|
B4164 |
 |
Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix
| short | Parenteral 50% dextrose solu |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 1 Line Edit | Clinical: Data |
|
|
|
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B4168 |
|
Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix
| short | Parenteral sol amino acid 3. |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 1 Line Edit | Clinical: Data |
|
|
|
|
B4172 |
|
Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix
| short | Parenteral sol amino acid 5. |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 1 Line Edit | Clinical: CMS Workgroup |
|
|
|
|
B4176 |
|
Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix
| short | Parenteral sol amino acid 7- |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 1 Line Edit | Clinical: CMS Workgroup |
|
|
|
|
B4178 |
|
Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - home mix
| short | Parenteral sol amino acid > |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 1 Line Edit | Clinical: Data |
|
|
|
|
B4180 |
|
Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix
| short | Parenteral sol carb > 50% |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Clinical: Data |
|
|
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|
B4185 |
|
Parenteral nutrition solution, not otherwise specified, 10 grams lipids
| short | Pn soln nos 10 grams lipids |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
B4187 |
|
Omegaven, 10 grams lipids
| short | Omegaven, 10 grams lipids |
|
|
|
B4189 |
|
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix
| short | Parenteral sol amino acid & |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Published Contractor Policy |
|
|
|
|
B4193 |
|
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix
| short | Parenteral sol 52-73 gm prot |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Published Contractor Policy |
|
|
|
|
B4197 |
|
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 | Parenteral sol 74-100 gm pro |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Published Contractor Policy |
|
|
|
|
B4199 |
|
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix
| short | Parenteral sol > 100gm prote |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Published Contractor Policy |
|
|
|
|
B4216 |
|
Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes), home mix, per day
| short | Parenteral nutrition additiv |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Code Descriptor / CPT Instruction |
|
|
|
|
B4220 |
|
Parenteral nutrition supply kit; premix, per day
| short | Parenteral supply kit premix |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Code Descriptor / CPT Instruction |
|
|
|
|
B4222 |
|
Parenteral nutrition supply kit; home mix, per day
| short | Parenteral supply kit homemi |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Code Descriptor / CPT Instruction |
|
|
|
|
B4224 |
|
Parenteral nutrition administration kit, per day
| short | Parenteral administration ki |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 1.0 | 1 Line Edit | Code Descriptor / CPT Instruction |
|
|
|
|
B5000 |
|
Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix
| short | Parenteral sol renal-amirosy |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
B5100 |
|
Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix
| short | Parenteral solution hepatic |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
B5200 |
|
Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix
| short | Parenteral sol hepatic fream |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|