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

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.