Lactation SOAP Notes That Support Clean Claims: Template, ICD-10 Mapping, and Examples

Most IBCLCs don't find out their documentation has a problem until a claim denial lands in the mailbox six weeks after the visit. By then the mother has moved on, the baby's feeding is resolved one way or another, and you're rebuilding the note from memory to appeal a $180 payment.

The denial wasn't about your clinical work. You assessed the latch correctly, spotted the posterior tongue tie, wrote a reasonable care plan. What the payer saw was a note that didn't justify the code you billed. No time documented. A generic "difficulty breastfeeding" assessment where a specific diagnosis would have supported a higher-level E/M. A plan without measurable follow-up.

This is the template that fixes that. It's a lactation-specific SOAP structure mapped to the ICD-10 codes and E/M levels payers actually want to see, with three complete worked examples and the eight most common denial reasons.

If you want the workflow version of this content (how to chart fast in a kitchen or a car between visits), see Home Visit Documentation. If you want the billing codes themselves in depth, see the IBCLC Billing Guide. This post is the bridge between the two: what to write so the codes you bill actually get paid.

Why a lactation SOAP note is different

General clinical SOAP templates were designed for a 15-minute primary-care visit about one condition, for one patient. A lactation consultation breaks all three assumptions.

• The visit is 45–75 minutes. That duration is only defensible if your note reflects it.
• There are often two patients. Maternal low supply and infant poor weight gain are clinically linked, but they bill under different ICD-10 families (O-codes vs. P-codes) and you have to pick one per claim.
• The objective data is measurable but easy to skip. Pre- and post-feed weights, LATCH scores, output counts, oral structure assessments. These are the data that support your code level. Without them, your visit looks like unbilled counseling.
• A lot of the work is education. Patient education time counts toward E/M selection when documented. When it isn't, you just gave it away.

A note that reads fine for clinical continuity can still fail for billing. The test isn't "could I reconstruct what happened from this?" It's "could an auditor?"

Seven rules for a defensible lactation note

Before the template itself, these rules apply to every visit.

1. Identify the patient by name and role. Mother or infant? This determines which ICD-10 family you use and which chart you bill under.
2. Document total time spent on the date of the encounter. Since 2021, E/M selection uses either total time or medical decision-making, and most IBCLCs default to time because lactation visits run long. Listing how the time was spent (counseling, chart review, care coordination) is best practice and strengthens the claim, though the 2021 AMA rules require only the total.
3. Lead with measurable data. Pre/post weights, transfer volumes, output counts, weight-loss percentage. "Latch improved" is impression; a 40 mL transfer differential across two visits is evidence.
4. Be specific on diagnoses. O92.4 (hypogalactia) is defensible. O92.70 (unspecified lactation disorder) is a catch-all, and payers generally reimburse documented specificity more readily than non-specific codes. Use the most specific code the documentation supports.
5. Link the plan to the assessment. Every recommendation should map back to a finding in your Objective section.
6. Document what was refused, deferred, or declined. If the family declined the frenotomy referral, write it. Same with deferred weighted feeds, declined supplementation, or missed follow-ups.
7. Sign and attest with your full credentials and NPI. "Jane Smith, RN, IBCLC, NPI 1234567890" on every note, not just the superbill.

The Template, field by field

S - Subjective

What the family tells you, in your structured form.

Required for initial visits:

• Chief concern (1–2 sentences, in their words)
• Pregnancy and birth history: gestational age, birth weight, delivery method, complications, skin-to-skin, separation
• Feeding history: current feeding method, supplementation type and volume, attempts tried, pumping routine and output
• Lactogenesis II onset: day, subjective fullness, prior engorgement or mastitis
• Maternal health: medications, breast surgery, thyroid/PCOS/prior fertility treatment, mental health
• Infant health: jaundice, voids and stools per 24 hours, alertness, prior weight loss percentage
• Pain: location, severity (0–10), timing (at latch, through feed, between feeds), associated symptoms (blanching, radiating pain, vasospasm color change)
• Psychosocial: confidence, anxiety, sleep, support system, prior feeding experience, goals

Required for follow-up visits:

• Interval summary (what's changed since last visit)
• Adherence to prior plan (kept, modified, abandoned)
• Current concerns
• Feed or output log summary
• Medication or supplement updates

Billing defensibility tip: Your Subjective section establishes the complexity the payer sees. A chief concern of "fussy at the breast" reads as low-complexity. "Bilateral nipple pain 8/10 with visible blanching, infant at 9 percent weight loss on day 7, supplementing 60 mL formula after each feed" reads as the moderate-to-high complexity you're actually treating.

O - Objective

What you observed and measured. This is the clinical data that carries the most weight in an audit.

Breast and nipple assessment:

• Appearance (symmetry, shape, skin integrity, glandular tissue on palpation, visible veins)
• Nipple condition (intact, cracking, bleeding, blanching, vasospasm, creasing after feed)
• Engorgement grade (bilateral vs. unilateral, firmness, resolution with removal)
• Signs of infection (redness, streaking, warmth, fever, tenderness)

Feeding observation:

• Position used (cradle, cross-cradle, laid-back, side-lying, football)
• Latch characteristics (asymmetric, lip flanging, gape >140°, seal, audible swallows per minute)
• Suck pattern (nutritive vs. non-nutritive, rhythm, pauses)
• Duration on each breast, with infant state (active, drowsy, asleep)
• Transfer quality (visible jaw excursion, audible swallows, rest patterns)

Measurable data (the anchor of the note):

• Pre-feed weight (grams, scale used, infant clothed or unclothed to diaper; be consistent)
• Post-feed weight (same conditions, immediately after feed)
• Transfer volume (post minus pre; 1 g = 1 mL)
• Total feed duration and breast split (e.g., "22 min: 14 left, 8 right")
• Infant weight today vs. birth weight vs. last known weight
• Percent weight loss from birth (if under 14 days)
• Output (voids and stools in last 24 hours, stool color/consistency)

Oral assessment (when indicated):

• Functional tongue mobility (elevation, lateralization, extension, cupping). This is the clinically meaningful assessment per ABM Protocol #11. Consider using the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) when available.
• Anatomical classification if relevant: Coryllos Types I to IV (insertion point) and/or Kotlow Classes I to IV (measured free tongue length). These describe anatomy, not function. Document them alongside the functional assessment, not in place of it.
• Lingual frenulum (appearance, attachment point, elasticity, restriction)
• Labial frenulum (Kotlow grade if assessed, though note the ABM Position Statement on Ankyloglossia (LeFort et al., 2021) does not recommend upper lip-tie release as a breastfeeding intervention)
• Palate (shape, height, arch)
• Jaw (symmetry, opening range, retrognathia)
• Structured scoring (LATCH or IBFAT) at first visit and repeated on follow-ups to demonstrate trajectory

Documentation tip: Weighted-feed data is the single most defensible piece of clinical evidence an IBCLC produces. Always record pre/post weights, the scale used, and the feeding conditions. If a weighted feed wasn't done, document why ("infant asleep at time of visit, weighted feed deferred to follow-up on 04/17/2026").

A - Assessment

Your clinical synthesis. This is where your IBCLC expertise shows, and it's the section that directly supports your code level and ICD-10 selection.

Structure your assessment around four elements:

• Clinical impression (what's going on, synthesized from S + O)
• Specific problem list (each issue stated as a clinical diagnosis, not a symptom)
• Risk factors (what elevates complexity: prematurity, IGT, prior breast surgery, maternal medications, multiples, late preterm)
• Progress on follow-up visits (improving, stable, worsening, with reference to prior objective data)

Coding-friendly language: Use clinical terminology that maps one-to-one to ICD-10. Write "insufficient milk transfer secondary to ineffective latch with anterior ankyloglossia," not "breastfeeding difficulty." The former supports P92.5 + Q38.1 and a moderate-complexity E/M. The latter reads as a nonspecific visit.

P - Plan

What happens next, and who does what.

Clinical recommendations (be specific):

• Positioning and latch modifications ("laid-back position with infant prone across torso, nipple aimed at palate, chin-first latch, asymmetric gape")
• Supplementation (method: SNS, cup, paced bottle, syringe; volume per feed; total daily; plan for taper)
• Pumping protocol (frequency, duration, single vs. double, flange size)
• Maternal care (heat or cold therapy, nipple treatment, mastitis management, pain control, hydration and nutrition)
• Products with sizing (nipple shield mm, flange mm, breast shells, pump make)

Referrals (with specific provider type):

• Pediatrician weight check, with interval
• ENT or pediatric dentist, for frenotomy evaluation
• Mental health, for a positive postpartum mood disorder screen
• Endocrinology or pharmacist, for galactagogue or hormonal workup

Follow-up plan:

• Next visit date or interval. Be specific: "follow-up 48 hours post-frenotomy," not "as needed"
• What to monitor between visits (output log, pain score, feeding duration)
• Red flags to watch for (signs of dehydration, mastitis, worsening jaundice)
• How to reach you between visits

Billing elements (part of the note, not a separate step):

• CPT code with time statement
• ICD-10 diagnosis code(s)
• Place of service code
• Whether a superbill was generated or claim submitted
• Signature, credentials, NPI

Plan-to-assessment link: Every item in your Plan should trace back to a finding in your Assessment. If you recommended a nipple shield, your Assessment should reference the latch problem it solves. If it doesn't, an auditor will call it not medically necessary.

ICD-10 code → Assessment language mapping

This is the piece most lactation SOAP templates skip. Payers pattern-match: certain codes expect certain language in the Assessment. Use this as a crib sheet.

Coding rule: Use the most specific code that your documentation supports. If you have the evidence for Q38.1 + P92.5, don't just bill P92.9. The higher specificity protects the higher E/M.

Three complete worked examples

Example 1: Initial home visit, maternal low supply

• Patient: [Mother name], 28yo, G2P2, 14 days postpartum
• Date of Service: 04/10/2026
• Place of Service: 12 (home)

S: G2P2, 14 days postpartum, vaginal delivery at 39w2d, uncomplicated. Chief concern: "I don't think I'm making enough milk." Infant dropped from 3.4 kg at birth to 3.1 kg at day-10 pediatrician visit (8.8% loss, approaching ABM 10% excessive-weight-loss threshold; has not regained birth weight by day 10, triggering ABM Protocol #3 evaluation). Currently breastfeeding 10–12x/24h then supplementing 60 mL formula after each feed per pediatrician's recommendation. Pumping 3x/day post-feed, 30 mL combined output across both breasts. Breast asymmetry noted by patient since puberty. Newly diagnosed primary hypothyroidism (elevated TSH on postpartum screening labs), started on levothyroxine 50 mcg daily 3 days ago. No breast surgery. No pain. Voids 6/24h, stools 3/24h (yellow, seedy). Alert, feeds vigorously. Confidence low, tearful during visit. Goal: reduce supplementation.

O:

• Breast exam: Widely spaced breasts (>4 cm intermammary distance), tubular appearance, minimal glandular tissue on palpation; Huggins Type IV morphology consistent with insufficient glandular tissue (IGT). No erythema, no masses.
• Nipples: Intact bilaterally, no cracking or blanching, everted.
• Feeding observation: Cross-cradle position. Asymmetric latch achieved, lip flanging adequate, gape 130°. Audible swallows 1:4 suck:swallow ratio. 22 min total, 14 min left, 8 min right. LATCH score: L=2, A=1, T=2, C=2, H=2 (total 9/10).
• Weighted feed: Pre-feed 3120 g, post-feed 3145 g. Transfer: 25 mL.
• Output: 6 voids, 3 stools in last 24 hours.
• Pump assessment: Spectra S2, current flange 24 mm (nipple measured 18 mm at base post-pumping; current flange is 6 mm oversized, exceeding the recommended 2–4 mm allowance per Wambach & Spencer), suction level 7, cycle 54. Recommended re-size to 21 mm flange (nipple 18 mm + 3 mm allowance).

A: Insufficient milk production, likely contributed by suspected insufficient glandular tissue (IGT, Huggins Type IV morphology) with superimposed possible hypothyroid effect on lactogenesis II. Inadequate milk transfer documented at 25 mL/feed at day 14, supporting ongoing supplementation need. Associated 8.8% weight loss at day 10 without regain of birth weight (approaching ABM 10% threshold per Protocol #3); current trajectory under review by pediatrician. Maternal emotional distress related to feeding, no postpartum depression screen triggers today. Infant thriving with current supplementation plan.

P:

1. Continue supplementation at current volume (60 mL post-feed) until weighted feed transfer improves or infant weight trajectory confirms adequacy.
2. Correct flange sizing: 21 mm flange (nipple 18 mm + 3 mm allowance, within the 2–4 mm guideline) for both breasts. Re-measure after one week of use, as nipple dimensions can change over the course of lactation.
3. Triple feeding schedule: Breastfeed → pump 15 min bilateral double-pump → supplement. Target 8 pump sessions/24h including one overnight session.
4. Galactagogue discussion deferred pending 2-week trial of corrected pumping mechanics. Will revisit at follow-up if transfer is under 40 mL.
5. Endocrinology coordination: Recommend patient ask prescribing provider to reassess thyroid levels at 4 weeks post-initiation of levothyroxine, as thyroid normalization may improve supply.
6. Pediatrician weight check in 72 hours (04/13/2026); results to be communicated to IBCLC.
7. IBCLC follow-up home visit 04/17/2026 (7 days).
8. Red flags reviewed: Signs of dehydration (fewer than 5 voids, dark urine), mastitis (fever, breast erythema), worsening weight loss.

Time: Total 55 minutes (45 face-to-face, 10 non-face-to-face charting and care coordination). CPT: 99204 (new patient, moderate complexity, time-based selection 45–59 min). ICD-10: O92.4 (hypogalactia), primary. Place of service: 12 (home). Superbill generated: Yes, provided to patient at conclusion of visit.

Signed: Jane Smith, RN, IBCLC, NPI 1234567890, 04/10/2026 18:42.

Example 2: Initial office visit, infant poor weight gain with suspected tongue tie (infant as patient)

• Patient: [Infant name], 11 days old, male
• Date of Service: 04/11/2026
• Place of Service: 11 (office)

S: Term infant, 39w3d at birth via uncomplicated vaginal delivery, birth weight 3.2 kg. Today's weight at pediatrician (this morning): 2.9 kg (9.4% loss from birth, approaching ABM 10% excessive-weight-loss threshold). Exclusively breastfeeding. Latches readily but slides off 2–3 times per feed; audible clicking reported by mother. Mother reports bilateral nipple pain 7/10 rated at latch and continuing through feed, left nipple visibly cracked. Feeds every 2 hours, 30–50 minutes per feed. Output last 24 hours: 4 voids, 1 stool (brown-yellow transitional). Mother alert, concerned, no depression screen concerns. Family declined prior frenotomy evaluation recommended by delivery hospital pediatrician.

O:

• Infant: Alert, active, tone normal. Skin without jaundice visible. Mild sunken fontanelle.
• Oral assessment:
  • Functional tongue mobility: elevation restricted (unable to elevate past mid-mouth with mouth wide open); limited lateralization; extension does not reach past the lower gum ridge; cupping absent
  • Anatomical classification: lingual frenulum visible, attached ~3 mm posterior to tongue tip (Coryllos Type II); measured free tongue length ~8 mm, consistent with Kotlow Class II (moderate ankyloglossia)
  • Functional assessment summary: findings consistent with clinically significant ankyloglossia impairing tongue motion during feeding
  • Labial frenulum: Kotlow Class 2 attachment; per the ABM Position Statement on Ankyloglossia (LeFort et al., 2021), upper lip-tie release is not recommended as a breastfeeding intervention. Documented but not the primary focus
  • Palate: high-arched but intact, no cleft
  • Jaw: symmetric, good opening range
• Maternal breast: Left nipple with visible horizontal fissure at base, erythematous, 2 mm depth. Right nipple intact. No erythema, streaking, or mass.
• Feeding observation: Cross-cradle position. Latch appears deep initially but baby slides to shallow position within 60 seconds, audible clicking throughout. Compression visible at unlatch; nipple returns creased and lipstick-shaped. LATCH score: L=1, A=1, T=2, C=0, H=2 (total 6/10).
• Weighted feed: Pre-feed 2902 g, post-feed 2938 g. Transfer: 36 mL over 28 min (both breasts). Per-feed target at 11 days (150 mL/kg/day ÷ 8 feeds): ~54 mL, so transfer deficit is ~18 mL.
• Output last 24h: 4 voids, 1 stool. Stool color transitioning but fewer than expected for day 11.

A: Neonatal feeding difficulty secondary to anterior ankyloglossia (Coryllos Type II, Kotlow Class II) with functional restriction of tongue elevation, extension, and lateralization, resulting in shallow compensatory latch and insufficient milk transfer (36 mL/28 min bilateral vs. ~54 mL target). Weight loss at 9.4% from birth at day 11 with output reduction (4/1 today) approaches the ABM excessive-weight-loss threshold and indicates borderline hydration status. Maternal nipple trauma (left nipple fissure) secondary to infant compression during feeds, likely driven by infant's ankyloglossia.

P:

1. Referral: Pediatric dentist Dr. [name] for frenotomy evaluation, expedited given weight loss trajectory. Visit scheduled within 48 hours.
2. Interim feeding plan:
   • Nipple shield 16 mm, fitted at visit, for left breast only until fissure heals
   • Triple feeding: Breastfeed → pump 15 min bilateral → supplement 20 mL per feed, human milk preferred, formula acceptable. Target 8–10 feeds/24h.
   • Paced bottle feeding technique demonstrated to mother for supplements
3. Nipple care: Saline rinse after feeds, lanolin between feeds, air-dry, no soap.
4. Weight check at pediatrician in 48 hours (04/13/2026) with results communicated to IBCLC.
5. IBCLC follow-up 48 hours post-frenotomy for latch reassessment.
6. Red flags reviewed: fewer than 4 voids/24h, lethargy, worsening jaundice, maternal fever.

Time: Total 60 minutes (50 face-to-face, 10 chart and care coordination). CPT: 99204 (new patient, infant as patient of record, moderate complexity, time-based 45–59 min). ICD-10: Q38.1 (ankyloglossia), primary; P92.5 (neonatal feeding difficulty at breast), secondary. Place of service: 11 (office). Superbill generated: Yes.

Signed: Jane Smith, RN, IBCLC, NPI 1234567890, 04/11/2026 11:17.

Example 3: Follow-up visit, post-frenotomy, weaning from triple feeds

• Patient: [Mother name], 6 weeks postpartum (infant is 4 weeks post-frenotomy, referenced for clinical context; infant is not the patient of record on this claim)
• Date of Service: 04/14/2026
• Place of Service: 12 (home)

S: Follow-up visit #4 for this dyad. Infant now 6 weeks. Post-frenotomy (04/13/2026) recovery uncomplicated; stretches performed for 4 weeks. Mother reports pain resolved by day 5 post-frenotomy. Currently triple feeding but down to 1 supplemental feed of 30 mL formula per day (from 8 supplements at the initial visit). Pumping 4x/day, combined output 120 mL per session. Mother wants to transition to exclusive breastfeeding. No concerns today. Infant weight at pediatrician yesterday: 4.2 kg, gained from 2.9 kg at 11 days (excellent trajectory). Output: 8+ voids, 4+ stools/24h.

O:

• Infant: Alert, thriving, well-hydrated, appropriate for age.
• Oral assessment: Functional tongue mobility fully restored post-frenotomy. Elevation, extension, lateralization, and cupping all within normal limits; free tongue length measured >16 mm (within Kotlow normal range, outside Class I–IV); frenulum healed with no reattachment.
• Maternal breast: Bilateral nipples intact, no fissures, prior left fissure fully healed, no erythema.
• Feeding observation: Cross-cradle then football position. Symmetric deep latch, lip flanging, no clicking. Audible swallows 1:2 suck:swallow ratio, sustained rhythm throughout. 18 min: 11 left, 7 right. LATCH score: L=2, A=2, T=2, C=2, H=2 (total 10/10).
• Weighted feed: Pre-feed 4182 g, post-feed 4252 g. Transfer: 70 mL over 18 min.
• Weight trajectory: 2.9 → 3.4 → 3.8 → 4.2 kg across the four visits; now at 50th percentile for adjusted age.

A: Successful lactation outcome with restored effective milk transfer at breast (infant's resolved neonatal feeding difficulty post-frenotomy documented at 70 mL/18 min, nearly tripled from initial 36 mL/28 min). Maternal supply sufficient for infant needs; nipple trauma fully resolved. Patient ready for discontinuation of supplementation and gradual pump weaning.

P:

1. Discontinue post-feed formula supplementation beginning today. Breastfeed on demand, minimum 8 feeds/24h.
2. Pumping taper:
   • This week: 2 sessions/day (morning and evening)
   • Next week: 1 session/day if weight stable
   • Discontinue when cleared at next pediatrician weight check
3. Weight check at pediatrician in 7 days (04/21/2026).
4. Care plan: Return to IBCLC PRN for any concerns. No routine follow-up scheduled.
5. Red flags reviewed: sudden weight loss, feeding aversion, maternal supply decrease, recurrent nipple pain.

Time: Total 35 minutes (28 face-to-face, 7 chart and care coordination). CPT: 99214 (established patient, moderate complexity, time-based 30–39 min). ICD-10: Z39.2 (routine postpartum follow-up), primary; Z39.1 (encounter for care and examination of lactating mother), secondary for ongoing lactation support. (The infant's resolved P92.5 / Q38.1 history is referenced in the narrative for clinical context but is not coded on this maternal claim. One patient per claim.) Place of service: 12 (home). Superbill generated: Yes.

Signed: Jane Smith, RN, IBCLC, NPI 1234567890, 04/14/2026 10:52.

The eight most common reasons lactation claims get denied

The denials IBCLCs see over and over, with the one-line fix for each.

1. Time not documented on a time-based E/M. If you selected 99204 by time, your note must state total time spent on the date of the encounter. Example: "Total time: 55 minutes (45 minutes face-to-face; 10 minutes chart review and care coordination)." Listing how the time was spent is best practice and helps defend the claim on review; the AMA 2021 rules require total time, not a mandatory split. Missing any time statement is a common denial reason for lactation visits.

2. Code-level inflation not supported by documentation. You billed 99204 (moderate complexity) but your note reads like a brief well-check. If the documented complexity supports 99202, bill 99202. A pattern of upcoding can trigger payer review of your broader claims history.

3. Non-specific ICD-10 when a specific code applies. O92.70 and P92.9 are catch-alls. If the documentation supports O92.4 (hypogalactia) or Q38.1 + P92.5 (tongue tie + neonatal feeding difficulty), use the specific codes. Documented specificity is generally easier to defend on review than a non-specific code.

4. Mismatched patient and diagnosis family. You billed under the mother but coded P92.5 (an infant code). Many payers' automated edits will reject or return the claim when the diagnosis code doesn't match the patient demographics. One patient per claim; O-codes for mom, P-codes for baby.

5. Assessment doesn't establish medical necessity. "Difficulty breastfeeding" doesn't tell the payer why a 60-minute consultation was needed. "Insufficient milk transfer (25 mL bilateral over 22 min) with infant at 8.8% weight loss and not regaining birth weight by day 10 (ABM Protocol #3 trigger), suspected IGT" does.

6. No measurable data in Objective. "Latch improved" is not measurable. A pre/post-feed weight differential is. A LATCH or IBFAT score is. A 24-hour output count is. Notes without measurable data read as counseling, which most payers don't cover at E/M rates.

7. Plan items not linked to assessment findings. You recommended a 16 mm nipple shield but never established a latch problem in your Objective or Assessment. The payer reads the recommendation as unsupported and denies the associated complexity.

8. Superbill missing required fields. The visit was documented perfectly, but the superbill you sent the patient was missing your NPI, your Tax ID, or had an incomplete ICD-10 code. The patient submits, gets denied for reimbursement, and blames you. See Building a Superbill in the billing guide for the complete checklist.

Template to workflow

Having the right template solves the first visit. It doesn't solve the tenth visit of the week, where the friction isn't knowing what to document. It's consistently doing it across visits in different homes on an unreliable cell signal without retyping the same fields each time.

The mechanical work that a template alone doesn't solve:

• Pre-filling the demographic and provider fields on every note and superbill
• Pulling the prior visit's weight into this visit's weight trajectory
• Showing the growth curve across all visits without manual plotting
• Suggesting the ICD-10 code that matches the assessment language you typed
• Generating the superbill as a PDF the moment you select the CPT code
• Syncing the whole thing when you regain signal in the driveway

These are workflow problems, not template problems. A template gives you the shape of the note. A purpose-built charting tool gives you the shape plus the time back. If you're spending more than 10–15 minutes on documentation and billing per visit, the tool is the bottleneck.

NuBloom is what we built for this. Lactation-specific SOAP templates pre-loaded, weighted-feed data plotted across visits automatically, ICD-10 and CPT codes suggested from the visit content, and superbills generated from the chart in one click. Works offline in any home. See how NuBloom compares to other IBCLC tools or our features page.

CPT and ICD-10 codes in this guide were last verified against official sources in April 2026. All example notes are composites; no real patient data is included.

Sources

• AMA CPT E/M Office Visit Guidelines — 2021+ time-based E/M code selection rules
• ICD-10-CM (CMS) — current ICD-10-CM code set and official guidelines
• HRSA Women's Preventive Services Guidelines (2019 cycle, current) — ACA breastfeeding coverage requirements
• HHS HIPAA Security Rule — ePHI safeguards for chart and superbill storage
• Academy of Breastfeeding Medicine Clinical Protocols — landing page for all ABM protocols
• IBLCE Resources — IBCLC professional scope and documentation standards (see Professional Standards / IBLCE Documents)
• LeFort, Y., Evans, A., Livingstone, V., Douglas, P., Dahlquist, N., Donnelly, B., Leeper, K., Harley, E., Lappin, S., & Academy of Breastfeeding Medicine. (2021). "Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads." Breastfeeding Medicine 16(4):278–281. DOI: 10.1089/bfm.2021.29179.ylf. PMID: 33852342.
• ABM Clinical Protocol #11: Guidelines for the Evaluation and Management of Neonatal Ankyloglossia and Its Complications in the Breastfeeding Dyad — ABM protocol PDF (current version hosted by the Academy of Breastfeeding Medicine).
• Kellams, A., Harrel, C., Omage, S., Gregory, C., & Rosen-Carole, C. (2017). "ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017." Breastfeeding Medicine 12(4):188–198. DOI: 10.1089/bfm.2017.29038.ajk. PMID: 28294631.
• Jensen, D., Wallace, S., & Kelsay, P. (1994). "LATCH: A Breastfeeding Charting System and Documentation Tool." JOGNN 23(1):27–32. PMID: 8176525.
• Kotlow, L.A. (1999). "Ankyloglossia (Tongue-Tie): A Diagnostic and Treatment Quandary." Quintessence International 30(4):259–262. PMID: 10635253.
• Kotlow, L.A. (2013). "Diagnosing and Understanding the Maxillary Lip-Tie (Superior Labial, the Maxillary Labial Frenum) as It Relates to Breastfeeding." Journal of Human Lactation 29(4):458–464. DOI: 10.1177/0890334413491325. PMID: 23821655.
• Huggins, K., Petok, E., & Mireles, O. (2000). "Markers of Lactation Insufficiency: A Study of 34 Mothers." In K. Auerbach (Ed.), Current Issues in Clinical Lactation (pp. 25–35). Jones and Bartlett Learning.
• Flaherman, V.J., Schaefer, E.W., Kuzniewicz, M.W., Li, S.X., Walsh, E.M., & Paul, I.M. (2015). "Early Weight Loss Nomograms for Exclusively Breastfed Newborns." Pediatrics 135(1):e16–e23. DOI: 10.1542/peds.2014-1532. Newborn Weight Tool: newbornweight.org.
• Wambach, K. & Spencer, B. (2026). Breastfeeding and Human Lactation, 7th ed. Burlington, MA: Jones & Bartlett Learning.

NuBloom generates lactation-specific SOAP notes and superbills from a single visit workflow. Pre-fills across visits, plots weighted-feed trends, maps ICD-10 to your assessment language, works offline. Try it free.