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

(home health agencyonly)61XMRI62XMedical/SurgicalSupplies(extension of 27X)63XDrugs RequiringSpecificIdentification64XHome IV TherapyServicesprimarily responsible for thepersonal care of the patientCharges for MagneticResonance Imaging of thebrain and other body parts.Charges for supply itemsrequired for patient care. Thecategory is an extension of27X for reporting additionalbreakdown where needed.Subcode 1 is for providersthat cannot bill supplies usedfor radiology proceduresunder radiology. Subcode 2is for providers that cannotbill supplies used for otherdiagnostic procedures.Charges for drugs andbiologicals requiring specificidentification as required bythe payer. IfHCPCS is used to describethe drug, enter theHCPCS code in UB-04 formfield number 44.Charges for intravenous drugtherapy services performed inthe patient’s residence. Forhome IV providers theHCPCS code must beentered for all equipment andall types of covered therapy.2 Hourly charge9 Other home health aideservices0 General classification1 Brain (including brainstem)2 Spinal cord (including spine)9 Other MRI1 Supplies incident to radiology2 Supplies incident to otherdiagnostic services0 General classification1 Single source drug2 Multiple source drug3 Restrictive prescription4 Erythropoietin (EPO), less than10,000 units5 Erythropoietin (EPO), 10,000 ormore units6 Drugs requiring detailed coding0 General classification1 Nonroutine nursing, central line2 IV site care, central line3 IV site/change, peripheral line4 Nonroutine nursing, peripheralline