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Official Description

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit
Short Descr Ef incomplete/modular
Coverage Special coverage instructions apply
Pricing Indicator(s) 39 – Supplies And Surgical Dressings - Parenteral and Enteral Nutrition
MPI A – Not applicable, as HCPCS priced under one methodology
CIM 65-10
MCM 2130
BETOS O1C – Enteral and parenteral
TOS Code(s) E – Enteral/parenteral nutrients/supplies
Added Date 1/1/1986
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE Not applicable/unspecified.
IOM 100-02, 15, 120
OTS Orthotic No
CCS Clinical Classification 223 - Enteral and parenteral nutrition
BO Orally administered nutrition, not by feeding tube
KX Requirements specified in the medical policy have been met
GA Waiver of liability statement issued as required by payer policy, individual case
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
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
GZ Item or service expected to be denied as not reasonable and necessary
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
EY No physician or other licensed health care provider order for this item or service
GW Service not related to the hospice patient's terminal condition
GX Notice of liability issued, voluntary under payer policy
CR Catastrophe/disaster related
SJ Third or more concurrently administered infusion therapy
CG Policy criteria applied
JW Drug amount discarded/not administered to any patient
Date
Action
Notes
1986-01-01 Added Code added 1/1/1986
Code
Description
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