Services and Circumstances That Require Additional Documentation

The submission of additional documentation is required only when certain CPT®/HCPCS codes are billed, or when additional documentation is needed for Palmetto GBA to process and or price a service.

When required, additional documentation should be submitted using the eServices portal and your claim must include the necessary information (electronic claim PWK segments or Item 19 on the CMS-1500 claim form) to alert Palmetto GBA that you have submitted the required documentation.

Whether you are submitting your additional documentation via eServices or fax, the following PWK data elements must be completed on your electronic claim.

Loop 2300

PWK01 (Attachment Report Type Code)
Use the values indicated in the TR3 to identify the type of attachment. Examples:

• M1 (Medical record attachment)
• OD (Orders and treatments document)
• P5 (Patient medical history document)
• PY (Physician’s report)

PWK02 (Attachment Transmission Code)

• Indicates a code identifying how the attachment will be sent
• PWK02 = BM (mail) FX (fax) or EL (electronically)

PWK05 (Identification Code Qualifier)

• Required when PWK02 = BM, FX or EL
• PWK05= AC

PWK06 (Attachment Control Number)

• A value assigned by the provider/software vendor to uniquely identify the attachment
• Must be 2–50 characters
• Can be all numeric, all alphabetical, and/or a combination
• ACN submitted on the claim must match the ACN entered on the PWK coversheet and form

View the Submitting Additional Documentation to Palmetto GBA article to assure proper claim submission and procedures.

Note: Additional documentation should not be submitted for services or circumstances other than those listed below. Documentation received for services or circumstances other than those listed (or if specifically requested by Palmetto GBA through the additional documentation request (ADR) process) will not be acknowledged and matched with your claim.

Important: When submitting one of the CPT®/HCPCS Codes below and the code is not presented in the procedure code selection box in eServices, additional documentation can be submitted via the PWK fax cover sheet until the procedure code is available in eServices.

CPT®/HCPCS Codes

Note: CPT® codes and modifiers begin with a numeric character and HCPCS codes and modifiers begin with an alpha character.

CPT® Codes

HCPCS Codes