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Official Description

Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix
Short Descr Parenteral sol 74-100 gm pro
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 1/1/1988
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 1
IOM 100-02, 15, 120
OTS Orthotic No
CCS Clinical Classification 223 - Enteral and parenteral nutrition
KX Requirements specified in the medical policy have been met
GZ Item or service expected to be denied as not reasonable and necessary
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
GA Waiver of liability statement issued as required by payer policy, individual case
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
GW Service not related to the hospice patient's terminal condition
JB Administered subcutaneously
GX Notice of liability issued, voluntary under payer policy
EY No physician or other licensed health care provider order for this item or service
JK One month supply or less of drug or biological
JW Drug amount discarded/not administered to any patient
KZ New coverage not implemented by managed care
SH Second concurrently administered infusion therapy
Date
Action
Notes
1988-01-01 Added Code added 1/1/1988
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