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

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(Outpatient or home) when the body’s own kidneyshave failed. Waste isremoved directly from theblood.83XPeritoneal Dialysis(Outpatient or home)84XContinuousAmbulatoryPeritoneal Dialysis(CCPD)(Outpatient or home)85XContinuous CyclingPeritoneal Dialysis(CCPD)(Outpatient or home)88XMiscellaneousDialysis89XOther Donor Bank(extension of 81X)A waste removal process,performed in an outpatient orhome setting, necessarywhen the bodies own kidneyshave failed. Waste isremoved indirectly by flushinga special solution betweenthe abdominal covering andthe tissue.A continuous dialysis processperformed in an outpatient orhome setting using thepatient peritoneal membraneas a dialyzer.A continuous dialysis processperformed in an outpatient orhome setting using amachine to make automaticchanges at night.Charges for dialysis servicesnot identified elsewhere.Charges for the acquisition,storage, and preservation ofall human organs (excluding2 Home supplies3 Home equipment4 Maintenance/100%5 Support services9 Other outpatient hemodialysis0 General classification1 Peritoneal/composite or otherrate2 Home supplies3 Home equipment4 Maintenance/100%5 Support services9 Other outpatient peritonealdialysis0 General classification1 CAPD/composite or other rate2 Home supplies3 Home equipment4 Maintenance/100%5 Support services9 Other outpatient CAPD0 General classification1 CCPD/composite or other rate2 Home supplies3 Home equipment4 Maintenance/100%5 Support services9 Other outpatient CCPD0 General classification1 Ultrafiltration2 Home dialysis aid visit9 Miscellaneous dialysis other0 General classification1 Bone
92XOther DiagnosticServices94XOther TherapeuticServices99XPatientConvenience Itemskidneys, livers, and hearts –see 81X).Charges for other therapeuticservices not otherwisecategorized.Charges for items generallyconsidered by the third partypayers to be strictlyconvenience items, and,therefore, are not covered.2 Organ (other than kidney)3 Skin9 Other donor bank0 General classification1 Peripheral vascular lab2 Electromyelogram3 Pap smear4 Allergy test5 Pregnancy test9 Other diagnostic services0 General classification1 Recreational therapy2 Education/training3 Cardiac rehabilitation4 Drug rehabilitation5 Alcohol rehabilitation6 Complex medical equipment –routine7 Complex medical equipment –ancillary9 Other therapeutic services0 General classification1 Cafeteria/guest tray2 Private linen service3 Telephone/telegraph4 TV/radio5 Nonpatient room rentals6 Late discharge charge7 Admission kits8 Beauty shop/barber9 Other patient convenienceitems** If you have any questions about this information, please contact Provider Services at1-800-338-7909. Local in the Des Moines area at 515-256-4609.
Page 1 and 2: Iowa Medicaid EnterpriseUB-04 Claim
Page 3 and 4: (non-hospital based)2 Hospice (hosp
Page 5 and 6: 14Type ofAdmission/VisitSITUATIONAL
Page 7 and 8: 72 Trans for Outpatient ServiceEnte
Page 9 and 10: Other11 Date of onset35-36 Occurren
Page 11 and 12: 46 Service UnitsSITUATIONALOutpatie
Page 13 and 14: 58 Insured’s name59 Patient’s R
Page 15 and 16: 77 *78 *79 *QualLastFirstLEAVEBLANK
Page 17 and 18: Revenue CodesBOX 42CODE DEFINED SUB
Page 19 and 20: 24XAll InclusiveAncillary25XPharmac
Page 21 and 22: 35XCT Scan36XOperating RoomServices
Page 23 and 24: 45XEmergency Room46XPulmonary Funct
Page 25 and 26: (home health agencyonly)61XMRI62XMe
Page 27: (electroencephalogram)75XGastro-Int

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

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