2025 HCPCS code B4157
(Active) Effective Date: N/A Revision Date: N/A Nutritional Products - Enteral Formulas and Additives Enteral and Parenteral Therapy Feed
Nutritionally complete enteral formula for inherited metabolic disorders; administered via feeding tube; 100 calories = 1 unit.
Modifiers may be used to indicate the setting of service or other relevant circumstances (e.g., different places of service). Consult with specific payer guidelines.
Medical necessity for B4157 is established when a patient has an inherited metabolic disorder that prevents the adequate absorption or utilization of nutrients through standard dietary intake. The formula must be medically necessary to maintain nutritional status and prevent complications associated with the underlying metabolic disorder.
The clinical responsibility lies with the physician or other qualified healthcare provider who diagnoses the metabolic disorder, orders the specific enteral formula, and monitors the patient's response to the therapy.This includes assessing nutritional status, adjusting the formula as needed, and managing any complications.
In simple words: This code covers a special liquid food formula given through a feeding tube to people with inherited conditions that prevent their bodies from properly using nutrients. The formula provides all the essential nutrients and is tailored to each patient's specific needs.
This HCPCS code, B4157, represents a nutritionally complete enteral formula specifically designed for patients with inherited metabolic diseases.The formula contains proteins, fats, carbohydrates, vitamins, and minerals, and may include fiber.It is administered through an enteral feeding tube (inserted into the stomach or small intestine) and is billed in units of 100 calories. The precise nutrient composition is tailored to meet the individual metabolic needs of the patient, addressing deficiencies caused by genetic or inherited metabolic conditions hindering nutrient absorption or utilization. Medicare covers modular nutrients within such formulas provided medical necessity is documented.
Example 1: A 6-month-old infant diagnosed with phenylketonuria (PKU) receives B4157 formula, adjusted to manage phenylalanine levels.The physician closely monitors phenylalanine levels through regular blood tests and adjusts the formula as needed., A 10-year-old child with maple syrup urine disease (MSUD) requires B4157 to meet specific branched-chain amino acid restrictions. The formula is provided in a hospital setting after a MSUD crisis is resolved, with the patient slowly transitioning to a home program., An adult with a rare inherited metabolic disorder receives home-based enteral nutrition with B4157, under the supervision of a registered dietitian and physician who adjust nutrient levels as needed. Patient compliance and feeding tube maintenance are monitored.
* Diagnosis of the inherited metabolic disorder.* Physician's order for the specific enteral formula.* Documentation of medical necessity, including the patient's nutritional status, specific metabolic needs, and the rationale for using the selected formula.* Details on the formula's composition and administration method.* Monitoring of the patient's response to the therapy, including any adverse effects.
** The unit of measure for billing B4157 is 100 calories.The specific products covered under this code may vary, depending on the manufacturer and the patient's unique nutritional needs.Always refer to the payer's specific coverage policies before billing.
- Payment Status: Active
- Fee Schedule: Specific historical fee schedule data is not available here. Check payer specific guidelines for historical reimbursement rates.
- Specialties:* Gastroenterology* Endocrinology* Genetics* Metabolism* Nutritional Support
- Place of Service:Office, Home, Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility