Iowa Medicaid Enterprise UB-04 Claim Form Health Insurance ...

43 Revenue Description43 Page ___ of ___Line2344 HCPCS/Rates/HIPPSRate CodesSITUATIONALSITUATIONALSITUATIONAL – Required if the providerenters a HCPCs “J-code” for a drug that hasbeen administered. Enter the National DrugCode (NDC) that corresponds to the J-codeentered in Field 44. The NDC must bepreceded with a “N4” qualifier. NDC shouldbe entered in NNNNN-NNNN-NN format. NOOTHER ENTRIES SHOULD BE MADE INTHIS FIELD.REQUIRED if claim is more than one page.Enter the page number and the total numberof pages for the claim.NOTE: The “PAGE ___ OF ___” andCREATION DATE on line 23 should bereported on all pages of the UB-04REQUIRED for Outpatient Hospital, InpatientSNF, and Home Health Agencies.Outpatient Hospital – Enter the HCPCS/CPTcode for each service billed, assigning aprocedure, ancillary or medical APG.Inpatient SNF – Enter the HCPCS codeW0511 for ventilator dependent patients,otherwise leave blank.Home Health Agencies – Enter theappropriate HCPCS code from the priorauthorization when billing for EPSDT relatedservices.All Others – Leave blank.DO NOT enter rates in this field.* When applicable, a procedure code modifiershould be displayed after the procedure code.SITUATIONAL45 Service Dates SITUATIONAL REQUIRED for Outpatient claims.