Navigating the Surge in SIU Audits of Lactation Consultant Services

/ Medicare, Medicaid & Private Payor Updates / By

(October 2, 2026): As health care providers and suppliers across the country will readily confirm, government and private payor examiners and investigators are actively auditing a wide range of services and supplies billed to insurance. This scrutiny has included audits by private payor insurance company Special Investigative Units (SIUs) of services billed by allied health care professionals such as lactation consultants and counselors.[1] SIUs are specialized divisions within commercial health insurance companies tasked with identifying, investigating, and recovering funds lost to suspected fraud, waste, and abuse.[2] Recently, these units have targeted lactation professionals' billing practices, focusing heavily on specific Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes. This article explores the regulatory framework surrounding lactation support, examines the specific codes under SIU investigation, identifies key risk areas for lactation consultants, and outlines proper billing and documentation practices to mitigate audit risks.

I. Overview of Lactation Consultant Services:

Lactation consultants are specialized allied health care providers who educate and assist mothers with breastfeeding and lactation. They serve as an essential extension of maternal-child healthcare services, focusing exclusively on the clinical needs of the breastfeeding mother-baby relationship. From prenatal education to managing complex feeding difficulties, lactation consultants help families achieve their infant feeding goals.

Liles Parker attorneys represent lactation consultants in audits by government and private payors around the country - Liles Parker

A. Responsibilities of a Lactation Consultant. A lactation consultant's responsibilities include education, clinical assessment, intervention, and support for mothers who want to breastfeed their babies. Lactation consultant services are fundamentally centered on the "dyad,"[3] the lactating parent and the infant treated as a single, interdependent unit.

Lactation consultants often begin their work before the baby is born. They educate expectant parents on the physiological process of lactation, the benefits of human milk, and what to expect in the immediate postpartum period. This anticipatory guidance helps establish realistic feeding goals and prepares parents to recognize early hunger cues, preventing common early breastfeeding challenges.

A lactation consultant's primary role is to clinically evaluate breastfeeding mechanics. During a consultation, they systematically collect subjective history and objective data to identify issues. Assessments conducted can be divided into two components:

Component #1: Maternal Assessment. They evaluate breast anatomy, nipple condition (e.g., trauma, flat or inverted nipples), signs of engorgement, plugged ducts, or mastitis, and assess the mother's milk production.

Component #2: Infant Assessment. They evaluate the infant's oral anatomy, suckling mechanics, and overall feeding effectiveness. This includes checking for conditions like ankyloglossia (tongue-tie), which can severely restrict tongue mobility and impede milk transfer.

To complete these assessments, a lactation consultant relies heavily on observing breastfeeding sessions to assess the baby’s ability to latch onto the breast, the mother’s positioning of the baby, and the baby’s swallowing of the mother’s milk. Lactation consultants also weigh an infant before and after feeding sessions to objectively measure milk transfer.

B. Development of an Individualized Care Plan. Based on the lactation consultant’s assessment of the breastfeeding dyad, they typically develop an individualized care plan. They provide hands-on assistance to correct latch and positioning, which often cause nipple pain and poor milk transfer. They also teach parents how to use breast pumps, supplemental nursing systems, and nipple shields. If milk supply is low, they guide the mother on strategies to increase production, such as adjusting feeding frequency or starting a pumping regimen.

C. Collaboration and Referral. Lactation consultants operate within a broader healthcare team. If they identify medical conditions outside their scope of practice—such as infant oral tethers, maternal infections requiring antibiotics, or severe infant dehydration—they must refer the dyad to an appropriate physician (e.g., pediatrician, ENT, or obstetrician). They must communicate their clinical findings and care plans back to primary care providers to ensure continuity of care.

D. Credentials. Professional certification is distinct from state licensure. The International Board Certified Lactation Consultant (IBCLC) credential does not, by itself, confer a right to practice; holders must comply with the legal requirements of the jurisdiction where they practice. Read the credential descriptions below together with the state-specific requirements in Section II.[4]

Organization Description and Scope Training and Accreditation Credential Awarded
International Board of Lactation Consultant Examiners (IBLCE) Certification for clinical lactation management. The credential does not replace any state-required license or authorize practice beyond the holder’s legally permitted scope. Eligibility includes a qualifying health-sciences background; 90 hours of lactation-specific education plus 5 hours of communication education; pathway-specific clinical experience of 300, 500, or 1,000 hours; and the certification examination. International Board-Certified Lactation Consultant (IBCLC)
Academy of Lactation Policy and Practice (ALPP) Provides foundational breastfeeding counseling and education. Refers complex clinical cases to an IBCLC or physician. Accredited by the NCCA. Requires completion of a 45+ hour training course and passing an exam. Certified Lactation Counselor (CLC)
Childbirth and Postpartum Professional Association (CAPPA) Focuses purely on education and advocacy (e.g., teaching prenatal classes). Non-clinical role. Not independently accredited. Requires completion of a short training program (often a few days). Certified Lactation Educator (CLE)
University of California, San Diego (UCSD) Division of Extended Studies.[5] Subjects covered include, but are not limited to:

  • Understanding the baby friendly hospital initiative,
  • Hazards of not breastfeeding; Contraindications;
  • Support and barriers;
  • Anatomy;
  • Physiology and hormones, infant instincts and organization;
  • Positioning and latch;
  • Getting enough breast milk;
  • Common concerns;
  • Jaundice management;
  • Breast pumps and equipment; and
  • Lactation as a profession.
 Requires completion of a several-day training program. Certified Lactation Specialist (CLS)
Women, Infants, and Children (WIC) Program. [6] Provides mother-to-mother support based on personal breastfeeding experience and basic training. Non-clinical support. Agency-specific training. Women, Infants, and Children (WIC) Peer Counselor
(Peer Counselor)

II. The Regulatory and Reimbursement Landscape of Lactation Service Counseling:

Among its many provisions, the Affordable Care Act (ACA) requires that most non-grandfathered[7] employer health insurance plans, individual health coverage purchased on insurance marketplaces, and certain state Medicaid plans cover breastfeeding support and supplies.[8] As the National Women’s Law Center has noted, the Health Resources and Services Administration (HRSA) requires that insurance plans cover "comprehensive lactation support and counseling, by a trained provider, and costs of breastfeeding equipment" without cost-sharing for the patient.[9] While this mandate significantly expanded access to breastfeeding support, the lack of specificity about who qualifies as a "trained provider" and which billing codes to use has created a complex, fragmented reimbursement environment.

A. State Licensure and Protected Titles. Before providing services, determine whether the applicable state law regulates clinical practice, use of a professional title, or both. Review any exemption against the practitioner’s qualifications and proposed services. The following examples illustrate different approaches and are not a complete state-by-state survey.

  • Rhode Island. Rhode Island licenses lactation consultants and lactation counselors under separate statutory chapters, subject to the applicable exemptions.[10] The current consultant rule requires current IBCLC board certification, in addition to its specified age, education, and examination requirements.[11] Counselor applicants must qualify for the Lactation Counselor - CLC or Lactation Counselor - ALC category. A counselor may not use the lactation consultant title unless separately licensed as a consultant. The Advanced Lactation Consultant (ALC) certification does not satisfy that separate licensing requirement.[12]
  • New Mexico. Licensure with the New Mexico Board of Nursing is not required to provide lactation care and services. A person who does not hold the Board’s lactation care provider license may not use the title licensed lactation care provider (LLCP) or otherwise imply that the person holds that New Mexico license.[13] The optional LLCP license is distinct from nursing licensure; a nursing license is not required to qualify. The Board expressly recognizes Certified Lactation Counselor (CLC) and IBCLC certifications for licensure. Holders of other qualifying certifications may petition for Board approval; applicants must also satisfy the rule’s other licensing requirements.[14]
  • Oregon. Oregon generally requires a license to practice lactation consultation or use a title indicating authority to do so, subject to statutory exemptions. The initial-license rule requires verification of IBCLC certification from the certifying organization, along with other application requirements.[15] Exemptions address other licensed practitioners, educational activities, and specified breastfeeding-support roles. The statute expressly permits a certified lactation counselor to perform the defined lactation services without a lactation consultant license. That exemption should not be treated as permission to claim a consultant license.[16]
  • Connecticut. Since July 1, 2026, compensated lactation consulting generally requires a state license, and the law restricts specified titles and designations, including lactation consultant and IBCLC. To qualify for that license, an applicant must hold IBCLC certification. The statute includes exemptions for specified licensed professionals and activities such as nonclinical peer support; each listed exemption includes a condition that the person does not refer to themselves as a lactation consultant. Review the precise exemption before relying on it.[17]
  • Georgia. In Raffensperger v. Jackson, decided May 31, 2023, the Georgia Supreme Court held that the state’s Lactation Consultant Practice Act violated the plaintiffs’ due process rights under the Georgia Constitution. The Georgia Secretary of State states that the licensing board has been disbanded and a lactation consultant license is no longer required to work in the state. Do not assume that this Georgia decision removes licensing requirements in other jurisdictions.[18]

B. Impact of the Absence of State Regulatory Oversight. Unfortunately, because most states do not require lactation consultants to be licensed, these allied health providers face significant credentialing and contracting challenges. As one commentator has noted:

“Most insurance companies, unfortunately, will only contract with licensed providers, making it incredibly difficult for lactation consultants to bill for their services. This forces IBCLCs without licensure to charge new parents, already struggling with hospital bills and the stress of a newborn child, self-pay prices for their essential services.”[19]

The absence of licensure and certification for lactation consultant services in most states has exacerbated the administrative problems these individuals face when trying to bill for their services. Most have been left trying to figure out how to code and bill for lactation consultation services on their own, without state regulatory oversight or assistance.

The licensing concerns described above relate to state-issued lactation credentials, not the availability of private professional certification. They should not be read as a universal insurer-contracting rule or as an absence of other applicable legal requirements.

C. State Practice Authority and Payor Recognition. In addition to any specific state requirements governing lactation practices, a practitioner must also review each payor’s coverage and payment requirements. Federal preventive-services guidance expressly states that reimbursement policy is outside its scope. For example, Blue Cross and Blue Shield of Illinois (BCBS-IL) policy RP043 identifies CLCs and IBCLCs who may be eligible for reimbursement, subject to the plan and provider agreement. It also addresses claims from independent practitioners who are outside the payor’s network.[20] Practitioners must verify the provider category each payor recognizes and obtain written clarification when a billing arrangement is uncertain.

III. Coding and Billing Risks in Lactation Services:

When billing for lactation services, practices must use the Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) instructions applicable to the service date, together with relevant payor requirements. A payor’s SIU may examine billing patterns or place claims under prepayment review when it suspects improper billing. Federal lactation-coverage requirements do not, by themselves, determine reimbursement for a particular practitioner or code. Before billing, confirm the practitioner’s recognized provider category and which services the applicable plan permits that practitioner to report.[21]

A. Evaluation and Management (E/M) and Preventive Counseling Codes. Do not infer automatic E/M eligibility from a nursing license or automatic ineligibility from the absence of a lactation-specific license. The American Medical Association's (AMA) Evaluation and Management (E/M) guidelines distinguish a physician or other qualified health care professional who independently reports a service from clinical staff working under supervision.[22]

A payor’s inclusion of preventive counseling codes, CPT® codes 99401–99404, in lactation benefit guidance does not establish that every lactation practitioner may bill them. BCBS-IL policy RP043, for example, lists these codes but excludes reimbursement of its listed physician-code group when submitted by non-physician qualified health care professionals. Apply that restriction only where the policy governs, together with applicable law and the provider agreement.[23]

B. Education and Self-Management Training (CPT® Codes 98960–98962). These codes describe face-to-face education and training for patient self-management using a standardized curriculum, provided by a qualified non-physician health care professional, each 30 minutes. CPT® code 98960 is for one patient; CPT® code 98961 is for 2–4 patients; and CPT® code 98962 is for 5–8 patients. Document the curriculum and qualifying time, and distinguish individual from group services. Caregiver or family participation does not, by itself, convert an individual service into a group service. Do not relabel an ordinary consultation as curriculum-based education solely to obtain a different payment.[24]

C. Lactation Services (S9443) and Parent–Infant Billing. S9443 describes lactation classes furnished by a nonphysician provider, per session. Do not treat the word classes as a universal group-only billing restriction. For example, Colorado Medicaid expressly uses S9443 with modifier U1 for individual sessions and U2 for group sessions, together with a duration modifier. These are Colorado Medicaid’s instructions – these are not necessarily the rules applied by other payors.[25]

For a one-on-one clinical assessment, confirm whether the payor accepts S9443 for the documented service. Do not relabel an assessment as a class merely to obtain payment, and do not switch to an E/M or preventive counseling code without verifying the practitioner’s eligibility and the code’s service requirements.

Clinical care may address both the lactating parent and infant, but treating the dyad does not automatically permit two claims. UnitedHealthcare’s Commercial and Individual Exchange policy considers S9443 for reimbursement only when the mother is identified as the patient, not the infant, and only once per mother-baby dyad per date of service. This restriction concerns S9443 under those products; evaluate any separately reported infant service under its own coding and payor requirements.[26]

Similarly, BCBS-IL policy RP043 treats the lactating member and baby as one patient for its lactation benefit and directs providers to bill one claim per session.[27]

D. Diagnosis Coding and Modifiers.Practitioners should select the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code from the documented encounter. Z39.1 describes an encounter for care and examination of a lactating mother and may be used for appropriate breastfeeding counseling encounters. Do not use a maternal code on an infant’s claim or add an unsupported disease diagnosis to obtain payment. Modifier 25 identifies a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day as a procedure or other service. It cannot supply a service that was not performed and should not be added merely to bypass an edit.[28]

IV. Documentation Best Practices to Mitigate Audit Risks:

A detailed clinical note requires proper authentication and timely completion. For example, Anthem’s New York commercial policy C-20003 expects entries at the time of service or shortly thereafter and states that completion should not exceed 30 days. It also requires a signature date within 30 days of service, subject to its contractual and legal qualifications. This payor-specific limit is not a nationwide deadline or a recommended waiting period.[29]

A practical encounter template should address the following:

  • Patient and Encounter Identity. Keep the parent's and infant's identifiers distinct and confirm that the chart matches the patient name on the claim.
  • Relevant Findings. Record pertinent history and observations. Document feeding observations or measured weights when obtained and distinguish reported information from direct observation.
  • Services and Plan. Describe the intervention and the education actually provided. Explain the individualized plan, follow-up instructions, and any referral or escalation.
  • Time. For time-dependent reporting, record the actual qualifying minutes and any start-and-stop information the applicable rule requires.
  • Authentication. Identify the author and authenticate the record using the appropriate signer's actual credentials and signing date.

Correct records transparently. Preserve the original entry, identify the person making a correction, and record the actual correction date and reason. Never backdate a signature or add an unperformed service to support an audit response. For holders of New Mexico’s separate lactation care provider license, falsifying or altering records to reflect incorrect or incomplete information is unprofessional conduct subject to Board of Nursing discipline. That authority does not depend on a concurrent nursing license. The cited lactation-provider disciplinary rule should not be applied to every person lawfully providing lactation care without that optional license; any other applicable legal or payor requirements must be assessed separately.[30]

V. Responding to an SIU Audit and Regulatory Exposure:

Lactation practices should conduct periodic reviews that trace selected claims from the clinical record through payment. If a payor’s SIU requests records, providers should take the following steps:

  • Preserve the Evidence. Retain relevant original records, amendment histories, submitted claims, remittance information, and correspondence. Do not reconstruct missing clinical work.
  • Identify the Governing Requirements. Confirm the requesting entity, affected plan, service dates, provider agreement, and applicable policy versions. Distinguish commercial requirements from Medicaid or Medicare rules.
  • Calendar Each Deadline. Track record-production, reconsideration, and appeal deadlines separately.
  • Control the Production. Check that the response contains the requested, applicable records for the correct patients and dates. Verify the legal basis for disclosure, use a secure transfer method, and retain an exact copy of the production.

An audit response must also protect patient privacy. The Health Insurance Portability and Accountability Act (HIPAA) applies to covered entities, including healthcare providers that conduct specified electronic transactions, and imposes obligations on business associates. Its Privacy Rule governs permitted uses and disclosures; its Security Rule requires safeguards for electronic protected health information. Determine the practice’s status and review the requirements applicable to its handling of patient records.[31]

A denied claim does not, by itself, establish fraud. For claims involving federal funds, knowingly presenting false or fraudulent claims can trigger civil penalties and treble damages under the federal False Claims Act. Its knowledge standard includes actual knowledge, deliberate ignorance, and reckless disregard; it does not require proof of specific intent to defraud.[32]

The federal healthcare-fraud statute, 18 U.S.C. § 1347, separately addresses knowing and willful schemes to defraud healthcare benefit programs in connection with the delivery of or payment for healthcare. The statutory definition includes public or private plans or contracts affecting commerce.[33]

VI. How Liles Parker Can Help:

The health care regulatory attorneys at Liles Parker PLLC have experience representing lactation practices in responding to and/or defending against government and private payor audits and investigations. Our attorneys can review whether a lactation practice’s clinical documentation supports the services billed and evaluate coding concerns under the applicable payor policies and provider agreements. When a payor SIU requests records or demands repayment, our attorneys can help prepare a response and evaluate the grounds for challenging the payor’s findings. We can also assist with appeals and corrective-action measures, including improvements to a practice’s compliance program.[34]

If your lactation practice has received an audit notice or has questions about its billing practices, Schedule a free initial consultation with Liles Parker.

annabella Denzel - Associate Attorney - Liles Parker - 150x150
Annabella Denzel
John D Uecke - Senior Paralegal - 150 x 150 - Liles Parker
John Uecke
| John Uecke

Annabella Denzel is an experienced health care regulatory attorney at Liles Parker. John Uecke is a senior paralegal at the firm and has decades of experience handling health care provider coding and billing issues. In addition to being an experienced health law attorney, Annabella is also a Certified Professional Coder (CPC). John holds certifications issued by multiple health care billing, coding, and compliance organizations. Annabella and John have extensive experience helping health care providers and suppliers defend against CMS program integrity audits by UPICs, SMRCs, and RACs. Are your lactation consultant services being audited? Schedule a free initial consultation with Liles Parker.

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