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

24XAll InclusiveAncillary25XPharmacy26XIV Therapy27XMedical/SurgicalSupplies andDevices(also see 62X, anextension of 27X)28XOncologyA flat rate charge incurred oneither a daily or total staybasis for ancillary servicesonly.Charges for medicationproduced, manufactured,packaged, controlled,assayed, dispensed, anddistributed under direction oflicensed pharmacies.Equipment charge oradministration of intravenoussolution by specially trainedpersonnel to individualsrequiring such treatment.This code should be usedonly when a discrete serviceunit exists.Charges for supply itemsrequired for patient care.Charges for the treatment oftumors and related diseases.9 Other0 General classification9 Other inclusive ancillary0 General classification1 Generic drugs2 Nongeneric drugs3 Take home drugs4 Drugs incident to otherdiagnostic services5 Drugs incident to radiology6 Experimental drugs7 Nonprescription8 IV solutions9 Other pharmacy0 General classification1 Infusion pump2 IV therapy/pharmacy services3 IV therapy/drug/supply delivery4 IV therapy/supplies9 Other IV therapy0 General classification1 Nonsterile supply2 Sterile supply3 Take home supplies4 Prosthetic/orthotic devices5 Pacemaker6 Intraocular lens7 Oxygen – take home8 Other implants9 Other supplies/devices0 General classification9 Other oncology29X Charges for medical 0 General classification