Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-024 - DMS-2008-J-5: Prosthetics - Additional Modifiers for Nutritional Formulas for Beneficiaries Ages 0 through 4 years

Current through Register Vol. 49, No. 6, June, 2024
Nutritional Formulae For Child Health Services
						  (EPSDT) Beneficiaries Ages 0-4 Only
The codes and modifiers below should be used to bill
						  for services provided for dates of service 06/01/07 through 05/31/08 if that
						  service has not been billed to date. For any services provided for dates of
						  service 06/01/08 or after, refer to Update Transmittal # 117 to the Prosthetics
						  Manual for codes to bill.
Procedure Code
M1
M2
M3
M4
Products
Age Range
B4149
EP
U7
UA
Compleat
0-4 yrs.
B4150
EP
U7
UA
Boost, Boost w Benefiber & FOS, Carnation Instant
						  Breakfast Lactose Free, Ensure, Ensure Fiber w FOS, Ensure High Protein, Ensure
						  HN, Ensure Powder, Fibersource, Fibersource HN, Fortison, Intraolite, Isocal,
						  Isocal HN, IsoSource, IsoSource HN, Jevity 1.0 CAL, Nutrapack, Nutren 1.0,
						  Nutren 1.0 w Fiber, Osmolite, Osmolite 1.0 CAL, Osmolite HN, Portagen,
						  Probalance, Promote, Promote w Fiber, Ultracal
0-4 yrs.
B4150
EP
U1
U7
UA
Boost Pudding, Ensure Pudding
0-4 yrs.
B4152
EP
U7
UA
Boost Plus, Carnation Instant Breakfast Lactose Free
						  Plus, Comply, Ensure Plus, Ensure Plus HN, Novasource 2.0, Nutren 1.5, Nutren
						  2.0, Osmolite 1.5 CAL, Scandishake, Two-Cal HN
0-4 yrs.
B4153
EP
U7
UA
Alitraq, Criticare HN, Isotein HN, Peptamen, Peptamen
						  1.5, Peptamen VHP, Peptamen w Prebio 1, Perative, Tolerex, Vital HN, Vivonex
						  Plus, Vivonex TEN,
0-4 yrs.
B4154
EP
U7
UA
Advera, AminAid, Choice DM, Boost Diabetic, Forta
						  Drink, Glucerna, Glytrol, Hepatic Aid, Impact, Impact w Fiber, IsoSource VHN,
						  Ketocal, Lipisorb, Lofenalac, Nepro, Nepro with Carb Steady, NutriHep, Protain
						  XL, Pulmocare, Resource Diabetic, Respalor, Similac 60/40, Suplena, Suplena
						  with Carb Steady, Traumacal, Trumaid Powder
0-4 yrs.
B4155
EP
U7
UA
Casec Powder, Fructose Powder, MCT Oil, Moducal,
						  Polycose Liquid, Procel Protein Power, Provimin, Sumacal
0-4 yrs.
B4155
EP
U1
U7
UA
Polycose Powder, Dextrose, Scandical
0-4 yrs.
B4155
EP
U2
U7
UA
Microlipids
0-4 yrs.
B4155
EP
U3
U7
UA
Product 80056, PKU 1, 2 and 3, RCF, Try 1 and 2
0-4 yrs.
B4158
EP
U7
UA
Enfamil, Enfamil AR Lipil, Enfamil Lactofree, Enfamil
						  Lactofree Lipil, Enfamil Lipil Low Iron, Enfamil Lipil w Iron, Enfamil Next
						  Step Lipil, Nutren Jr., Nutren Jr. w Fiber, Resource for Kids, Resource Just
						  for Kids w Fiber
0-4 yrs.
B4159
EP
U7
UA
Enfamil Next Step, Prosobee Lipil, Enfamil Prosobee
						  Lipil, Isomil, Isomil Advance Soy w Iron, Prosobee
0-4 yrs.
B4160
EP
U7
UA
Enfamil Enfacare Lipil Powder, Kindercal, Kindercal w
						  Fiber, Pediasure, Pediasure w Fiber
0-4 yrs.
B4160
EP
U1
U7
UA
Enfamil Premature Lipil 24 CAL Low Iron, Enfamil
						  Premature Lipil 24 CAL w Iron, Similac Neosure, Similac Neosure Advance,
						  Special Care Advance 20, Special Care Advance 20 w Iron, Special Care Advance
						  24, Special Care Advance 24 w Iron
0-4 yrs.
B4161
EP
U7
UA
Alimentum, EleCare, Enfamil Nutramigen Lipil, Enfamil
						  Pregestimil, Neocate Infant Formula, Neocate Jr., Neocate One + (Pediatric
						  E028) Liquid, Neocate One + Powder, Nutramigen, Peptamen Jr. Pregestimil,
						  Similac Alimentum Advance w Iron, Vivonex Pediatric
0-4 yrs.
B4162
EP
U7
UA
Calcilo XD, Cyclinex-1, Cyclinex-2, Hominex-1,
						  Hominex-2, I-Valex-1, I-Valex-2, Ketonex-1, Ketonex-2, Low Phe Try Diet Powder,
						  Maxamaid MSUD, Maxamaid XLYS Try, Maxamaid XP, Maxamaid Xphen Try, Maxamum
						  MSUD, Maxamum XP, MSUD Analog, MSUD 1 and 2, Periflex, Periflex Advanced,
						  Periflex Infant, Periflex Junior, Phenex-1, Phenex-2, Phenyl Free 1, Phenyl
						  Free 2, Propimex-1, Propimex-2, XP Analog, XLys, XTrp Maxamaid, Xphe Maxamaid,
						  XPhe XTyr Maxamaid, Xphe Maxamum, Xphe, XTyr Analog, Xphen, Try Analog
0-4 yrs.
B4162
EP
U1
U7
UA
XMTVI Maxamaid
0-4 yrs.
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