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

(electroencephalogram)75XGastro-IntestinalServices76XTreatment orObservation Room79XLithotripsy80XInpatient RenalDialysis81XOrgan Acquisition(see 89X)82XHemodialysismeasuring impulsefrequencies and differencesin electrical potential invarious brain areas to obtaindata used in diagnosing braindisorders.Procedure room charges forendoscopic procedures notperformed in the operatingroom.Charges for the use of atreatment room or the roomcharge associated withoutpatient observationservices. HCPCS codeW9220 must be used withthese codes on outpatientclaims.Charges for the use oflithotripsy in the treatment ofkidney stones.A waste removal processperformed in an inpatientsetting using an artificialkidney when the bodies ownkidneys have failed. Thewaste may be removeddirectly from the blood orindirectly from the blood byflushing a special solutionbetween the abdominalcovering and the tissue.The acquisition of a kidney,liver or heart for transplantuse. (All other human organsfall under category 89X.)A waste removal process,performed in an outpatient orhome setting, necessary0 General classification9 Other gastro-intestinal0 General classification1 Treatment room2 Observation room9 Other treatment/observationroom0 General classification9 Other lithotripsy0 General classification1 Inpatient hemodialysis2 Inpatient peritoneal(nonCAPD)3 Inpatient continuousambulatory peritoneal dialysis4 Inpatient continuous cyclingperitoneal dialysis (CCPD)9 Other inpatient dialysis0 General classification1 Living donor – kidney2 Cadaver donor – kidney3 Unknown donor – kidney4 Other kidney acquisition5 Cadaver donor – heart6 Other heart acquisition7 Donor – liver9 Other organ acquisition0 General classification1 Hemodialysis/composite orother rate