Enteral Nutrients - Product Classification List
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1 Enteral Nutrients - Product Classification List The following product list identifies the correct HCPCS code to be used for enteral nutrients. This list is not all-inclusive. Questions concerning the coding of items not on this list should be directed to the SADMERC. For codes,,, and, only products on this list may be billed using these codes. If a manufacturer or supplier thinks that another product meets the definition of one of these codes, they should contact the SADMERC for a coding determination. The SADMERC must issue a written determination approving the use of codes - before one of these codes may be used for a new product or a product not on the list. The appearance of a product on this list does not guarantee coverage. This list is not a formal part of the medical policy. PRODUCT NAME: Accupep HPF Accupepha Acerflex Advera Alitraq AminAid AMTF AMTF Diabetic AMTF High Cal 2.0 AMTF High Protein AMTF Pediatric AMTF Pulmonary AMTF Renal AMTF Renal 2.0 AMTF Trauma Analog Formulas XP Analog MSUD Analog XPHEN,TYR Analog XPTM Analog XMTVI Analog XMET Analog XLYS, TRY Analog XLEU Analog Boost Boost High Protein Boost Plus Boost with Fiber Casec Choice DM HCPCS CODE:
2 Citrotein Compleat-B Compleat-B Modified Complete Pediatric Comply Criticare HN Crucial Deliver 2.0 DiabetiSource Egg/Pro Powder EleCare Elementra Enfamil Ensure Ensure with Fiber Ensure HN Ensure HP Ensure Plus Ensure Plus HN Ensure Powder Entera Entera Isotonic Entera Isotonic Fiber Entera OPD Enteralife HN Enteralife HN-2 Enteralife HN Fiber Entrition 1.5 Entrition HN Essential ProPlus Essential Protein Fiber 7 Fiberlan Fibersource Fibersource HN Fibrad Fortison Fulfil Glucerna Gluco-Pro Glutasorb Glytrol Hearty Balanace Hepatic-Aid Hi ProCal Immun-Aid Immunocal Impact Impact 1.5 Impact with Fiber
3 Introlite Isocal Isocal HN Isocal HN Plus Isocal II Isofiber Isolan Isomil Isosource IsoSource 1.5 Isosource HN Isosource VHN Isotein Isotera Isotonic Jevity Jevity Plus Jevity RTH Kindercal L-Emental L-Emental Hepatic L-Emental Pediatric L-Emental Plus Lipisorb Lonalac Magnacal Magnacal Renal Maxamaid Formulas XP Maxamaid MSUD Maxamaid XPHEN,TYR Maxamaid XMTVI Maxamaid XMET Maxamaid XLYS, TRY Maxamaid XLEU Maxamaid Maxamum Formulas XP Maxamum MSUD Maxamum XMTVI Maxamum XMET Maxamum XLYS, TRY Maxamum XLEU Maxamum MCT Oil Med Pass 2.0 Med Plus 2.0 Meritene Microlipid Moducal Naturite Naturite Plus Neocate Infant Formula
4 Neocate One + Liquid Neocate One + Powder Nepro Newtrition (Flavors) Newtrition 1.5 Newtrition HN Newtrition Isofiber Newtrition Isotonic Nitrolan (Nitro-Pro) Nitro-Pro (Nitrolan) Novasource 2.0 NovaSource Pulmonary Novasource Renal NuBasics NuBasics 2.0 Complete NuBasics Plus NuBasics VHP NuBasics with Fiber Nutramigen Nutrapak Nutren 1.0 Nutren 1.0 with Fiber Nutren 1.5 Nutren 2.0 Nutren Junior Nutren Junior with Fiber Nutren VHP NutriAssist 1.5 Nutri-Drink Nutri-Drink Plus Nutriflavor NutriHep Nutrilan Nutrition Nutrition Plus Nutrivent Optimental Original N.O. Smoothee Osmolite Osmolite HN Osmolite HN Plus Oxepa Pediasure Pedisure with Fiber Peptamen Peptamen 1.5 Peptamen VHP Peptamin Junior Peptical Perative
5 Periflex Phlexy-10 Bars Phlexy-10 Capsules Phlexy-10 Drink Mix Phlexy-Vits Polycose Portagen Pre-Attain Precision HN Precision Isotera Precision LR Powder Pregestimil ProBalance Procare ProCell Protein Promix ProMod Promote Promote with Fiber Propac Plus Pro-Peptide Pro-Peptide for Kids Pro-Petide VHN ProSobee ProSource Protein Protain XL Provide Pulmocare RCF (Ross Carb Free) Reabilan Reabilan HN Renalcal Replete Replete with Fiber Resource ReSource Benefiber Resource Diabetic Resource for Kids ReSource Instant Protein Powder ReSource Just For Kids with Fiber Resource Plus Respalor Restore-X SandoSource Peptide Similac with Iron SLD SoyPro Stresstein
6 Subdue Sumacal Suplena (Replena) Susta II Sustacal Sustacal Basic Sustacal Fiber Sustacal HC Sustacal Plus Sysco Classic Lactose Free ProCal Tolerex Traumacal Travasorb Hepatic Travasorb HN Travasorb MCT Travasorb Renal Travasorb STD Powder Twocal HN Ultracal Ultracal HN Plus Ultralan Vital HN Vitaneed Vivonex HN Vivonex Pediatric Vivonex Plus Vivonex STD Powder Vivonex T.E.N.
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