PDF Enteral Nutrients, Equipment and Supplies - CBIC

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Round 2

Single Payment Amounts

Enteral Nutrients, Equipment and Supplies

Akron, OH

4

Albany-Schenectady-Troy, NY

6

Albuquerque, NM

8

Allentown-Bethlehem-Easton, PA-NJ

10

Asheville, NC

13

Atlanta-Sandy Springs-Marietta, GA

15

Augusta-Richmond County, GA-SC

17

Austin-Round Rock-San Marcos, TX

19

Bakersfield-Delano, CA

22

Baltimore-Towson, MD

24

Baton Rouge, LA

26

Beaumont-Port Arthur, TX

29

Birmingham-Hoover, AL

31

Boise City-Nampa, ID

33

Boston-Cambridge-Quincy, MA-NH

35

Bridgeport-Stamford-Norwalk, CT

38

Bronx-Manhattan, NY CBA

40

Buffalo-Niagara Falls, NY

42

Cape Coral-Fort Myers, FL

44

Central-Chicago Metro CBA

47

Charleston-North Charleston-Summerville, SC

49

Chattanooga, TN-GA

51

Colorado Springs, CO

54

Columbia, SC

56

Columbus, OH

58

Dayton, OH

60

Deltona-Daytona Beach-Ormond Beach, FL

63

Denver-Aurora-Broomfield, CO

65

Detroit-Warren-Livonia, MI El Paso, TX Flint, MI Fresno, CA Grand Rapids-Wyoming, MI Greensboro-High Point, NC Greenville-Mauldin-Easley, SC Hartford-West Hartford-East Hartford, CT Honolulu, HI Houston-Sugar Land-Baytown, TX Huntington-Ashland, WV-KY-OH Indiana-Chicago Metro Indianapolis-Carmel, IN Jackson, MS Jacksonville, FL Knoxville, TN Lakeland-Winter Haven, FL Las Vegas-Paradise, NV Little Rock-North Little Rock-Conway, AR Los Angeles County CBA Louisville/Jefferson County, KY-IN McAllen-Edinburg-Mission, TX Memphis, TN-MS-AR Milwaukee-Waukesha-West Allis, WI Minneapolis-St. Paul-Bloomington, MN-WI Nashville-Davidson--Murfreesboro--Franklin, TN Nassau-Brooklyn-Queens-Richmond County Metro CBA New Haven-Milford, CT New Orleans-Metairie-Kenner, LA North East NY CBA Metro North Port-Bradenton-Sarasota, FL Northern NJ Metro CBA Northern-Chicago Metro CBA Ocala, FL Oklahoma City, OK Omaha-Council Bluffs, NE-IA Orange County CBA Oxnard-Thousand Oaks-Ventura, CA

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

67 69 72 74 76 79 81 83 85 88 90 92 94 97 99 101 104 106 108 110 113 115 117 119 122 124 126 129 131 133 135 138 140 142 144 147 149 151

Page 2 of 231

Palm Bay-Melbourne-Titusville, FL

154

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD

156

Phoenix-Mesa-Glendale, AZ

158

Portland-Vancouver-Hillsboro, OR-WA

160

Poughkeepsie-Newburgh-Middletown, NY

163

Providence-New Bedford-Fall River, RI-MA

165

Raleigh-Cary, NC

167

Richmond, VA

169

Rochester, NY

172

Sacramento--Arden-Arcade--Roseville, CA

174

Salt Lake City, UT

176

San Antonio-New Braunfels, TX

179

San Diego-Carlsbad-San Marcos, CA

181

San Francisco-Oakland-Fremont, CA

183

San Jose-Sunnyvale-Santa Clara, CA

185

Scranton--Wilkes-Barre, PA

188

Seattle-Tacoma-Bellevue, WA

190

South-West-Chicago-Metro CBA

192

Southern NY Metro CBA

194

Springfield, MA

197

St. Louis, MO-IL

199

Stockton, CA

201

Suffolk County CBA

204

Syracuse, NY

206

Tampa-St. Petersburg-Clearwater, FL

208

Toledo, OH

210

Tucson, AZ

213

Tulsa, OK

215

Virginia Beach-Norfolk-Newport News, VA-NC

217

Visalia-Porterville, CA

219

Washington-Arlington-Alexandria, DC-VA-MD-WV

222

Wichita, KS

224

Worcester, MA

226

Youngstown-Warren-Boardman, OH-PA

229

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 3 of 231

CBA Name

Akron, OH Akron, OH Akron, OH

HCPCS Code

Enteral Nutrients, Equipment and Supplies

HCPCS Code Description

B4034

ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

B4035

ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

B4036

ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Modifier 1 Modifier 2 Modifier 3 SPA

$3.25 $5.82 $4.50

Akron, OH

B4081 NASOGASTRIC TUBING WITH STYLET

$14.32

Akron, OH

B4082 NASOGASTRIC TUBING WITHOUT STYLET

$10.38

Akron, OH

B4083 STOMACH TUBE - LEVINE TYPE

$1.60

Akron, OH

B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, ANY TYPE, EACH

$24.40

Akron, OH Akron, OH Akron, OH Akron, OH

B4088 B4149 B4150 B4152

GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACH ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER THAN 1. 5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

$30.00 $0.95 $0.39 $0.32

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 4 of 231

CBA Name

Akron, OH Akron, OH Akron, OH

Enteral Nutrients, Equipment and Supplies

HCPCS Code

HCPCS Code Description

Modifier 1 Modifier 2 Modifier 3 SPA

B4153 B4154 B4155

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS AND PEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFIC NUTRIENTS, CARBOHYDRATES (E. G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E. G. GLUTAMINE, ARGININE), FAT (E. G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

$1.12 $0.70 $0.70

Akron, OH

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

MS

$34.43

Akron, OH

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

NU

$688.50

Akron, OH

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

RR

$68.85

Akron, OH

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

UE

$516.38

Akron, OH

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

MS

$32.50

Akron, OH

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

NU

$650.00

Akron, OH

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

RR

$65.00

Akron, OH

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

UE

$487.50

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 5 of 231

CBA Name

HCPCS Code

Enteral Nutrients, Equipment and Supplies

HCPCS Code Description

Modifier 1 Modifier 2 Modifier 3 SPA

Akron, OH

E0776 IV POLE

NU

BA

KG

$55.00

Akron, OH

E0776 IV POLE

RR

BA

KG

$5.50

Akron, OH

E0776 IV POLE

UE

BA

KG

Albany-Schenectady-Troy, NY

B4034

ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Albany-Schenectady-Troy, NY

B4035

ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Albany-Schenectady-Troy, NY

B4036

ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

$41.25 $3.10 $5.78 $4.21

Albany-Schenectady-Troy, NY

B4081 NASOGASTRIC TUBING WITH STYLET

$14.70

Albany-Schenectady-Troy, NY

B4082 NASOGASTRIC TUBING WITHOUT STYLET

$10.05

Albany-Schenectady-Troy, NY

B4083 STOMACH TUBE - LEVINE TYPE

$1.62

Albany-Schenectady-Troy, NY

B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, ANY TYPE, EACH

$24.40

Albany-Schenectady-Troy, NY

B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACH

$29.00

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 6 of 231

Enteral Nutrients, Equipment and Supplies

CBA Name

Albany-Schenectady-Troy, NY Albany-Schenectady-Troy, NY Albany-Schenectady-Troy, NY Albany-Schenectady-Troy, NY Albany-Schenectady-Troy, NY Albany-Schenectady-Troy, NY

HCPCS

Code

HCPCS Code Description

ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT

NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY

INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1

B4149 UNIT

Modifier 1 Modifier 2 Modifier 3 SPA

$0.95

B4150 B4152

ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER THAN 1. 5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

$0.39 $0.32

B4153 B4154 B4155

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS AND PEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

ENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFIC NUTRIENTS, CARBOHYDRATES (E. G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E. G. GLUTAMINE, ARGININE), FAT (E. G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

$1.17 $0.70 $0.72

Albany-Schenectady-Troy, NY

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

MS

$32.23

Albany-Schenectady-Troy, NY

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

NU

$644.51

Albany-Schenectady-Troy, NY

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

RR

$64.45

Albany-Schenectady-Troy, NY

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM

UE

$483.38

Albany-Schenectady-Troy, NY

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

MS

$30.40

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 7 of 231

CBA Name

HCPCS Code

Enteral Nutrients, Equipment and Supplies

HCPCS Code Description

Modifier 1 Modifier 2 Modifier 3 SPA

Albany-Schenectady-Troy, NY

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

NU

$608.03

Albany-Schenectady-Troy, NY

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

RR

$60.80

Albany-Schenectady-Troy, NY

B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM

UE

$456.02

Albany-Schenectady-Troy, NY

E0776 IV POLE

NU

BA

KG

$55.00

Albany-Schenectady-Troy, NY

E0776 IV POLE

RR

BA

KG

$5.50

Albany-Schenectady-Troy, NY

E0776 IV POLE

UE

BA

KG

Albuquerque, NM

B4034

ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Albuquerque, NM

B4035

ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

Albuquerque, NM

B4036

ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

$41.25 $3.03 $5.50 $4.15

Albuquerque, NM

B4081 NASOGASTRIC TUBING WITH STYLET

$14.32

Albuquerque, NM

B4082 NASOGASTRIC TUBING WITHOUT STYLET

$10.05

DMEPOS Competitive Bidding Program

Round 2 SPA - Effective July 01, 2013

Page 8 of 231

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