically waiving every patient's responsibility. Why This Matters for Lactation Providers We've heard statements such as: "The ACA says lactation is always free." "It's unethical to bill patients." "Patients should never owe anything." Unfortunately, those statements oversimplify a very complex area of insurance law. While many lactation visits are covered without cost-sharing, many others are not. Examples include: Visits after a preventive benefit has been exhausted. Services that fall outside the plan's preventive benefit. Out-of-network services. Plans that are exempt from certain ACA preventive service requirements. Claims denied because coverage requirements were not met. In those situations, patient responsibility may be entirely appropriate under the patient's health plan. Our Philosophy At SunShyn, we believe patients deserve complete transparency. That means: Billing the services that were actually provided. Following payer policies. Explaining benefits clearly. Helping providers understand when patient responsibility applies. Encouraging correction of billing practices that don't align with payer contracts or applicable regulations. Doing the right thing isn't always the easiest approach—but it protects both providers and patients in the long run. The Bottom Line The Affordable Care Act significantly improved access to breastfeeding support. It did not create a blanket rule that every lactation patient will never owe anything. Patient responsibility is determined by the patient's insurance benefits, the provider's participation agreement, and the circumstances of the claim—not by a general assumption that all lactation care must be free. Understanding that distinction helps providers remain compliant while giving patients accurate, honest information about their coverage. Disclaimer: This article is for educational purposes only and is not legal advice. Provider contracts, state laws, and payer policies vary. Providers should review their participation agreements and seek legal or compliance guidance for specific situations.

The services you provide—not the patient's remaining benefits—should determine what appears on the claim. One billing practice we've seen recommended is to remove HCPCS code S9443 from an Aetna claim once a patient has exhausted their covered lactation counseling benefit. The reasoning is often that leaving S9443 on the claim may cause the remaining balance to be assigned to the patient. While that may sound like a way to protect the patient, it raises an important compliance question: If S9443 accurately described every previous visit, why would the exact same service suddenly disappear from the claim simply because the patient's benefit has been exhausted? The Service Didn't Change Imagine a patient receives six lactation visits. For visits one through five, the provider performs the same comprehensive lactation counseling, documents the same type of encounter, and bills S9443. On visit six, the provider performs the exact same service. The only difference? The patient has exhausted their S9443 benefit. If nothing about the visit changed, why should the claim change? Insurance Benefits Shouldn't Determine What Was Performed A patient's insurance benefits determine: Whether the payer will reimburse a service How many visits are covered Whether patient responsibility applies They do not change what happened during the encounter. Medical coding is intended to describe the services that were actually performed—not simply the services that are still payable. The Medical Record and the Claim Should Tell the Same Story If the documentation clearly supports lactation counseling consistent with S9443 on every visit, but the final visit omits that code solely because the benefit has been exhausted, an auditor could reasonably ask: "Why does the documentation describe the same service, but the claim no longer reports it?" If the answer is: "Because insurance wouldn't pay it." that explanation is based on reimbursement—not on the clinical services that were actually delivered. Coding Should Not Change Because Coverage Changes One of the fundamental principles of compliant medical billing is that code selection should be based on: The service provided The documentation Applicable coding guidance Payer policy It should not change simply because the patient's benefits have been used. The same documented service should generally be coded the same way unless the nature of the service itself has changed or the payer has published instructions directing otherwise. Protecting Patients Is Important—But So Is Accurate Claims Reporting Every provider wants to minimize unexpected costs for patients. However, the solution should not be to remove a code that accurately reflects the care provided if the only reason for removing it is that the benefit has been exhausted. Instead, providers should understand: the payer's published benefit limitations, their contractual obligations, patient financial responsibility, and any available appeal or exception processes. Our Philosophy At SunShyn, we believe every claim should accurately reflect the care that was delivered. If today's visit is clinically the same as the previous five visits, our starting point is that the coding should also be consistent. Insurance benefits may determine whether a service is paid. They should not determine whether that service appears on the claim. The Bottom Line Running out of benefits does not change the care you provided. If S9443 accurately described the visit before the benefit was exhausted, the exhaustion of that benefit alone does not change the nature of the service that was performed. Coding should tell the story of the patient's care—not simply the story of what the insurance company is still willing to reimburse. Disclaimer: This article is for educational purposes only and does not constitute legal or coding advice. Providers should follow applicable CPT/HCPCS guidance, payer policies, contractual requirements, and seek compliance advice when appropriate.

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?"

When "adding a modifier to make it pay" creates more risk than reward. One of the most common coding mistakes I see in lactation billing is the routine use of modifier 59. Some billing companies automatically append modifier 59 whenever a claim denies or when multiple codes are billed together. While that may occasionally result in payment, it is not what modifier 59 was designed for—and using it without a valid reason can significantly increase a provider's audit risk. What Is Modifier 59? Modifier 59 (Distinct Procedural Service) is intended to identify a procedure or service that is separate and distinct from another procedure that would normally be bundled together under National Correct Coding Initiative (NCCI) edits. In other words, modifier 59 exists to identify an exception to a bundling rule—not to bypass denials or increase reimbursement. CMS has repeatedly stated that modifier 59 should only be used when documentation clearly supports a distinct service and no more specific modifier is appropriate. Why This Matters for IBCLCs Most services billed by IBCLCs are not typically subject to NCCI procedure-to-procedure bundling edits with one another. That means there is usually no bundled service that requires an exception. If there is no bundling edit to override, there is generally no reason to append modifier 59. Simply adding it because a claim denied or because "that's how we've always billed it" is not a compliant coding strategy. Modifier 59 Does Not Fix Denials Modifier 59 is frequently—but incorrectly—used to try to overcome denials related to: Non-covered services Frequency limits Prior authorization requirements Medical necessity Telehealth eligibility Payer-specific reimbursement policies Provider credentialing issues None of these situations are appropriate reasons to use modifier 59. If a claim is denying because the payer does not cover a service, the service exceeds benefit limits, or the wrong CPT/HCPCS code was selected, modifier 59 does not change those facts. "It Paid" Doesn't Mean It Was Correct A common misconception is: "The insurance company paid it, so the modifier must have been appropriate." Unfortunately, that's not how claim compliance works. Many claims are processed automatically. A payment only means the claim passed the payer's edits at that moment. It does not mean the modifier was correctly reported or that the claim will withstand a future audit. Payers regularly review modifier usage during post-payment audits and may request documentation to determine whether a distinct procedural service actually occurred. Unnecessary Modifier 59 Use Can Increase Audit Risk Modifier 59 is one of the most closely monitored modifiers in medical billing because it has historically been associated with improper unbundling. Routine use without documentation may result in: Medical record requests Pre-payment review Post-payment audits Payment recoupments Increased scrutiny of future claims Even if no repayment is ultimately required, responding to an audit can consume significant time and resources. Ask These Questions Before Using Modifier 59 Before appending modifier 59, ask yourself: Is there actually an NCCI procedure-to-procedure edit between these codes? Did I perform a truly separate and distinct service? Does my documentation clearly support that separate service? Am I using modifier 59 to identify a legitimate exception—or simply trying to obtain payment? If you cannot confidently answer "yes" to those questions, modifier 59 likely does not belong on the claim. The Bottom Line For most routine lactation claims, modifier 59 has little to no role because the services commonly reported by IBCLCs are not normally bundled together in a way that requires a distinct procedural service modifier. Rather than treating modifier 59 as a solution for denials, providers should identify why a claim denied in the first place. The correct solution may involve a different diagnosis, a payer-specific policy, a telehealth rule, credentialing requirements, or a different covered service—not a modifier. When it comes to compliance, the safest approach is also the simplest: If there isn't a documented, distinct procedural service requiring an exception to an NCCI bundling edit, don't use modifier 59. Disclaimer: This article is for educational purposes only and is not legal advice. Coding decisions should be based on CPT guidance, CMS National Correct Coding Initiative (NCCI) policies, payer-specific requirements, and the facts documented in the individual medical record.

Why getting paid doesn't always mean the claim was billed correctly. As insurance coverage for lactation services continues to evolve, many IBCLCs are looking for ways to obtain reimbursement from commercial insurance plans. Unfortunately, some billing companies and online groups have begun recommending the use of Medical Nutrition Therapy (MNT) codes—particularly 97802 and 97803—for routine lactation consultations. The reasoning is often simple: "The claims pay." However, payment alone does not determine whether a claim was coded correctly. In fact, using Medical Nutrition Therapy codes for lactation counseling may expose providers to significant audit and recoupment risk. What Are Nutrition Therapy Codes? CPT codes 97802 and 97803 were created for Medical Nutrition Therapy (MNT). These codes describe services involving nutritional assessment, intervention, and ongoing management of medical conditions through nutrition therapy. Medicare limits payment for MNT to registered dietitians (RDs) and nutrition professionals who meet specific statutory requirements, and many commercial insurers adopt similar eligibility standards or establish their own credentialing requirements. Coverage and eligible provider types vary by payer. (law.cornell.edu) An IBCLC credential is not the same as a Registered Dietitian credential, and an IBCLC should not assume they are eligible to bill MNT simply because breastfeeding involves infant nutrition. Breastfeeding Is Not Automatically Medical Nutrition Therapy Breastfeeding certainly involves nutrition, but a comprehensive lactation consultation is much broader than nutrition counseling. A typical IBCLC visit may include: Latch and positioning assessment Milk transfer evaluation Pumping guidance Oral anatomy assessment Maternal breast assessment Nipple pain management Supplementation planning Return-to-work planning Milk supply concerns Feeding observations Individualized lactation care planning These services are fundamentally different from Medical Nutrition Therapy as described by CPT. Scope of Practice Matters One of the most overlooked compliance issues is scope of practice. Even if a payer processes and pays a nutrition code, providers should ask: Am I qualified under this payer's policy to report this code? Does the service I performed meet the CPT description? Does my documentation support Medical Nutrition Therapy rather than lactation counseling? If the answer to any of these questions is "no," payment alone does not eliminate the compliance risk. "It Paid" Is Not a Compliance Standard One of the most common misconceptions in medical billing is: "If insurance paid it, it must be correct." Unfortunately, that is not how claim compliance works. Claims are frequently paid through automated systems that cannot evaluate whether: the provider was eligible to report the code, the documentation supports the reported service, the CPT code accurately describes what occurred, or the payer intended to reimburse that provider type. Many audits occur months or even years after payment. The Real Financial Risk If an insurer later determines that a nutrition therapy code was billed inappropriately, the consequences may include: Repayment of previously paid claims Medical record requests Expanded audits of additional claims Increased scrutiny of future billing Administrative burden responding to audit requests These risks can significantly outweigh any short-term reimbursement gained from using a questionable coding strategy. Every Payer Is Different Some insurers may credential IBCLCs differently than others. Some state laws may expand the services certain provider types can bill. Some plans may have unique reimbursement policies. That is why providers should never rely solely on statements such as: "Everyone bills it." "The Facebook group said it works." "Our billing company told us to use it." Instead, providers should verify: their own credentialing status, the payer's published billing policies, the CPT code definition, and whether the documentation truly supports the service billed. Choose Compliance Over Convenience The goal of medical billing is not simply to obtain payment. It is to submit claims that accurately reflect the services provided, are supported by documentation, and comply with payer requirements. As lactation reimbursement continues to grow, IBCLCs deserve billing strategies that are both effective and defensible during an audit. Using codes simply because they reimburse may create unnecessary risk for providers who trust that their claims are being billed correctly. When in doubt, ask questions, request the supporting policy, and remember: The best billing strategy is one you can confidently defend if your records are ever reviewed. Disclaimer: This article is for educational purposes only and is not legal advice. CPT coding, payer policies, provider eligibility, and scope-of-practice requirements vary by payer, state, and contract. Providers should review applicable policies and consult qualified compliance or legal professionals when necessary.

According to industry reports, billing errors and lack of visibility into claims contribute to billions of dollars in lost or delayed revenue each year. For individual healthcare providers, this lack of transparency can mean more than financial uncertainty—it can impact compliance, patient trust, and professional accountability. As healthcare providers increasingly partner with third-party organizations for billing and insurance administration, one issue deserves far more attention than it receives: access to your own claims. Many providers assume they will be able to review claims submitted on their behalf, verify payments, monitor denials, and understand how their services are being billed. In reality, that is not always the case. Within the lactation industry, there are organizations whose business models provide providers with little or no direct access to claim information. Depending on the contractual arrangement, claims may be submitted under the organization’s Tax Identification Number (TIN), and providers may not receive access to payer portals, claim status, remittance advice, or detailed payment information. Before entering into any billing or contracting relationship, providers should understand exactly what information they will—and will not—be able to access. Understanding Your Responsibilities One of the biggest misconceptions in healthcare is that outsourcing billing transfers responsibility. It does not. Whether billing is performed by an employee, an independent billing company, or another organization, the healthcare provider remains responsible for the accuracy of the services documented and the claims submitted in support of those services. If an insurance company conducts an audit, questions medical necessity, requests documentation, or identifies an overpayment, it is ultimately the provider whose clinical services are being reviewed. That makes transparency essential. The Risks of Limited Access Without direct access, providers may have no independent way to verify: Which NPI was used on a claim. Which CPT® or HCPCS codes were billed. Whether diagnosis codes or modifiers were changed. Whether claims were corrected or resubmitted. Whether denials were appealed. What the insurance company actually paid. What contractual adjustments were taken. Whether patient responsibility was calculated correctly. Without this information, providers must rely entirely on the organization handling their billing. While many organizations operate professionally and ethically, every provider should have the ability to independently review activity involving services they personally rendered. Consider a hypothetical scenario: a provider discovers months later that claims were submitted using incorrect codes, resulting in underpayment. Without access to claims data, identifying and correcting the issue becomes significantly more difficult—and may even fall outside timely filing limits. Documentation Matters Medical records are legal documents. Any edits made during the billing process should accurately reflect the care provided, comply with payer requirements, preserve the integrity of the medical record, and be appropriately governed by policy. Providers should understand who has the authority to modify documentation, what types of edits may be made, and how those changes are tracked. Because providers remain responsible for the accuracy of documentation submitted in support of claims, they should always know how their records are being handled. Business Continuity and Protection Even when billing is performed correctly, lack of access creates unnecessary business risk. Consider what would happen if: Your billing relationship ended unexpectedly. The organization closed or changed ownership. You needed records for an audit. You wanted to verify reimbursement trends. You wished to compare payments with your payer contracts. You needed to investigate a patient complaint. If you cannot immediately access your own claims and payment information, resolving these situations becomes far more difficult. Business continuity depends on maintaining access to your own financial and billing records. Questions Every Provider Should Ask Before signing any contract, ask: Will I have access to every claim submitted for my services? Can I review payer remittance advice and Explanation of Benefits (EOBs)? Will I have access to payer portals? Can I verify claim status independently? Who controls the billing data? What happens if our contract ends? How quickly will my records be transferred back to me? Can I obtain detailed reports showing payments, denials, and adjustments? These questions should be answered clearly and, ideally, in writing. Building Trust Through Transparency Transparency benefits everyone involved. Providers gain confidence that services are being billed accurately. Billing professionals demonstrate accountability. Patients benefit from more accurate billing and better continuity of care. Strong partnerships are built on open communication—not restricted access. Final Thoughts Healthcare providers should never have to wonder how services performed under their professional credentials are being billed. Every provider deserves the ability to review claims, understand reimbursements, verify billing accuracy, and maintain access to records involving their own patients. Whether you are contracting with a traditional billing company, a management organization, or another third-party network, ask questions before you sign. Understand who controls your billing information, what access you will have, and how records will be maintained. Take time to review your current billing arrangements and advocate for transparency in your contracts. Ensuring access today can prevent significant challenges tomorrow. Transparency is not about mistrust. It is about protecting your license, your patients, your practice, and your professional reputation. This article is intended for educational purposes and is not legal advice. Providers should review their contracts carefully and consult qualified legal counsel regarding specific contractual or regulatory questions.

If you've ever billed Aetna for lactation services, you've probably realized that it doesn't work quite like most other commercial insurance plans. Questions such as: Should I bill S9443? Do I also bill a time-based code? Can I use a home visit E/M code? What counts toward Aetna's six covered lactation visits? How should I bill time when both the breastfeeding parent and infant are seen? are among the most common questions we hear from IBCLCs. While every provider must code according to their professional licensure, documentation, payer contracts, and the services actually performed, understanding how Aetna commonly processes lactation claims can help reduce denials and improve compliance. S9443 Is the Foundation of Most Aetna Lactation Claims For most Aetna lactation claims, HCPCS S9443 serves as the primary lactation service code. Although the HCPCS description refers to a lactation class, Aetna commonly recognizes S9443 as the lactation-specific code used by qualified providers for outpatient lactation services. For many IBCLCs, S9443 appears on nearly every Aetna claim. Why Is There Usually a Second Code? S9443 identifies that lactation services were provided, but it does not fully describe the professional work performed during a comprehensive consultation. A typical IBCLC visit may include: Maternal assessment Infant assessment Observation of a feeding Latch assessment Pump evaluation Oral assessment Parent education Development of a care plan Coordination with other healthcare professionals Because of this, many Aetna claims include a second code to more completely describe the additional professional service provided. Option 1: Preventive Counseling Codes (99401–99404) Many providers report one of the preventive counseling CPT codes in addition to S9443. CPT Code Typical Time 99401 Approximately 15 minutes 99402 Approximately 30 minutes 99403 Approximately 45 minutes 99404 Approximately 60 minutes These codes describe preventive medicine counseling and risk factor reduction. However, when billed for the baby, they are not deemed preventative and will be applied to the deductible if it has not been met. The selected code should be supported by the documentation. Documentation should support: Preventive counseling Education provided Medical necessity Assessment performed Individualized care plan Time, most import for IBCLCs billing. Option 2: Home or Residence Evaluation & Management (E/M) Codes Not every provider uses preventive counseling CPT codes. Providers who are qualified to report Evaluation & Management (E/M) services and who perform a medically necessary home or residence E/M service may report the appropriate home/residence E/M code instead of a preventive counseling CPT code. This is not a replacement for S9443. Instead: S9443 remains the primary lactation service code, and The home/residence E/M code replaces the preventive counseling code as the second code on the claim when appropriate. Whether an E/M code may be billed depends on: The provider's license (CLC holders can only bill for S9443, meaning even counseling codes exceed their scope) Place of Service (only an option for in-home visits) Documentation The services actually performed Providers should consistently ensure that their documentation justifies the chosen level of E/M service. For IBCLCs, the justification typically relies on the visit duration, as complexity cannot be used due to their scope of practice. Understanding Aetna's Six Covered Lactation Visits One of the most common misunderstandings about Aetna is the belief that members receive six complete lactation visits at no cost. In reality, many Aetna plans describe the preventive benefit as covering up to six uses of HCPCS S9443. This is a per patient benefit, and does not always renew at the first of the year. Some plans only allow more class codes for a new baby. Importantly, the accompanying preventive counseling CPT code or home/residence E/M code is not intended to reduce the patient's available S9443 benefit. When Claim Processing Doesn't Match the Benefit Unfortunately, claim processing does not always reflect the intended benefit design. Some providers have experienced situations where Aetna appears to incorrectly count the accompanying preventive counseling CPT code toward the patient's six covered S9443 services or otherwise processes the benefit inconsistently. When this occurs, providers may see: Unexpected patient responsibility Denials after only a few visits Incorrect benefit exhaustion Conflicting explanations from different Aetna representatives Resolving these situations can be difficult and often requires: Reviewing the Explanation of Benefits (EOB) Contacting Provider Services Filing corrected claims or appeals Keeping detailed notes, reference numbers, and representative names Persistence is often necessary, as different representatives may interpret the benefit differently. Billing Time When Both Mother and Baby Are Seen Lactation care is unique because two patients are frequently evaluated during the same appointment. Both the breastfeeding parent and infant may receive medically necessary assessments, diagnoses, treatment plans, and separate insurance claims. However, the same provider time should never be billed twice. For example, if a lactation consultation lasts 90 minutes, it would generally not be appropriate to report 90 minutes on the mother's claim and another 90 minutes on the baby's claim. That would represent duplicate billing because the same 90 minutes of professional work would be counted twice. Instead, the provider's documented time should be allocated between the two patients based on the medically necessary services provided to each. Mom is most likely to be covered preventatively and also most likely to be included on the plan. For many office visits, the preventive counseling code reported on the mother's claim reaches its highest reportable time threshold at approximately 60 minutes. When a medically necessary lactation consultation extends beyond that, providers may appropriately allocate the remaining documented time to the infant's claim, provided the infant also received separately documented, medically necessary services. For example: Total appointment: 90 minutes Mother's claim S9443 Appropriate preventive counseling CPT code supporting approximately 60 minutes Infant's claim S9443 Appropriate accompanying code supporting the remaining approximately 30 minutes of documented services The important principle is that the combined reported time across both claims should never exceed the provider's actual time spent delivering billable services during the encounter. Simply duplicating the full visit length on both claims may create duplicate billing concerns and increase audit risk. Documentation Is Critical Whether your second code is a preventive counseling CPT code or a home/residence E/M code, documentation should clearly support every service billed. Good documentation includes: Medical necessity Comprehensive assessment Clinical findings Education provided Individualized care plan Time documentation when applicable(this is always the case for IBCLCs) Documentation supporting any reported E/M service Strong documentation remains your best protection during audits and appeals. Best Practices When billing Aetna: Include S9443 when appropriate for the lactation service provided. Select the accompanying code that accurately reflects the additional professional service performed. Never choose codes based solely on reimbursement. Never duplicate provider time across the mother's and infant's claims. Verify benefits before every patient (or inform patients with appropriate intake forms) Review every Explanation of Benefits for claim processing errors. Appeal incorrect benefit interpretations when appropriate. Keep detailed records of all communications with Aetna. Final Thoughts Aetna lactation billing is more nuanced than selecting a single billing code. For most claims, S9443 serves as the primary lactation service code, while the accompanying code may be either a preventive counseling CPT code or, when appropriate, a home/residence E/M code reported by a qualified provider. Understanding how these codes work together, allocating provider time appropriately between the breastfeeding parent and infant, and recognizing when claim processing errors occur can help reduce denials, improve compliance, and ensure patients receive the benefits to which they are entitled. As with all payer policies, Aetna's requirements may change and can vary by the member's specific benefit plan. Providers should always bill based on the services actually performed, their professional licensure, their payer contracts, and current Aetna billing guidance.

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.

The short answer is yes—but whether you'll be paid depends on the patient's insurance plan, the payer's policies, and how the visit is documented and billed. Telehealth has become an important tool for lactation care, allowing IBCLCs to support families who may otherwise have difficulty accessing services. However, unlike many other healthcare specialties, telehealth coverage for lactation services is far from consistent. Understanding when telehealth is covered—and when it isn't—is essential to avoiding denied claims and unexpected patient balances. Does Insurance Cover Telehealth Lactation Visits? Some insurance companies reimburse telehealth lactation visits, while others limit coverage or exclude them entirely. Coverage may depend on factors such as: The patient's insurance company The specific employer-sponsored or individual health plan State insurance mandates Whether the provider is in-network The services performed during the visit Current payer policies Two patients with the same insurance company may have different telehealth benefits simply because they have different plans. For that reason, it is never safe to assume telehealth is covered without verifying benefits. Is Telehealth Required to Be Covered Under the ACA? The Affordable Care Act requires many health plans to provide breastfeeding support and counseling without cost-sharing when delivered by an in-network provider. However, the law does not require every plan to cover those services via telehealth. Some plans cover virtual lactation visits exactly as they would in-person visits, while others only reimburse in-person care or apply additional restrictions. Verify Benefits Before Every Telehealth Visit Before scheduling a telehealth appointment, verify: Is telehealth lactation covered? Are there any visit limits? Is prior authorization required? Is the provider required to be in-network? Does the patient's specific plan have telehealth restrictions? Taking a few minutes to verify benefits can prevent claim denials and help patients understand any financial responsibility before the appointment. This issue can be addressed by using intake forms that inform patients about potential costs if their plan does not cover telehealth or lactation services. It's important to ensure patients understand that it's their responsibility to verify coverage; otherwise, they will be responsible for the costs. Many small practices do not have front desk staff to verify coverage, and the time required for this task can be excessive. Additionally, most billing companies do not handle this verification, leaving the responsibility to the provider if adequate intake forms are not used. Can HCPCS Code S9443 Be Used for Telehealth? In some cases, yes. Whether S9443 may be billed for a telehealth lactation visit depends on the payer's reimbursement policies and the patient's individual plan. Some insurers reimburse S9443 when provided through telehealth, while others only reimburse the code for in-person services or may not cover telehealth lactation services at all. Always follow the payer's current billing guidelines and documentation requirements. Documentation Matters Telehealth documentation should generally include everything required for an in-person lactation consultation, along with information specific to the virtual encounter. This often includes: Confirmation that the visit occurred via telehealth The technology platform used The locations of the provider and patient, if required by the payer Consent for telehealth, when required Medical necessity Complete assessment and care provided Time spent, when applicable Documentation requirements vary among payers, so always review current policies. Can You Assess Both Mother and Baby During Telehealth? Often, yes. Many lactation consultations involve assessing both the breastfeeding parent and the infant through video. A virtual visit may allow the IBCLC to observe: Positioning Latch Milk transfer behaviors Infant feeding cues Breastfeeding technique Pump flange fit Bottle-feeding technique Parent education and counseling However, some situations require an in-person evaluation. Concerns such as poor weight gain, dehydration, jaundice, oral abnormalities, suspected tongue-tie requiring hands-on assessment, or maternal breast complications may warrant referral for an in-person visit or additional medical evaluation. Clinical judgment should always determine whether telehealth is appropriate. Common Reasons Telehealth Claims Are Denied Telehealth lactation claims may be denied because: The patient's plan does not cover telehealth lactation services. Telehealth benefits were not verified before the visit. Required modifiers or place of service information were omitted when required. Documentation does not support medical necessity. The provider is out-of-network. The patient's plan only covers in-person breastfeeding counseling. Many denials are preventable with careful eligibility verification and accurate documentation. Best Practices for IBCLCs Before providing telehealth lactation services: Verify benefits for every patient. Confirm telehealth coverage under the patient's specific plan. Review payer-specific billing requirements. Document the encounter thoroughly. Explain potential financial responsibility if coverage cannot be confirmed. These steps help reduce claim denials while ensuring patients understand their benefits before receiving care. Final Thoughts Telehealth has expanded access to lactation care for many families, but insurance coverage remains inconsistent across payers and health plans. Rather than assuming telehealth is covered, IBCLCs should verify benefits for each patient, understand payer-specific billing requirements, and maintain thorough documentation for every encounter. A little preparation before the visit can prevent significant billing issues afterward and help ensure both providers and patients have realistic expectations about coverage and reimbursement.