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

35XCT Scan36XOperating RoomServices37XAnesthesia38XBlood39XBlood Storageand Processing40XOther ImagingServicesradioisotope laboratoryutilizing radioactive materialsas required for diagnosis andtreatment of patients.Charges for computedtomographic scans of thehead and other parts of thebody.Charges for servicesprovided to patient byspecifically trained nursingpersonnel who assistedphysicians in surgical/relatedprocedures during andimmediately followingsurgery.Charges for anesthesiaservices in the hospital.Charges for blood must beseparately identified forprivate payer purposes.Charges for the storage andprocessing of whole blood.2 Therapeutic9 Other0 General classification1 Head scan2 Body scan9 Other CT scans0 General classification1 Minor surgery2 Organ transplant – other thankidney7 Kidney transplant9 Other operating room services0 General classification1 Anesthesia incident toradiology2 Anesthesia incident to otherdiagnostic services4 Acupuncture9 Other anesthesia0 General classification1 Packed red cells2 Whole blood3 Plasma4 Platelets5 Leukocytes6 Other components7 Other derivatives(cryoprecipitates)9 Other blood0 General classification1 Blood administration9 Other blood storage andprocessing0 General classification1 Diagnostic mammography2 Ultrasound