Enteral Nutrition Documentation Page 2
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3DRUG DESCRIPTION
HCPCS CODE
DRUG DESCRIPTION
HCPCS CODE
FORMULA ALIMENTUM ADV BTL 32 OZ
B4161
FORMULA NUTREN 1 VAN 1 CAL/ML
B4150
FORMULA ALIMENTUM POWER
B4161
FORMULA NUTREN 1.0 W/FIBER
B4150
FORMULA BENEPROTEIN 8 OZ PWD
B4155
FORMULA NUTREN 1.5 VAN 1.5 CAL/
B4152
FORMULA BOOST CHOCOLATE
B4150
FORMULA NUTREN 2 VAN 2 CAL/ML
B4152
FORMULA BOOST HI PROTEIN VANIL
B4150
FORMULA NUTREN JR W/FIBER VAN
B4160
FORMULA BOOST KID ESS 1.5 FBR
B4160
FORMULA NUTREN JR. VANILLA
B4160
FORMULA BOOST KID ESS 1.5 VAN
B4160
FORMULA OPTIMENTAL VANILLA 8 OZ
B4153
FORMULA BOOST PLUS CHOCOLATE
B4152
FORMULA OSMOLITE 1.5 CAL 1L RTH
B4152
FORMULA BOOST PLUS VANILLA 237
B4152
FORMULA OSMOLITE 1.5 CAL 240ML
B4152
FORMULA BOOST VANILLA
B4150
FORMULA OSMOLITE HN 1.06 CAL/ML
B4150
FORMULA BOOST W/FIBER VANILLA
B4150
FORMULA OSMOLITE HN RTH 1000 ML
B4150
FORMULA BRIGHT BEGINNINGS SOY
B4160
FORMULA OXEPA VANILLA 8 OZ
B4154
FORMULA CARN G/START SUPR DHA
B4158
FORMULA PEDIALYTE 32 OZ CHLD 12
B4103
FORMULA CARNA G/START SUPR PWD
B4158
FORMULA PEDIASURE BANANA CREAM
B4160
FORMULA CARNATION LF VANIL VHC
B4152
FORMULA PEDIASURE CHOCOLATE
B4160
FORMULA CERALYTE 90 LEMON 50
B4103
FORMULA PEDIASURE STRAWBERRY 8
B4160
FORMULA COMPLEAT 1.07 CAL/ML
B4149
FORMULA PEDIASURE VAN 8 OZ 1
B4160
FORMULA COMPLEAT PED 1 CAL/ML
B4149
FORMULA PEDIASURE W/FIBER VAN
B4160
FORMULA DIABETISOURCE AC
B4154
FORMULA PEDIATRIC EO28 GRAPE
B4161
FORMULA DUOCAL UNFLVD POWDER
B4155
FORMULA PEDIATRIC E028 ORG/PIN
B4161
FORMULA ELECARE POWDER 14.1 OZ
B4161
FORMULA PEDIATRIC 3028 TROPICA
B4161
FORMULA ELECARE VAN PWD 14.1
B4161
FORMULA PEPDITE JR UNFLV PKT
B4161
FORMULA ENF LF W/LIPIL 13 OZ
B4158
FORMULA PEPTAMEN 1.5 UNFLVD
B4153
FORMULA ENFACARE LIPIL 14 OZ PW
B4160
FORMULA PEPTAMEN AF UNFLAV 250
B4153
FORMULA ENFAMIL AR W/LIPIL PWD
B4158
FORMULA PEPTAMEN JR PREBIO VAN
B4161
FORMULA ENFAMIL GENTLEASE PWD
B4158
FORMULA PEPTAMEN JR UNFLAV 1
B4161
FORMULA ENFAMIL LIPIL W/FE PWD
B4158
FORMULA PEPTAMEN JR VAN 1 CAL
B4161
FORMULA ENSURE CHOC 1.06 CAL/ML
B4150
FORMULA PEPTAMEN JR W/FIBER VA
B4161
FORMULA ENSURE PLUS CHOC
B4152
FORMULA PEPTAMEN UNFLV 250 ML
B4153
FORMULA ENSURE PLUS
B4152
FORMULA PEPTAMEN VANILLA
B4153
STRAWBERRY
FORMULA ENSURE PLUS VAN 8 OZ 50
B4152
FORMULA PEPTAMEN W/PREBIO VANI
B4153
FORMULA ENSURE STRAWBERRY 1.06
B4150
FORMULA PEPTINEX 1.5 VANILLA
B4153
FORMULA ENSURE VAN 1.06 CAL/ML
B4150
FORMULA PEPTINEX DT PED 250 ML
B4161
FORMULA ENSURE W/FIBER VAN 1
B4150
FORMULA PEPTINEX DT PED/FIBER
B4161
FORMULA FIBERSOURCE HN 250ML
B4150
FORMULA PHENEX 2 PWD (>12)
S9435
FORMULA GLUCERNA 8 OZ 1 CAL/ML
B4154
FORMULA PHENEX 2 VAN PWD (>12)
S9435
FORMULA GLYTROL DIAB VANILLA
B4154
FORMULA POLYCOSE POWDER 746 2.
B4155
FORMULA GOOD ST 2 S/SOY 24 OZ
B4159
FORMULA PORTAGEN PWD 1 LB (>12)
B4150
FORMULA GOOD ST 2 SUPR SOY PWD
B4159
FORMULA PORTAGEN PWD 1 LB <=12
B4158
FORMULA GOOD START NATURAL CUL
B4158
FORMULA PREGESTIMIL PWDR 1 LB 1
B4161
FORMULA IMPACT W/FIBER
B4154
FORMULA PRO-PHREE PWD 350 GM
B4155
FORMULA ISOMIL ADV W/FE LF PWD
B4159
FORMULA PROMOTE 8 OZ 1 CAL/ML
B4150
FORMULA ISOMIL W/FE PWD 12.9 OZ
B4159
FORMULA PROMOTE W/FIBER 8 OZ 1.
B4150
FORMULA ISOSOURCE 1.5 CAL
B4152
FORMULA PROPIMEX 2 PWD (>12)
S9435
FORMULA ISOSOURCE HN VANILLA
B4150
FORMULA PROSOBEE LIPIL PWD
B4159
FORMULA JEVITY 1 RTH 1000ML
B4150
FORMULA PULMOCARE VAN 1.5 CAL/M
B4154
FORMULA JEVITY 1.2 1500 ML BTL
B4150
FORMULA RCF LOW IRON SOY 81 CAL
B4155
FORMULA JEVITY 1.2 RTH 1000 ML
B4150
FORMULA RENALCAL 2 CAL/ML
B4154
FORMULA JEVITY 1.5 RTH 1000 ML
B4152
FORMULA REPLETE W/FIBER VAN
B4150
FORMULA JEVITY 8 OZ 1 CAL/ML
B4150
FORMULA RESOURCE GLUTASOLVE
B4155
FORMULA JEVITY 8 OZ 1.2 CAL/ML
B4150
FORMULA RESOURCE JFK W/FIBER
B4160
FORMULA JEVITY 8 OZ 1.5 CAL/ML
B4152
FORMULA RESOURCE JUST FOR KIDS
B4160
FORMULA KETOCAL 4:1 300 GM PWD
B4154
FORMULA RESOURCE PEACH 186400
B4150
FORMULA KINDERCAL TF W/FIBER
B4160
FORMULA SCANDISHAKE CHOCO 3 OZ
B4152
FORMULA MCT OIL 32 OZ
B4155
FORMULA SIMILAC ADV/FE RTF 32
B4158
FORMULA MICROLIPID 89 ML 400 CAL
B4155
FORMULA SIMILAC ADVANCE/FE PWD
B4158
FORMULA NEOCATE INFANT POWDER
B4161
FORMULA SIMILAC NEOSURE ADV PW
B4160
FORMULA NEOCATE JR POWDER
B4161
FORMULA SIMILAC PM 60/40 16 OZ
B4154
FORMULA NEOCATE JR TROP FR PWD
B4161
FORMULA SUPLENA CARB STEADY
B4154
FORMULA NEOCATE ONE+ 60 GM PWD
B4161
FORMULA TOLEREX 80 GM
B4153
FORMULA NEOCATE ONE+ PWD PKT
B4161
FORMULA TWOCAL HN VAN 8 OZ 2
B4152
FORMULA NEPRO W/CARB STEADY VA
B4154
FORMULA VITAL HN PWDR 766 1
B4153
FORMULA NEXT STEP LIP PWD 24
B4158
FORMULA VIVONEX PED PWDR
B4161
FORMULA NEXT STEP PROSOB LIP24
B4159
FORMULA VIVONEX RTF 1000 ML
B4153
FORMULA NOVASOURCE RENAL 8 OZ
B4154
FORMULA VIVONEX TEN PWDR
B4153
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