Anthem Blue Cross Blue Shield of Georgia policy
CG-MED-89 Home Parenteral Nutrition
CG-MED-89 Home Parenteral Nutrition is a public Anthem Blue Cross Blue Shield of Georgia policy (policy CG-MED-89). It lists 27 CPT or HCPCS codes, 26 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-MED-89
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| B4164 | On the list | Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix | Policies naming B4164 |
| B4168 | On the list | Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix | Policies naming B4168 |
| B4172 | Not listed | Policies naming B4172 | |
| B4176 | On the list | Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix | Policies naming B4176 |
| B4178 | On the list | Parenteral nutrition solution; amino acid, greater than 8.5%, (500 ml = 1 unit) - home mix | Policies naming B4178 |
| B4180 | On the list | Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix | Policies naming B4180 |
| B4185 | On the list | Parenteral nutrition solution, not otherwise specified, 10 grams lipids | Policies naming B4185 |
| B4187 | On the list | Omegaven, 10 grams lipids | Policies naming B4187 |
| B4189 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix | Policies naming B4189 |
| B4193 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix | Policies naming B4193 |
| B4197 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix | Policies naming B4197 |
| B4199 | On the list | Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, over 100 grams of protein - premix | Policies naming B4199 |
| B4216 | On the list | Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per day | Policies naming B4216 |
| B4220 | On the list | Parenteral nutrition supply kit; premix, per day | Policies naming B4220 |
| B4222 | On the list | Parenteral nutrition supply kit; home mix, per day | Policies naming B4222 |
| B4224 | On the list | Parenteral nutrition administration kit, per day | Policies naming B4224 |
| B5000 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Aminosyn-RF, NephrAmine, RenAmine - premix | Policies naming B5000 |
| B5100 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, HepatAmine - premix | Policies naming B5100 |
| B5200 | On the list | Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids - FreAmine-HBC - premix | Policies naming B5200 |
| B9004 | On the list | Parenteral nutrition infusion pump, portable | Policies naming B9004 |
| B9006 | On the list | Parenteral nutrition infusion pump, stationary | Policies naming B9006 |
| B9999 | On the list | NOC for parenteral supplies | Policies naming B9999 |
| S9364 | On the list | Home infusion therapy, total parenteral nutrition (TPN) (do not use with home infusion codes S9365- S9368 using daily vol | Policies naming S9364 |
| S9365 | On the list | Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Policies naming S9365 |
| S9366 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Policies naming S9366 |
| S9367 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Policies naming S9367 |
| S9368 | On the list | Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula, and nursing visits coded separately) per diem | Policies naming S9368 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list