Tables for Medicare Reimbursement for Home Parenteral and Enteral Nutrition

Table 1: DME MAC

Jurisdiction	DME MAC
A	National Heritage Insurance Company (NHIC) www.medicarenhic.com/dme/index.shtml Areas covered: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont
B	AdminaStar Federal, Inc www.adminastar.com Areas covered: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin
C	Cigna www.cignamedicare.com Areas covered: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia
D	Noridian Administrative Services www.noridianmedicare.com Areas covered: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming

Table 2: Example of DMEPOS Fee Schedule for Common Enteral Items

Item	HCPCS	Allowable (dollars)*
Formula	B4149	1.57 per 100 kilocalories
Formula	B4150	0.67 per 100 kilocalories
Formula	B4152	0.56 per 100 kilocalories
Formula	B4153	1.92 per 100 kilocalories
Formula	B4154	1.22 per 100 kilocalories
Formula	B4155	0.95 per 100 kilocalories
Syringe Feed Supply Kit	B4034	6.12 per day
Gravity Feed Supply Kit	B4036	8.00 per day
Pump Feed Supply Kit	B4035	11.66 per day
Gastrostomy Tube	B4086	35.69 per tube
IV Pole	E0776	101.98 (new) 25.81 (rent per month)
Pump With Alarm	B9002	1,226.26 (new) 118.77 (rent per monh)

*100 kilocalories = 1 unit of service

Table 3: Example of DMEPOS Fee Schedule for Common Parenteral Items

Item	HCPCS	Allowable (dollars)
PN* compounded (AA 10 to 51 grams protein, dextrose, electrolytes, TE, vitamins)	B4189	172.31 per day
PN compounded (AA 52 to 73 grams protein, dextrose, electrolytes, TE, vitamins)	B4193	222.67 per day
PN compounded (AA 74 to 100 grams protein, dextrose, electrolytes, TE, vitamins)	B4197	271.08 per day
PN compounded (AA > 100 grams protein, dextrose, electrolytes, TE, vitamins)	B4199	309.77 per day
Lipids (10 grams = 1 unit of service)	B4185	10.89 per unit
PN Infusion Portable Pump	B9004	2,446.04 (new) 387.23 (rent per month)
PN Infusion Stationary Pump	B9006	2446.04 (new) 387.23 (rent per month)
PN Supply Kit (premix)	B4220	7.76 per day
PN Administration Kit	B4224	24.25 per day
IV Pole	E0776	101.98 (new) 25.81 (rent per month)

*PN = Parenteral Nutrition

Table 4: Enteral Product Classification

HCPCS	Enteral Formula Classification Description	Product Example
B4149	Blenderized natural food formulas	Compleat
B4150	Nutritionally complete with intact nutrient formulas	Fibersource, Fitbersoure HN Jevity 1 Cal, Jevity 1.2 Cal Isosource, Isosource HN Nutren 1.0, Nutren Fiber Osmolite 1 Cal, Osmolite 1.2 Cal Probalance, Promote Promote Fiber
B4152	Nutritionally complete, calorically dense formulas	Ensure Plus, Isosource VHN Jevity 1.5, Novasource 2.0 Nutren 1.5, Nutren 1.5 Fiber Nutren 2.0, Two Cal HN
B4153	Nutritionally complete with hydrolyzed protein formulas	Crucial, Optimental Peptamen, Peptamen 1.5 Peptines, Peptinex DT Vital HN, Vivonex Plus Vivonex RTF, Vivonex TEN
B4154	Nutritionally complete for special metabolic needs, excluding inherited disease of metabolism formulas	AlitraQ, diabetisource AC Glucerna, Glucerna Select Glytrol, Modulen IBD Nepro, Novasource Pulmonary Novasource Renal, Nutren Renal Nutrihep, Perative, Pivot 1.5 Pulmocare, Renalcal
B4155	Nutritionally incomplete/modular nutrient formulas	Duocal, MCT oil

Table 5 Some ICD-9 Codes for Home Parenteral Nutrition

ICD-9 Code	Diagnosis
555.9	Regional Enteritis
560.9	Intestinal Obstruction
579.9	Malabsorption
577.1	Chronic Pancreatitis
579.3	Short Bowel Syndrome

Table 6 Some ICD-9 Codes for Home Enteral Nutrition

ICD-9 Code	Diagnosis
555.9	Crohn’s Disease
150	Esopheal Cancer
438.82	Dsyphagia Due to Stroke
530.84	Tracheosophageal Fistula