016-06-08 Ark. Code R. § 24
Nutritional Formulae For Child Health Services (EPSDT) Beneficiaries Ages 0-4 Only | ||||||
The codes and modifiers below should be used to bill for services provided for dates of service 06/01/07 through 05/31/08 if that service has not been billed to date. For any services provided for dates of service 06/01/08 or after, refer to Update Transmittal # 117 to the Prosthetics Manual for codes to bill. | ||||||
Procedure Code | M1 | M2 | M3 | M4 | Products | Age Range |
B4149 | EP | U7 | UA | Compleat | 0-4 yrs. | |
B4150 | EP | U7 | UA | Boost, Boost w Benefiber & FOS, Carnation Instant Breakfast Lactose Free, Ensure, Ensure Fiber w FOS, Ensure High Protein, Ensure HN, Ensure Powder, Fibersource, Fibersource HN, Fortison, Intraolite, Isocal, Isocal HN, IsoSource, IsoSource HN, Jevity 1.0 CAL, Nutrapack, Nutren 1.0, Nutren 1.0 w Fiber, Osmolite, Osmolite 1.0 CAL, Osmolite HN, Portagen, Probalance, Promote, Promote w Fiber, Ultracal | 0-4 yrs. | |
B4150 | EP | U1 | U7 | UA | Boost Pudding, Ensure Pudding | 0-4 yrs. |
B4152 | EP | U7 | UA | Boost Plus, Carnation Instant Breakfast Lactose Free Plus, Comply, Ensure Plus, Ensure Plus HN, Novasource 2.0, Nutren 1.5, Nutren 2.0, Osmolite 1.5 CAL, Scandishake, Two-Cal HN | 0-4 yrs. | |
B4153 | EP | U7 | UA | Alitraq, Criticare HN, Isotein HN, Peptamen, Peptamen 1.5, Peptamen VHP, Peptamen w Prebio 1, Perative, Tolerex, Vital HN, Vivonex Plus, Vivonex TEN, | 0-4 yrs. | |
B4154 | EP | U7 | UA | Advera, AminAid, Choice DM, Boost Diabetic, Forta Drink, Glucerna, Glytrol, Hepatic Aid, Impact, Impact w Fiber, IsoSource VHN, Ketocal, Lipisorb, Lofenalac, Nepro, Nepro with Carb Steady, NutriHep, Protain XL, Pulmocare, Resource Diabetic, Respalor, Similac 60/40, Suplena, Suplena with Carb Steady, Traumacal, Trumaid Powder | 0-4 yrs. | |
B4155 | EP | U7 | UA | Casec Powder, Fructose Powder, MCT Oil, Moducal, Polycose Liquid, Procel Protein Power, Provimin, Sumacal | 0-4 yrs. | |
B4155 | EP | U1 | U7 | UA | Polycose Powder, Dextrose, Scandical | 0-4 yrs. |
B4155 | EP | U2 | U7 | UA | Microlipids | 0-4 yrs. |
B4155 | EP | U3 | U7 | UA | Product 80056, PKU 1, 2 and 3, RCF, Try 1 and 2 | 0-4 yrs. |
B4158 | EP | U7 | UA | Enfamil, Enfamil AR Lipil, Enfamil Lactofree, Enfamil Lactofree Lipil, Enfamil Lipil Low Iron, Enfamil Lipil w Iron, Enfamil Next Step Lipil, Nutren Jr., Nutren Jr. w Fiber, Resource for Kids, Resource Just for Kids w Fiber | 0-4 yrs. | |
B4159 | EP | U7 | UA | Enfamil Next Step, Prosobee Lipil, Enfamil Prosobee Lipil, Isomil, Isomil Advance Soy w Iron, Prosobee | 0-4 yrs. | |
B4160 | EP | U7 | UA | Enfamil Enfacare Lipil Powder, Kindercal, Kindercal w Fiber, Pediasure, Pediasure w Fiber | 0-4 yrs. | |
B4160 | EP | U1 | U7 | UA | Enfamil Premature Lipil 24 CAL Low Iron, Enfamil Premature Lipil 24 CAL w Iron, Similac Neosure, Similac Neosure Advance, Special Care Advance 20, Special Care Advance 20 w Iron, Special Care Advance 24, Special Care Advance 24 w Iron | 0-4 yrs. |
B4161 | EP | U7 | UA | Alimentum, EleCare, Enfamil Nutramigen Lipil, Enfamil Pregestimil, Neocate Infant Formula, Neocate Jr., Neocate One + (Pediatric E028) Liquid, Neocate One + Powder, Nutramigen, Peptamen Jr. Pregestimil, Similac Alimentum Advance w Iron, Vivonex Pediatric | 0-4 yrs. | |
B4162 | EP | U7 | UA | Calcilo XD, Cyclinex-1, Cyclinex-2, Hominex-1, Hominex-2, I-Valex-1, I-Valex-2, Ketonex-1, Ketonex-2, Low Phe Try Diet Powder, Maxamaid MSUD, Maxamaid XLYS Try, Maxamaid XP, Maxamaid Xphen Try, Maxamum MSUD, Maxamum XP, MSUD Analog, MSUD 1 and 2, Periflex, Periflex Advanced, Periflex Infant, Periflex Junior, Phenex-1, Phenex-2, Phenyl Free 1, Phenyl Free 2, Propimex-1, Propimex-2, XP Analog, XLys, XTrp Maxamaid, Xphe Maxamaid, XPhe XTyr Maxamaid, Xphe Maxamum, Xphe, XTyr Analog, Xphen, Try Analog | 0-4 yrs. | |
B4162 | EP | U1 | U7 | UA | XMTVI Maxamaid | 0-4 yrs. |
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Roy Jeffus, Director
016.06.08 Ark. Code R. § 024