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

67 A-Q Other DiagnosisCodes68 Untitled69 Admitting Diagnosis70 A-C Patient’s Reason forVisitSITUATIONALOPTIONALSITUATIONALSITUATIONAL71 PPS (ProspectivePayment System)Code OPTIONAL No entry required.72 ECI (External Causeof Injury codesOPTIONAL No entry required.73 Untitled OPTIONAL No entry required.74 Principal ProcedureCode and Date74 A-E Other ProcedureCodes and DatesSITUATIONALSITUATIONAL75 Untitled OPTIONAL No entry required.76 *W Unable to clinically determine if present attimeof admission.(blank) Diagnosis is exempt from POAreporting.1 Invalid indicator – do not submit!REQUIRED if a diagnosis other than theprincipal is made. Enter the ICD-9-CM codesfor additional diagnosis.No entry required.REQUIRED for Inpatient hospital claims.Inpatient Hospital – The admitting diagnosisis required.REQUIRED if visit is unscheduled. Patient’sReason for Visit is required for all unscheduledoutpatient visits for outpatient bills.REQUIRED for the principal surgicalprocedure, enter the ICD-9-CM procedurecode and surgery date, when applicable.REQUIRED for additional surgicalprocedures, enter the ICD-9-CM procedurecodes and surgery dates.Attending Provider Name and IdentifiersNPIEnter the NPI of the attending physician.REQUIREDRequired when claim/encounter contains anyservices other than nonscheduledtransportation services.