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Specialty Enteral Formulas

Effective with dates of service on or after February 4, 2011 claims submitted to the durable medical equipment Medicare administrative contractor (DME MACs) for Healthcare Common Procedure Coding System (HCPCS) codes B4149, B4153–B4157, B4161, and B4162 will no longer be subjected to least costly alternative payment policy and downcoded to B4150 or B4152 (semi-synthetic intact protein/protein isolate formulas). For dates of service on or after February 4, 2011, claims for HCPCS codes B4149, B4153–B4157, B4161, and B4162 will be denied as not reasonable and necessary unless the coverage criteria for specialty nutrients is met. Suppliers also have the option of using the upgrade modifiers as noted in the recent DME MAC publication on use of upgrade modifiers.   

Refer to the local coverage determination for enteral nutrition for additional coverage, coding, and documentation requirements.

Specialty Enteral Formulas
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