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ENTERAL PRODUCT CLASSIFICATION LIST The following list of enteral formulae is provided as a guideline for prescribers and dispensers: This is not an all-inclusive list, but is meant to assist providers in prescribing and determining the correct item code for billing. For products not listed below, dispensers are to use their judgment in selecting the appropriate product coding classification based upon the prescriber's order, general categorical descriptions, and Medicaid coverage criteria (see DME Policy Guidelines at http://www.emedny.org/ProviderManuals/DME/index.html for coverage criteria). Powdered, liquid, fiber-added, calcium-added and high protein forms of the same formula are billed under the same code. Special metabolic formulas categorized under B4157 should be billed using B4162 if provided to a pediatric patient. Standard formulas categorized as B4150 should be billed using appropriate code if provided to a pediatric patient. Bolded Italicized products are subject to coverage by the Women, Infants and Children (WIC) program. WIC must be accessed prior to requests for Medicaid reimbursement. PRODUCT 80056 Acerflex Accupepha Advantage 10+ Advantage 60+ Advera Albumax Alimentum Alitraq Powder Amin-Aid Powder Analog Formulas Apple Fiber Aquasol E Arginine Amino Acid AMTF Revised 8/18/09 CODE B4155 B4162 B4153 B4150 B4150 B4154 B4155 B4161 B4153 B4154 B4162 B9998 B9998 B4155 B4150 PRODUCT AMTF Diabetic AMTF High Cal 2.0 AMTF Pediatric AMTF Renal AMTF Renal 2.0 AMTF Trauma Attain BCAD-1 BCAD-2 Bio-care Boost Boost Diabetic Boost Plus Boost Pudding Bright Beginnings Soy CODE B4154 B4152 B4158 B4154 B4154 B4154 B4150 B4162 B4157 B4150 B4150 B4154 B4152 B4150 B4160 Page 1 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT Calcilo XD Calories Plus CIB Lactose Free CIB Lactose Free Plus CIB Lactose Free VHC Casec Powder Choice DM Citrulline 1000 Amino Acid Compleat Compleat Pediatric Complete Amino Acid Comply Complex Essential MSD Complex MSUD AA Blend Complex MSUD Drink Mix Criticare-HN Crucial Cyclinex-1 Cyclinex-2 Cystine Amino Acid Deliver 2.0 Diabetisource AC Duocal EAA Egg/Pro EleCare Revised 8/18/09 CODE B4162 B4152 B4150 B4152 B4152 B4155 B4154 B4155 B4149 B4149 B4155 B4152 B4157 B4155 B4155 B4153 B4153 B4162 B4157 B4155 B4152 B4154 B4155 B4155 B4155 B4161 PRODUCT Elemental 028 Extra Enfamil AR Enriched Antioxidant Formula Ensure Ensure Light Ensure Plus Ensure Pudding Enteralife HN Enteralife HN-2 Entrition HN Epulor Essential Amino Acid Essential Protein Plus Essential Protein FAA Fibersource Fibersource HN Flavonex Forta Drink or Shake Fortison GA GA gel Gevral Protein Glucerna Select/Shake Gluco-Pro Glutamine-Plain CODE B4154 B4158 B4155 B4150 B4150 B4152 B4150 B4150 B4150 B4150 B4155 B4155 B4155 B4155 B4153 B4150 B4150 B9998 B4150 B4150 B4157 B4155 B4155 B4154 B4154 B4155 Page 2 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT Glutamine Rapid Release Glutapak-10 Glutarex-1 Glutarex-2 Glutasolve Glutasorb Glytrol Good Start Soy Good Start 2 Soy HCU Cooler HCU Express HCU Gel HCY 1 HCY 2 Hepatic-Aid Hominex-1 Hominex-2 HOM 1 HOM 2 HPF Plus Immu-life Immun-Aid Immune System Booster Immunocal Imu-Plus Impact Revised 8/18/09 CODE B4155 B4155 B4162 B4157 B4155 B4153 B4154 B4159 B4159 B4155 B4155 B4155 B4162 B4157 B4154 B4162 B4157 B4155 B4155 B4155 B4155 B4154 B4155 B4155 B4155 B4154 PRODUCT Impact 1.5 Impact Glutamine Impact Recover IntensiCal Introlite Isocal Isocal HN Plus Isocal-HN Isocal II Isoleucine Amino Acid Isoleucine 1000 Amino Acid Isomil Isosource Isosource 1.5 Isosource VHN Isosource-HN I-Valex-1 I-Valex-2 Jevity 1 Cal Jevity 1.2 Cal Jevity 1.5 Cal Juven K-PAX (tube feedings only) KetoCal Ketonex 1 Ketonex 2 CODE B4154 B4153 B4154 B4153 B4150 B4150 B4150 B4150 B4150 B4155 B4155 B4159 B4150 B4152 B4154 B4150 B4162 B4157 B4150 B4150 B4152 B4155 B4155 B4154 B4162 B4157 Page 3 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT Kindercal LactAid tablets Lactofree L-Emental L-Emental AA Glutamine L-Emental AA Arginine L-Emental Pediatric L-Emental Hepatic Leucine Lipisorb Powder Lipistart Lipomul Lofenelac Lonalac Lophlex Lorenzo Oil LMD LPS 15/30 Magnacal Renal Maximaid formulas Maximum formulas MCT Oil MCT Procal Microlipid Moducal Modulen IBD Revised 8/18/09 CODE B4160 B9998 B4158 B4161 B4155 B4155 B4161 B4154 B4155 B4154 B4158 B4155 B4154 B4150 B4155 B4154 B4157 B4155 B4154 B4162 B4157 B4155 B4162 B4155 B4155 B4154 PRODUCT Monogen MMA/PA Gel MMA/PA Express MSUD Diet MSUD Express MSUD Gel MSUD-1 MSUD-2 Naturite Naturite Plus Neocate Nepro Nestle Flavor Pkts Neutra-Phos Nitrolan NovaSource 2.0 NovaSource Pulmonary Novasource Renal Nutri-Drink Nutramigen Nutramigen AA Nutra Pro Nutraplete Nutrassist-1.5 Nutren Junior Nutren-1 CODE B4155 B4155 B4155 B4162 B4155 B4155 B4155 B4155 B4150 B4152 B4161 B4154 B9998 B9998 B4150 B4152 B4154 B4154 B4150 B4161 B4161 B4154 B4155 B4152 B4160 B4150 Page 4 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT Nutren-1.5 Nutren-2 Nutren Pulmonary Nutren Renal Nutrifocus NutriHeal Nutrihep NutriRenal NutriVent NutriVir NutriVir NSA Optimental OA 1 OA 2 OS 1 OS 2 Osmolite Osmolite 1.2 Osmolite 1.5 Pediatric E028 Pediasure Pepdite One + Peptamen Peptamen 1.5 Diet Peptamen Jr Peptamen VHP Revised 8/18/09 CODE B4152 B4152 B4154 B4154 B4154 B4150 B4154 B4154 B4154 B4155 B4155 B4153 B4162 B4157 B4155 B4155 B4150 B4150 B4152 B4161 B4160 B4161 B4153 B4153 B4161 B4153 PRODUCT Peptinex DT Peptinex Pediatric DT Peptical Perative Periflex PFD-1 PFD-2 Phenex 1 Phenex 2 PhenylAde Amino Acid PhenylAde Drink Mix PhenylAde Essential PhenylAde 40 PhenylAde 60 PhenylAde MTE Phenylalalanine AA Phenylene Phenylene 75 Phenyl-Free 1 Phenyl-Free 2 Phenylfree 2HP Phlexy-10 Pivot 1.5 PKU1 PKU2 PKU3 CODE B4153 B4161 B4153 B4153 B4162 B4155 B4155 B4162 B4157 B4155 B4157 B4157 B4157 B4155 B4155 B4155 B4157 B4155 B4162 B4157 B4157 B4155 B4154 B4155 B4155 B4155 Page 5 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT PKU Cooler PKU Express PKU Gel Polycose Portagen Pregestimil ProBalance ProCell Product 3200AB Product 3232A Product 80056 Profiber Promix ProMod Promote Propac Pro-Peptide Pro-Peptide for Kids Pro-Peptide VHN Pro-Phree Propimex 1 Propimex 2 Prosobee Pro-Stat 64 Pro-Stat 101 Pro-Stat 121 Revised 8/18/09 CODE B4155 B4162 B4162 B4155 B4150 B4161 B4150 B4155 B4162 B4161 B4155 B4150 B4155 B4155 B4150 B4150 B4153 B4161 B4153 B4155 B4162 B4157 B4159 B4155 B4155 B4155 PRODUCT Pro-Stat 150 ProSource ProSure Protain XL Proteinex ProViMin Pulmocare ReGain Plus Re-Gen Re-Gen Sugar-free Renalcal ReNeph Replete Resource Resource Arginaid Resource Diabetic Resource for Kids Resource Glutasolve ReSource Instant Protein Resource Plus Resource Support Resource 2.0 Respalor Restore-X Resurgex Resurgex Plus CODE B4155 B4155 B4154 B4154 B4155 B4155 B4154 B4154 B4154 B4154 B4154 B4154 B4150 B4150 B4155 B4154 B4160 B4155 B4155 B4152 B4152 B4152 B4154 B4155 B4155 B4152 Page 6 of 8 ENTERAL PRODUCT CLASSIFICATION LIST PRODUCT Ross Carbohydrate Free Scandi Shake Similac PM 60/40 SoyPro Subdue Subdue Plus Sumacal Suplena Sustacal Sustacal Pudding Sustagen Sympt-X Glutamine Tarvil (requires prior approval) Tolerex Traumacal Traum-Aid HBC TwoCal-HN TYR 1 TYR 2 TYR Cooler TYR Express TYR gel Tyrosine AA Tyrex-1 Revised 8/18/09 CODE B4155 B4152 B4154 B4155 B4153 B4153 B4155 B4154 B4150 B4150 B4150 B4155 B4154 B4153 B4154 B4154 B4152 B4155 B4155 B4155 B4155 B4162 B4155 B4162 PRODUCT Tyrex-2 Tyrosine TYROS 2 UCD-1 UCD-2 Ultracal Ultracal HN Plus Ultracare Kids Valine Amino Acid Valine 1000 Amino Acid Vari-Flavors Vitaflo Flavor Packets Vital Jr Vital-HN Vitaneed Vivonex flavor pkts Vivonex Pediatric Vivonex Plus Vivonex RTF Vivonex-TEN WND 1 WND 2 CODE B4157 B4155 B4157 B4155 B4155 B4150 B4150 B4154 B4155 B4155 B9998 B9998 B4161 B4153 B4149 B9998 B4161 B4153 B4153 B4153 B4162 B4157 Page 7 of 8 ENTERAL PRODUCT CLASSIFICATION LIST Use code B4100 #Food thickener, administered orally, per ounce for products such as Thick-It, Thick-n-Easy and Thicken-Up. A Dispensing Validation System (DVS) authorization number is required, obtained through the Medicaid Eligibility Verification System (MEVS). (For questions on obtaining a DVS authorization through MEVS, call Computer Science Corporation at 1-800-343-9000.) Enteral formula requires voice interactive telephone prior authorization (1-866-211-1736). Only the prescriber can initiate an authorization. Dispensers are responsible for validating that the prescriber’s authorization matches the fiscal order and for correctly coding the product through the authorization system. The Prescriber Worksheet and Dispenser Worksheet are available by clicking on your specific Provider Manual link at http://www.emedny.org/ProviderManuals/index.html, then clicking the Provider Communications link, then on the worksheet link. Paper prior approval is required for code B9998, when the prescriber orders greater than 2000 calories per day for any combination of formula(s), or if over 1000 calories per day for code B4155 is needed. Questions may be referred to the Division of Provider Relations and Utilization Management at 1-800-342-3005. Revised 8/18/09 Page 8 of 8
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