MEDICALLY NECESSARY
THE FOLLOWING CODES ARE USED TO REPRESENT ENTERAL SUPPLIES AND DME:
B4034 Enteral Feeding Supply Kit; Syringe fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape.
B4035 Enteral Feeding Supply Kit; Pump fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4036 Enteral Feeding Supply Kit; gravity fed, per day, includes, but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4081 Nasogastric tubing with stylet
B4082 Nasogastric tubing without stylet
B4083 Stomach tube Levine type
B4087 Gastrostomy/jejunostomy tube, standard, any material, any type, each
B4088 Gastrostomy/jejunostomy tube, low-profile, any material, any type, each
B4105 In-line cartridge containing digestive enzyme(s) for enteral feeding, each
B4148 Enteral feeding supply kit; elastomeric control fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B9002 Enteral nutrition infusion pump, any type
B9998 NOC for enteral supplies
E0776 IV pole
THE FOLLOWING CODES ARE USED TO REPRESENT NUTRITIONAL FORMULAS AND ENTERAL NUTRITION:
B4149 Enteral formula, blendarized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit.
B4150 Enteral formula, nutritionally complete with intact nutrients, included proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit.
B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 KCAL/ML) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral tube, 100 calories= 1 unit.
B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral tube, 100 calories= 1 unit.
B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit.
B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (eg, glucose polymers, proteins/amino acids (eg, glutamine, arginine), fat, (eg, medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories= 1 unit.
B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit.
B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4161 Enteral formula, for pediatrics, hydrolyzed amino acids and peptide chain proteins, includes, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit.
THE FOLLOWING CODES ARE USED TO REPRESENT MEDICAL FOODS FOR INBORN ERRORS OF METABOLISM ADMINISTERED ORALLY OR THROUGH A TUBE:
B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.
S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
S9434 Modified solid food supplements for inborn errors of metabolism
S9435 Medical foods for inborn errors of metabolism
NOT COVERED
B4100 Food thickener, administered orally, per ounce
B4102 Enteral formula, for adults, used to replace fluids and electrolytes (eg, clear liquids), 500 ml= 1 unit
B4103 Enteral formula for pediatrics, used to replace fluids and electrolytes (eg, clear liquids), 500 ml= 1 unit
B4104 Additive for enteral formula (eg, fiber)
S9432 Medical foods for non-inborn errors of metabolism
THE FOLLOWING CODE IS NOT COVERED EXCEPT FOR MEMBERS ENROLLED IN NJ PRODUCTS SUBJECT TO THE NJ MANDATE, OR WHO HAVE A BENEFIT FOR THIS SERVICE:
T2101 Human breast milk processing, storage and distribution only