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Official Description

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
Short Descr Ef ped complete soy based
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 Not applicable/unspecified.
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
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
BO Orally administered nutrition, not by feeding tube
Date
Action
Notes
2005-01-01 Added Code added 1/1/2005
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Description
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