| HCPCS Code: |
B4158 |
| Long Description: |
Enteral formula, for pediatrics, nutritionally complete 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 Description: |
Ef ped complete intact nut |
| Pricing Indicator 1: |
46 (Carrier priced (e.g., not otherwise classified, individual determination, carrier discretion, gap-filled amounts)) |
| Multiple Pricing Code: |
A (Not applicable as HCPCS priced under one methodology) |
| Coverage Issues Manual 1: |
65-10 |
| Statute Number: |
|
| Coverage Code: |
D (Special coverage instructions apply) |
| ASC Payment Group Code: |
|
| Processing Note Number: |
|
| Berenson-Eggers Type of Service (BETOS) Code: |
O1C (Enteral and parenteral) |
| Type of Service Code 1: |
E (Enteral/parenteral nutrients/supplies (effective 04/95)) |
| Anesthesia Base Unit Quality: |
0 |
| Code Added: |
01-01-2005 |
| Action Effective Date: |
01-01-2005 |
| Action Code: |
N (No maintenance for this code) |
