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Official Description

Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit
Short Descr Ef ped fluid and electrolyte
Coverage Special coverage instructions apply
Pricing Indicator(s) 46 – Supplies And Surgical Dressings - Carrier priced (e.g., not otherwise classified, individual determination, carrier discretion, gap-filled amounts)
MPI A – Not applicable, as HCPCS priced under one methodology
CIM 65-10
BETOS O1C – Enteral and parenteral
TOS Code(s) E – Enteral/parenteral nutrients/supplies
Added Date 1/1/2005
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 0
IOM 100-03, 3, 180.2
OTS Orthotic No
CCS Clinical Classification 223 - Enteral and parenteral nutrition
KX Requirements specified in the medical policy have been met
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
BO Orally administered nutrition, not by feeding tube
GZ Item or service expected to be denied as not reasonable and necessary
GA Waiver of liability statement issued as required by payer policy, individual case
UB Medicaid level of care 11, as defined by each state
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
Date
Action
Notes
2005-01-01 Added Code added 1/1/2005
Code
Description
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