HCPCS code B4152: Enteral formula, nutritionally complete, 100 calories

Better understand how to properly use and bill for HCPCS code B4152 with our short guide that has a list of documentation and billing requirements.

Use Code

## **What is HCPCS code B4152?** HCPCS code B4152 has a code description: 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 as maintained by CMS falls under Enteral Formulas and Additives. This code is a crucial component of the billing and coding for enteral nutrition, a method of delivering nutrients directly to the gastrointestinal tract via a feeding tube. This code specifically identifies a type of formula that is "nutritionally complete" and "calorically dense." To elaborate, the formula contains all the necessary macronutrients (proteins, fats, and carbohydrates) and micronutrients (vitamins, minerals, and may include fiber) a patient needs to meet their daily nutritional requirements. It is designed to be the patient's sole or primary source of nutrition. To add, the key distinguishing feature of B4152 is that the formula has a concentration of 1.5 kcal/ml or greater. This high caloric density is essential for patients who require a large number of calories but are fluid-restricted or have limited tolerance for large volumes of feeding. For example, a patient with congestive heart failure, renal disease, or other conditions where fluid intake needs to be carefully monitored. The code reflects this by billing per 100-calorie unit, making it easy to track and reimburse based on the patient's energy needs rather than just the volume of formula.

## **HCPCS code B4152 documentation requirements** For a patient's enteral nutrition to be covered by Medicare, they must have a permanent impairment that prevents them from consuming or absorbing enough nutrients from an oral diet. The medical record must clearly show the medical necessity for the specific type and amount of formula. Key documentation elements include: - **A Standard Written Order (SWO)**: This must be on file before the item is delivered. - **Medical necessity**: The patient's medical record must substantiate the need for enteral nutrition. This includes the patient's diagnosis and other relevant information like the duration of the condition, clinical course, prognosis, and functional limitations. - **Justification for calorically dense formula**: If a calorically dense formula (B4152) is ordered, the medical record should specify why a standard formula (B4150) cannot meet the patient's metabolic needs. This may include documentation of other formulas that were tried and failed or were considered and ruled out. - **Proof of delivery**: Documentation is needed to show the patient received the formula.

## **B4152 billing requirements** For billing essentials, here's what you need to keep in mind: - **Units**: Bill B4152 using 1 unit for every 100 calories of formula provided. If two different formulas are provided that both fall under the same HCPCS code, you should bill them on a single claim line with units reflecting the total calories of both. - **Modifiers**: Specific modifiers may be required for billing, such as BA (item(s) furnished in conjunction with parenteral/enteral nutrition services) and KX (all coverage criteria have been met). The specific modifiers can vary by payer and state. - **Prior authorization**: While some payers may not require prior authorization for B4152, it's essential to check with each specific insurance plan. For example, some state Medicaid programs may not require prior authorization for a certain quantity of units per month (e.g., 1050 units), but may require it if that quantity is exceeded.

## **Related codes** - **B4150**: 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 - **B4153**: 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 - **B4154**: 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

Frequently asked questions

Most payers, including Medicare, consider oral enteral nutrition to be a non-covered service unless specific, limited circumstances apply. The BO modifier (orally administered enteral nutrition) is used to indicate this.

One unit equals 100 calories. To determine the units, you divide the total calories by 100. For example, a 1-liter container of a 1.5 kcal/ml formula has 1,500 calories. This would be billed as 15 units.

The requirement for a CMN or DIF varies. While some payers may still use these forms, Medicare has eliminated the requirement for them on most claims for dates of service after January 1, 2023. However, all the information that would have been on these forms must still be present in the patient's medical record.