Nutritional Diagnosis Grid - Alabama Medicaid Agency

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Pediasure with Fiber 1-13 Pepdite One+ 1-10 Peptamen ≥ 11 Adult Peptamen 1.5 Adult Peptamen AF >12 months Adult Peptamen Bariatric N/A Adult Peptamin Junior 1-10 Peptamen Junior Fiber 1-10 N/A Peptamen Junior-Prebio Peptamen Junior 1.5 >12 months - 10 years >12 months - 13 years N/A N/A Peptamen OS >12 months Adult Peptamen OS 1.5 >12 months Adult Tube fed patients, acute care or chronic tube feedings: Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Jakob-Creutzfeldt disease (046.1); Other demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Supranuclear Palsy (333.0); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Malnutrition (261); Post-op feeding, within 30 days of surgery (579.3) Metabolically stressed with impaired GI function due to intractable diarrhea (787.91); Inflammatory Bowel Disease (558.9); Ulcerative colitis (556.9); GI surgery, up to 4 weeks pre- or post-op only (564.2); Malabsorption (579.9); CF ( 277.00); Short Bowel Syndrome (579.3); Chronic pancreatitis (577.1); Crohn’s disease (555.0, 555.1, 555.2, 555.9) Impaired GI function (579.8, 579.9, 558.9, 564.2, 536.9) short bowel syndrome (579.3), pancreatic insufficiency (577.8) chronic diarrhea (787.91, 564.5), radiation enteritis (558.1), and delayed gastric emptying (536.8); Cerebral palsy (343.9) Impaired GI function (579.8, 579.9, 558.9, 564.2, 536.9, 569.8, 558.1, 579.3, 787.91) and increased caloric requirements (261, 799.4, 199.1, 263.8, 263.0, 707.0, 879.8, 998.83, 940-949), including those with malabsorption (579.9) complicated by fluid restriction (428.0, 276.6), elevated caloric requirements, volume sensitivity, shortened feeding cycle, or aggressive goal rate attainment; Cerebral palsy (343.9) GI impairment: short bowel syndrome: 579.3, IBD: 558.9, malabsorption syndrome: 579.9, cow’s milk enteropathy/sensitivity: 579.8; Crohn’s disease: 555.0, 555.1, 555.2, 555.9, GI fistula, intractable diarrhea 787.91, 564.5; AIDS-related GI disorders: 042, celiac disease: 579.0, cystic fibrosis: 277.0, chronic diarrhea: 787.91, pancreatic disorders 577.9; Acute Protein Malnutrition: 263.9; Organ Transplant: V42.0-42.9 Critically ill obese patient - Acute hepatitis C with coma: 70.41; Hyponatremia/other electrolyte disturbance: 276.1; Metabolic acidosis/other acid base disturbances: 276.2; Hypovolemia: 276.5; Cerebral edema: 348.5; Malignant hypertension: 401.00 - 404.00; Hypertensive urgency: 402.91; Acute myocardial infarction: 410.00; Acute cor pulmonale: 415.0; Atrial fibrillation: 427.31; Congestive heart failure: 428.1; Cerebral vascular accident: 433.00; Hepatic necrosis: 570; Hepatic encephalopathy: 572.2; Hypoxemia: 799.02; Respiratory arrest: 799.1; Respiratory failure following trauma or surgery: 518.5; Acute respiratory failure: 518.81; Other pulmonary insufficiency, NEC, such as ARDS: 518.82; Chronic respiratory failure with no acute component: 518.83; Acute and chronic respiratory failure: 518.84; Other diseases of the lung, NEC, such as broncholithiasis: 518.89; Acute renal failure: 584; Severe shortness of breath: 786.05; Tachypnea, substernal chest pain: 786.51; Abnormal chest x-ray: 793.1; Poisonings: 960-989; Hypothermic injury: 991; Heat injuries: 992; Barotrauma: 993; Anaphylactic shock: 995.6; Sepsis: 995.91; Severe sepsis with acute or multiple organ dysfunction: 995.92; Terminally ill: 799.3; Obesity: 278.0 Impaired GI function, to include IBD (558.9) , short bowel syndrome (579.3), CF (277.00), chronic diarrhea (787.91, 564.5), malabsorption (579.9), delayed gastric emptying (536.8), HIV/AIDSrelated malabsorption (042), and growth failure (783.4, 784.3); Cerebral palsy (343.9) Impaired GI function, to include IBD (558.9) , short bowel syndrome (579.3), CF (277.00), chronic diarrhea (787.91, 564.5), malabsorption (579.9), delayed gastric emptying (536.8), HIV/AIDSrelated malabsorption (042), and growth failure (783.4, 784.3); Cerebral palsy (343.9) Chronic diarrhea: (787.91); intestinal malabsorption: (579.0 - 579.9); growth failure: (783.4, 784.3); short bowel syndrome: (579.3); bowel transplant: (V42.8-42.9); Cerebral palsy: (343.0 - 343.4, 343.8- 343.9); Crohn’s Disease: (555.0, 555.1, 555.2, 555.9); HIV or AIDS: (042); cystic fibrosis: (277.0); Cerebral palsy: (343.9) Impaired GI Function: Intractable Diarrhea: 787.91; Inflammatory Bowel Disease: 558.9; GI surgery, within 4 weeks pre- or post-op: 564.2; Malabsorption 579.9; Short Bowel Syndrome: 579.3; Chronic pancreatitis: 577.1; Crohn’s disease: 555.0, 555.1, 555.2, 555.9; Radiation enteritis: 558.1; Ulcerative colitis: 556.9 Cystic fibrosis: (277.0); Cerebral palsy: (343.0 - 343.4, 343.8-343.9); HIV or AIDS: (042); short bowel syndrome: (579.3); pancreatitis: (577.0, 577.1); IBD: (558.9); Malnutrition: (261) Cystic fibrosis: (277.0); Cerebral palsy: (343.0 - 343.4, 343.8-343.9); HIV or AIDS: (042); short bowel syndrome: (579.3); pancreatitis: (577.0, 577.1); IBD: (558.9); Malnutrition: (261); Crohn’s Disease: (555.0, 555.1, 555.2, 555.9) 14 10/1/11
Peptamen with Prebio ≥ 10 Adult Peptinex DT > 12 months Adult Perative ≥ 4 Adult Inflammatory Bowel Disease (558.9); Ulcerative colitis (556.9); GI surgery, up to 4 weeks pre- or post-op only (564.2); Malabsorption (579.9); CF (277.00); Short Bowel Syndrome (579.3); Chronic pancreatitis (577.1); Crohn’s disease (555.0, 555.1, 555.2, 555.9); HIV or AIDS (042); Cerebral palsy (343.9) Inflammatory Bowel Disease (558.9); Ulcerative colitis (556.9); GI surgery, up to 4 weeks pre- or post-op only (564.2); Malabsorption (579.9); CF (277.00); Short Bowel Syndrome (579.3); Chronic pancreatitis (577.1); Crohn’s disease (555.0, 555.1, 555.2, 555.9); HIV or AIDS (042) Metabolically stressed patients with multiple fractures (829.0), wounds (879.8), burns (940.0-949.9), decubitus ulcers (707.0), surgery, within 30 days post-op (998.83), hypermetabolism (794.7) Periflex Infant/Junior ≥ 2 PKU (270.1) Periflex Advance PKU >12 months N/A Phenylketonuria (PKU): 270.1 PFD 1 < 3 Congenital heart disease (746.9), CHF (428.0), bronchopulmonary dysplasia (770.7), other specified inborn errors of metabolism PFD 2 > 2 Adult Disorders of amino acid metabolism (270.0, 270.1, 270.2, 270.3, 270.4, 270.5, 270.6, 270.7, 270.8, 270.9, 277.1, 277.2) Phenex-1 ≤ 3 PKU/hyperphenylalaninemia (270.1) Phenex-2 > 12 months Adult PKU/hyperphenylalaninemia (270.1) PhenylAde > 12 months Adult PKU (270.1) Phenylade 40 > 2 Adult PKU (270.1) Phenylade 60 >12 months N/A Phenylketonuria (PKU): 270.1 PhenylAde Amino Acid >12 months N/A Phenylketonuria (PKU): 270.1 Phenylade Essential >12 months N/A Phenylketonuria (PKU): 270.1 Phenylade MTE > 2 Adult PKU (270.1) PhenylAde Phebloc >12 years Adult Phenylketonuria (PKU): 270.1 Phenyl-Free 1 All PKU/hyperphenylalaninemia (270.1) Phenyl Free 2 ≥ 2 Adult PKU/hyperphenylalaninemia (270.1) Phenyl Free 2 HP > 12 months Adult PKU/hyperphenylalaninemia (270.1) Phenylene >12 months - 8 years N/A PKU/hyperphenylalaninemia: 270.1 Phenylene 75 >9 Adult PKU/hyperphenylalaninemia: 270.1 Phlexy-10 > 12 months Adult PKU/hyperphenylalaninemia (270.1) Phlexy Vits ≥ 11 Adult PKU/hyperphenylalaninemia (270.1) Pivot 1.5 CAL ≥ 10 Adult For patients with increased caloric requirement and/or a fluid restriction unable to maintain adequate nutrition orally (584.9, 586, 585, 428.0, 276.6, 949.3, 949.4, 949.5) PKU 2 > 12 months PKU (270.1) PKU 2 Tomato >5 N/A PKU/hyperphenylalaninemia: 270.1 PKU 3 > 8 PKU (270.1) PKU Cooler 10 ≥3 N/A Phenylketonuria (PKU): 270.1 PKU Cooler 15 ≥3 N/A Phenylketonuria (PKU): 270.2 PKU Cooler 20 ≥3 N/A Phenylketonuria (PKU): 270.3 PKU Express ≥ 8 Adult PKU (270.1) PKU Gel 1-10 PKU (270.1) PKU Lophlex > 4 years Adult PKU (270.1) 15 10/1/11
Page 1 and 2: NUTRITIONAL PRODUCT GRID PRODUCT PE
Page 3 and 4: Diabetisource AC ≥ 10 Adult Duoca
Page 5 and 6: FiberSource HN > 12 months Adult Co
Page 7 and 8: Isosource Protein/ Isosource HN ≥
Page 9 and 10: Kindercal TF/ Kindercal TF w/Fiber
Page 11 and 12: Nutren 1.0 with Fiber ≥ 10 Adult
Page 13: Optimental > 10 Adult Metabolically
Page 17 and 18: Pulmocare > 12 months Adult Pulmona
Page 19: XLYS, XTRP Analog 1-10 N/A Glutaric

Nutritional Diagnosis Grid - Alabama Medicaid Agency

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