Enteral Nutrition Reimbursement Documentation



Patient’s Name:Medicaid ID #Date of Birth:Medical Diagnoses: Method of feeds: oral NG NJ-tube G tube GJ tube(need to qualify oral feeds) Is patient unable to reach or maintain weight and height at the 10th percentile for age and sex without supplemental feeding? YesPlease provide growth chart NoDoes patient have a disease or dysfunction of the digestive tract, including dysphagia, which causes nutritional deficiency with insufficient nutrients to maintain body weight by impaired delivery of nutrients to the small bowel? YesDescribe: NoFormula Name:HCPC Code: ( on back)Total Volume for 30 days:Amount required to meet 100% of daily estimated needs for one day, total Kcal/day______________Anticipated length of time needed: _____monthsMethod of Administration:SyringeGravityPump* type:_________________________Describe how feeds are administered:ContinuousIntermittentBolusombination (explain)___________________*Must document reason of necessity for pump. Check all that apply (attach medical/clinical documentation)Severe diarrheaDumping syndromeRefluxAspirationBlood glucose fluctuationsNissenJejunal feedsVentilated and/or trachedFeeding difficulties (oral aversions)_______________________________________ Date: _______________ Time: _______________ signatureStatement of Medical Necessity:__________________________________MD/LIP Contact #:_____________Date: ______________Enteral Nutrition DocumentationJan 09DRUG DESCRIPTIONHCPCS CODEDRUG DESCRIPTIONHCPCS CODEFORMULA ALIMENTUM ADV BTL 32 OZB4161FORMULA NUTREN 1 VAN 1 CAL/MLB4150FORMULA ALIMENTUM POWERB4161FORMULA NUTREN 1.0 W/FIBERB4150FORMULA BENEPROTEIN 8 OZ PWDB4155FORMULA NUTREN 1.5 VAN 1.5 CAL/B4152FORMULA BOOST CHOCOLATEB4150FORMULA NUTREN 2 VAN 2 CAL/MLB4152FORMULA BOOST HI PROTEIN VANILB4150FORMULA NUTREN JR W/FIBER VANB4160FORMULA BOOST KID ESS 1.5 FBRB4160FORMULA NUTREN JR. VANILLAB4160FORMULA BOOST KID ESS 1.5 VANB4160FORMULA OPTIMENTAL VANILLA 8 OZB4153FORMULA BOOST PLUS CHOCOLATEB4152FORMULA OSMOLITE 1.5 CAL 1L RTHB4152FORMULA BOOST PLUS VANILLA 237B4152FORMULA OSMOLITE 1.5 CAL 240MLB4152FORMULA BOOST VANILLAB4150FORMULA OSMOLITE HN 1.06 CAL/MLB4150FORMULA BOOST W/FIBER VANILLAB4150FORMULA OSMOLITE HN RTH 1000 MLB4150FORMULA BRIGHT BEGINNINGS SOYB4160FORMULA OXEPA VANILLA 8 OZB4154FORMULA CARN G/START SUPR DHAB4158FORMULA PEDIALYTE 32 OZ CHLD 12B4103FORMULA CARNA G/START SUPR PWDB4158FORMULA PEDIASURE BANANA CREAMB4160FORMULA CARNATION LF VANIL VHCB4152FORMULA PEDIASURE CHOCOLATEB4160FORMULA CERALYTE 90 LEMON 50B4103FORMULA PEDIASURE STRAWBERRY 8B4160FORMULA COMPLEAT 1.07 CAL/MLB4149FORMULA PEDIASURE VAN 8 OZ 1B4160FORMULA COMPLEAT PED 1 CAL/MLB4149FORMULA PEDIASURE W/FIBER VANB4160FORMULA DIABETISOURCE ACB4154FORMULA PEDIATRIC EO28 GRAPEB4161FORMULA DUOCAL UNFLVD POWDERB4155FORMULA PEDIATRIC E028 ORG/PINB4161FORMULA ELECARE POWDER 14.1 OZB4161FORMULA PEDIATRIC 3028 TROPICAB4161FORMULA ELECARE VAN PWD 14.1B4161FORMULA PEPDITE JR UNFLV PKTB4161FORMULA ENF LF W/LIPIL 13 OZB4158FORMULA PEPTAMEN 1.5 UNFLVDB4153FORMULA ENFACARE LIPIL 14 OZ PWB4160FORMULA PEPTAMEN AF UNFLAV 250B4153FORMULA ENFAMIL AR W/LIPIL PWDB4158FORMULA PEPTAMEN JR PREBIO VANB4161FORMULA ENFAMIL GENTLEASE PWDB4158FORMULA PEPTAMEN JR UNFLAV 1B4161FORMULA ENFAMIL LIPIL W/FE PWDB4158FORMULA PEPTAMEN JR VAN 1 CALB4161FORMULA ENSURE CHOC 1.06 CAL/MLB4150FORMULA PEPTAMEN JR W/FIBER VAB4161FORMULA ENSURE PLUS CHOCB4152FORMULA PEPTAMEN UNFLV 250 MLB4153FORMULA ENSURE PLUS STRAWBERRYB4152FORMULA PEPTAMEN VANILLAB4153FORMULA ENSURE PLUS VAN 8 OZ 50B4152FORMULA PEPTAMEN W/PREBIO VANIB4153FORMULA ENSURE STRAWBERRY 1.06B4150FORMULA PEPTINEX 1.5 VANILLAB4153FORMULA ENSURE VAN 1.06 CAL/MLB4150FORMULA PEPTINEX DT PED 250 MLB4161FORMULA ENSURE W/FIBER VAN 1B4150FORMULA PEPTINEX DT PED/FIBERB4161FORMULA FIBERSOURCE HN 250MLB4150FORMULA PHENEX 2 PWD (>12)S9435FORMULA GLUCERNA 8 OZ 1 CAL/MLB4154FORMULA PHENEX 2 VAN PWD (>12)S9435FORMULA GLYTROL DIAB VANILLAB4154FORMULA POLYCOSE POWDER 746 2.B4155FORMULA GOOD ST 2 S/SOY 24 OZB4159FORMULA PORTAGEN PWD 1 LB (>12)B4150FORMULA GOOD ST 2 SUPR SOY PWDB4159FORMULA PORTAGEN PWD 1 LB <=12B4158FORMULA GOOD START NATURAL CULB4158FORMULA PREGESTIMIL PWDR 1 LB 1B4161FORMULA IMPACT W/FIBERB4154FORMULA PRO-PHREE PWD 350 GMB4155FORMULA ISOMIL ADV W/FE LF PWDB4159FORMULA PROMOTE 8 OZ 1 CAL/MLB4150FORMULA ISOMIL W/FE PWD 12.9 OZB4159FORMULA PROMOTE W/FIBER 8 OZ 1.B4150FORMULA ISOSOURCE 1.5 CALB4152FORMULA PROPIMEX 2 PWD (>12)S9435FORMULA ISOSOURCE HN VANILLAB4150FORMULA PROSOBEE LIPIL PWDB4159FORMULA JEVITY 1 RTH 1000MLB4150FORMULA PULMOCARE VAN 1.5 CAL/MB4154FORMULA JEVITY 1.2 1500 ML BTLB4150FORMULA RCF LOW IRON SOY 81 CALB4155FORMULA JEVITY 1.2 RTH 1000 MLB4150FORMULA RENALCAL 2 CAL/MLB4154FORMULA JEVITY 1.5 RTH 1000 MLB4152FORMULA REPLETE W/FIBER VANB4150FORMULA JEVITY 8 OZ 1 CAL/MLB4150FORMULA RESOURCE GLUTASOLVEB4155FORMULA JEVITY 8 OZ 1.2 CAL/MLB4150FORMULA RESOURCE JFK W/FIBERB4160FORMULA JEVITY 8 OZ 1.5 CAL/MLB4152FORMULA RESOURCE JUST FOR KIDSB4160FORMULA KETOCAL 4:1 300 GM PWDB4154FORMULA RESOURCE PEACH 186400B4150FORMULA KINDERCAL TF W/FIBERB4160FORMULA SCANDISHAKE CHOCO 3 OZB4152FORMULA MCT OIL 32 OZB4155FORMULA SIMILAC ADV/FE RTF 32B4158FORMULA MICROLIPID 89 ML 400 CALB4155FORMULA SIMILAC ADVANCE/FE PWDB4158FORMULA NEOCATE INFANT POWDERB4161FORMULA SIMILAC NEOSURE ADV PWB4160FORMULA NEOCATE JR POWDERB4161FORMULA SIMILAC PM 60/40 16 OZB4154FORMULA NEOCATE JR TROP FR PWDB4161FORMULA SUPLENA CARB STEADYB4154FORMULA NEOCATE ONE+ 60 GM PWDB4161FORMULA TOLEREX 80 GMB4153FORMULA NEOCATE ONE+ PWD PKTB4161FORMULA TWOCAL HN VAN 8 OZ 2B4152FORMULA NEPRO W/CARB STEADY VAB4154FORMULA VITAL HN PWDR 766 1B4153FORMULA NEXT STEP LIP PWD 24B4158FORMULA VIVONEX PED PWDRB4161FORMULA NEXT STEP PROSOB LIP24B4159FORMULA VIVONEX RTF 1000 MLB4153FORMULA NOVASOURCE RENAL 8 OZB4154FORMULA VIVONEX TEN PWDRB4153FORMULA NUTRAMIGEN PWDR 1LB 10B4161 ................
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