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Product
Reimbursement Codes
Some
insurance companies and state programs that cover our products
require a reimbursement or Healthcare Common Procedure Code (HCPC).
These codes are listed here for your convenience.
Pediatric
GI/Allergy |
| |
Product |
Nutricia
Item |
Reimbursement |
HCPCS
Code |
Neocate
Infant Formula |
10804 |
49735-0108-04 |
B4161 |
Neocate
Infant with DHA and ARA |
12595 |
49735-0125-95 |
B4161 |
Neocate
One+ Powder |
11048 |
49735-0110-48 |
B4161 |
Neocate
Junior (Unflavored) |
11790-USA |
49735-0117-90 |
B4161 |
Neocate
Junior (Tropical Fruit) |
12124-USA |
49735-0121-24 |
B4161 |
Neocate
Junior (Chocolate) |
12690 |
49735-0126-90 |
B4161 |
EO28
Splash (Grape) |
12670 |
49735-0126-70 |
B4161 |
EO28
Splash (Tropical Fruit) |
12666 |
49735-0126-66 |
B4161 |
EO28
Splash (Orange-Pineapple) |
11050 |
49735-0110-50 |
B4161 |
Pepdite
Junior (Unflavored) |
11766 |
49735-0117-66 |
B4161 |
Pepdite
Junior (Banana) |
11780 |
49735-0117-80 |
B4161 |
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Metabolics |
|
Analog
Range |
Product |
Code |
Code |
HCPCS
Code |
XPhe
Analog, now Periflex Infant |
11880 |
49735-0118-80 |
B4162 |
MSUD
Analog |
11886 |
49735-0118-86 |
B4162 |
XPhe,
XTyr Analog |
11885 |
49735-0118-85 |
B4162 |
XPTM
Analog |
11884 |
49735-0118-84 |
B4162 |
XMTVI
Analog |
11887 |
49735-0118-87 |
B4162 |
XMet
Analog |
11881 |
49735-0118-81 |
B4162 |
XLys,
XTrp Analog |
11882 |
49735-0118-82 |
B4162 |
XLeu
Analog |
11888 |
49735-0118-88 |
B4162 |
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Maxamaid Range |
XPhe
Maxamaid, orange |
12357 |
49735-0123-57 |
B4162 |
XPhe
Maxamaid, unflavored |
12358 |
49735-0123-58 |
B4162 |
XPhe
Maxamaid, strawberry |
12371 |
49735-0123-71 |
B4162 |
MSUD
Maxamaid |
12360 |
49735-0123-60 |
B4162 |
XPhe,
XTyr Maxamaid |
12362 |
49735-0123-62 |
B4162 |
XMTVI
Maxamaid |
12361 |
49735-0123-61 |
B4162 |
XMet
Maxamaid |
12363 |
49735-0123-63 |
B4162 |
XLys,
XTrp Maxamaid |
12359 |
49735-0123-59 |
B4162 |
XLeu
Maxamaid |
12364 |
49735-0123-64 |
B4162 |
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Maxamum Range |
XPhe
Maxamum, orange (cans) |
12302 |
49735-0123-02 |
B4157
or B4162 |
XPhe
Maxamum, unflavored (cans) |
12301 |
49735-0123-01 |
B4157
or B4162 |
XPhe
Maxamum, orange (sachets) |
12312 |
49735-0123-12 |
B4157
or B4162 |
XPhe
Maxamum, unflavored (sachets) |
12311 |
49735-0123-11 |
B4157
or B4162 |
XPhe
Maxamum Drink, berry |
12524 |
49735-0125-24 |
B4157
or B4162 |
XPhe
Maxamum Drink, orange |
12551 |
49735-0125-51 |
B4157
or B4162 |
MSUD
Maxamum |
12340 |
49735-0123-40 |
B4157
or B4162 |
XMTVI
Maxamum |
12342 |
49735-0123-42 |
B4157
or B4162 |
XMet
Maxamum |
12341 |
49735-0123-41 |
B4157
or B4162 |
XLys,XTrp
Maxamum |
12344 |
49735-0123-44 |
B4157
or B4162 |
XLeu
Maxamum |
12343 |
49735-0123-43 |
B4157
or B4162 |
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Lophlex |
Lophlex,
Berry |
12169 |
49735-0121-69 |
B4155 |
Lophlex,
Orange |
12167 |
49735-0121-67 |
B4155 |
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Periflex/Acerflex |
Periflex
Infant, formerly XPhe Analog |
11880 |
49735-0118-80 |
B4162 |
Periflex
Junior, unflavored |
11402 |
49735-0114-02 |
B4162
or B4157 |
Periflex
Junior, orange |
11401 |
49735-0114-01 |
B4162
or B4157 |
Periflex
Junior, chocolate |
12531 |
49735-0125-31 |
B4162
or B4157 |
Periflex
Advance, unflavored |
12650 |
49735-0126-50 |
B4162 |
Periflex
Advance, orange |
12652 |
49735-0126-52 |
B4162 |
Periflex
Advance, chocolate |
12651 |
49735-0126-51 |
B4162 |
Acerflex |
10026 |
49735-0100-26 |
B4162 |
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Phlexy-10 System |
Bars |
10077 |
49735-0100-77 |
A9270 |
Drink
Mix (Blackcurrant/Apple) |
11467 |
49735-0114-67 |
B4155 |
Drink
Mix (Tropical Surprise) |
11910 |
49735-0119-10 |
B4155 |
Capsules |
11809 |
49735-0118-09 |
A9270 |
Tablets |
11951 |
49735-0119-51 |
A9270 |
Add-Ins |
11810 |
49735-0118-10 |
B4155 |
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Other Metabolics |
MSUD
Aid |
10143 |
49735-0101-43 |
N/A |
Methionaid |
10242 |
49735-0102-42 |
N/A |
XMet,
XCys Analog |
11653 |
N/A |
N/A |
XMet,
XCys Maxamaid |
11457-1 |
N/A |
N/A |
Lanaflex |
12643 |
49735-0126-43 |
B4157 |
Milupa
PKU 2 Tomato |
309087
- Case |
81361-9087-01 |
B4162
or B4157 |
Milupa
PKU 2 |
659346 |
81361-9346-01 |
B4155 |
Milupa
PKU 3 |
659347 |
81361-9347-01 |
B4155 |
Milupa
HOM 2 |
659357 |
81361-9357-01 |
B4155 |
Milupa
MSUD 2 |
659351 |
81361-9351-01 |
B4155 |
Milupa
OS 2 |
659349 |
81361-9349-01 |
B4155 |
Milupa
TYR 2 |
659353 |
81361-9353-01 |
B4155 |
Milupa
UCD 2 |
659361 |
81361-9361-01 |
B4155 |
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Neurology |
| |
Product |
Nutricia
Item |
Reimbursement |
HCPCS
Code |
Ketocal
4:1 |
16670 |
49735-0166-70 |
B4154 |
Ketocal
3:1 |
16672 |
49735-0166-72 |
B4154 |
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Other
Nutritionals |
| |
Product |
Nutricia
Item |
Reimbursement |
HCPCS
Code |
Monogen |
667097 |
49735-0170-97 |
B4150
or B4158 |
Super
Soluble Duocal |
10280 |
49735-0102-80 |
B4155 |
Polycal |
21152 |
49735-0111-52 |
B4155 |
Protifar |
21134 |
49735-0111-34 |
B4155 |
Complete
Amino Acid Module |
10124-1 |
49735-0101-24 |
B4155 |
Essential
Amino Acid Module |
11490-1 |
49735-0114-90 |
B4155 |
Phlexy-Vits |
10685 |
49735-0106-85 |
A9270 |
Flavor
Packets |
|
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Cherry
Vanilla |
10249 |
49735-0102-49 |
N/A |
Grapefruit |
10133 |
49735-0101-33 |
N/A |
Lemon-Lime |
10158 |
49735-0101-58 |
N/A |
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Low
Protein Products |
|
Loprofin |
Product |
Nutricia
Item |
Reimbursement |
HCPCS
Code |
Drink
Mix |
L512 |
49735-0151-25 |
S9434
or S9435* |
Cereal
Loops |
L513 |
49735-0151-35 |
S9434
or S9435* |
Spaghetti |
L501 |
49735-0150-15 |
S9434
or S9435* |
Macaroni
Penne |
L502 |
49735-0150-25 |
S9434
or S9435* |
Spirals |
L503 |
49735-0150-35 |
S9434
or S9435* |
Vermicelli |
L504 |
49735-0150-45 |
S9434
or S9435* |
Lasagne |
L505 |
49735-0150-55 |
S9434
or S9435* |
Sweet
Biscuits (Cookies) |
L506 |
49735-0150-65 |
S9434
or S9435* |
Chocolate
Cream Biscuits |
L507 |
49735-0150-75 |
S9434
or S9435* |
Crackers |
L508 |
49735-0150-85 |
S9434
or S9435* |
Vanilla
Cream Wafers |
L509 |
49735-0150-95 |
S9434
or S9435* |
Chocolate
Cream Wafers |
L510 |
49735-0151-05 |
S9434
or S9435* |
Orange
Cream Wafers |
L511 |
49735-0151-15 |
S9434
or S9435* |
Baking
Mix |
L514 |
49735-0151-45 |
S9434
or S9435* |
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Wel-Plan |
Baking
Mix |
WP501 |
49735-0150-16 |
S9434
or S9435* |
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Milupa |
Product |
Nutricia
Item |
Reimbursement |
HCPCS
Code |
lp-drink |
LC523 |
49735-0152-34 |
S9434
or S9435* |
lp-drink
chocolate |
L515 |
49735-0151-54 |
S9434
or S9435* |
lp-fruity
pear cereal mix |
LC524 |
49735-0152-44 |
S9434
or S9435* |
lp-fruity
apple-banana cereal mix |
L525 |
49735-0152-54 |
S9434
or S9435* |
lp-flakes |
L519 |
49735-0151-94 |
S9434
or S9435* |
lp-ringlets
chocolate |
L520 |
49735-0152-04 |
S9434
or S9435* |
lp-chips
paprika |
L521 |
49735-0152-14 |
S9434
or S9435* |
lp-snack
italian |
L522 |
49735-0152-24 |
S9434
or S9435* |
lp-bar
apricot |
L516 |
49735-0151-64 |
S9434
or S9435* |
lp-bar
fruits of the forest |
L517 |
49735-0151-74 |
S9434
or S9435* |
lp-bar
apple-cinnamon |
L518 |
49735-0151-84 |
S9434
or S9435* |
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* Some private
insurers accept these codes. |
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