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

72 Trans for Outpatient ServiceEnter corresponding codes to indicatewhether ornot treatment billed on this claim is related toanycondition listed below.Up to seven codes may be used to describetheconditions surrounding a patient’s treatment.General01 Military service related02 Condition is employment related here04 HMO enrollee05 Lien has been filedInpatient Only80 Neonatal level II or III unit81 Physical rehabilitation unit82 Substance abuse unit83 Psychiatric unitX3 IFMC approved lower level of care, ICFX4 IFMC approved lower level of care, SNF91 Respite careOutpatient Only84 Cardiac rehabilitation program85 Eating disorder program86 Mental health program87 Substance abuse program88 Pain management program89 Diabetic education program90 Pulmonary rehabilitation program98 Pregnancy indicator – outpatient orrehabilitation agency18-28 Condition Codes SITUATIONALSpecial Program IndicatorA1 EPSDTA2 Physically handicapped children’sprogramA3 Special federal funding