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.

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 Fax Cover Sheet or PWK Fax Cover Sheet until the procedure code is available in eServices.

CPT/HCPCS Codes
01999
15999
17999
19499
20999
21089
21299
21499
21899
22899
22999
23929
24999
25999
26989
27299
27599
27899
28899
29799
29999
30999
31299
31599
31899
32999
33999
36299
37501
37799
38129
38589
38999
39499
39599
40799
40899
41599
41899
42299
42699
42999
43289
43499
43659
43999
44238
44799
44899
44979
45399
45499
45999
46999
47379
47399
47579
47999
48999
49329
49659
49999
50549
50949
51999
53899
54699
55559
55899
55970
55980
58578
58579
58679
58999
59897
59898
59899
60659
60699
64999
66999
67299
67399
67599
67999
68399
68899
69399
69799
69949
69979
76120
76125
76496
76497
76498
76499
76999
77299
77399
77499
77799
78099
78199
78299
78399
78499
78599
78699
78799
78999
79999
80299
81099
81400
81401
81402
81403
81404
81405
81406
81407
81408
81479
81599
82664
84999
85999
86486
86812
86813
86816
86817
86821
86822
86825
86826
86849
86999
87299
87798
87799
87899
87999
88099
88199
88299
88399
88749
89240
89398
90284
90399
90654
90655
90657
90660
90661
90669
90749
90899
90999
91299
92499
92700
93799
93998
94799
95199
95999
96360
96368
96379
96549
96999
97039
97139
97151
97152
97153
97154
97155
97156
97157
97158
97799
99082
99199
99429
99499
99600
0159T
0188T
0189T
0190T
0195T
0196T
0337T
0346T
0359T
0360T
0361T
0363T
0364T
0365T
0366T
0367T
0368T
0369T
0370T
0371T
0372T
0374T
0387T
0388T
0389T
0390T
0391T
0406T
0407T
0479T
0480T
0483T
0505T
0506T
0507T
0508T
0509T
0510T
0511T
0512T
0513T
0514T
0515T
0516T
0517T
0518T
0519T
0520T
0521T
0522T
0523T
0524T
0525T
0526T
0527T
0528T
0529T
0530T
0531T
0532T
0533T
0534T
0535T
0536T
0537T
0538T
0539T
0540T
0541T
0542T
0543T
0544T
0545T
0546T
0547T
0548T
0549T
0550T
0551T
0552T
0553T
0554T
0555T
0556T
0557T
0558T
0559T
0560T
0561T
0562T
A0999
A4290
A4563
A4640
A4641
A4642
A4648
A4650
A9501
A9504
A9508
A9509
A9516
A9526
A9527
A9529
A9532
A9536
A9542
A9543
A9544
A9545
A9546
A9547
A9550
A9553
A9554
A9555
A9557
A9559
A9563
A9564
A9566
A9567
A9570
A9571
A9582
A9584
A9586
A9597
A9598
A9699
A9999
C1823
C9399
D2999
D5899
D6199
D7999
D9999
E1399
J0120
J0475
J0715
J0735
J0833
J0945
J1060
J1094
J1130
J1170
J1230
J1330
J1435
J1457
J1710
J1725
J1729
J1810
J1890
J1990
J2180
J2275
J2278
J2320
J2650
J2795
J2910
J2950
J3010
J3305
J3310
J3398
J3400
J3472
J3490
J3591
J7199
J7309
J7315
J7331
J7332
J7401
J7629
J7799
J7999
J9044
J9118
J9219
J9999
L7510
L8499
L8604
L8608
L8699
L9900
Q0507
Q0508
Q0509
Q2028
Q2036
Q2038
Q2039
Q3001
Q4050
Q4051
Q4116
Q4117
Q4118
Q4125
Q4126
Q4128
Q4130
Q4134
Q4135
Q4138
Q4140
Q4142
Q4143
Q4145
Q4146
Q4147
Q4149
Q4150
Q4151
Q4153
Q4154
Q4155
Q4157
Q4158
Q4161
Q4163
Q4164
Q4165
Q4167
Q4168
Q4169
Q4170
Q4171
Q4173
Q4174
Q4175
Q4176
Q4179
Q4182
Q4183
Q4184
Q4185
Q4188
Q4190
Q4191
Q4192
Q4193
Q4197
Q4198
Q4200
Q4201
Q4202
Q4203
Q4204
Q4205
Q4206
Q4208
Q4209
Q4210
Q4211
Q4212
Q4213
Q4214
Q4215
Q4216
Q4217
Q4220
Q4221
Q4222
Q4226
Q5116
Q5118
Q9953
Q9954
Q9962
Q9969
V2785
V2799
V5299
 
 
 

Modifiers

22
24
52
53
55
62
66
73
74
77
GM

Important Note: While Palmetto GBA has made every attempt to identify all services that will require additional documentation, the above list is not all-inclusive due to the nature of health care and changes in coding and pricing requirements.

Palmetto GBA reserves the right to require additional documentation for any claim.
Claims rejected with the following Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) identified on a remittance advice would indicate documentation is required and the claim should be resubmitted as a new claim with the necessary documentation. Providers receiving these rejections for lack of documentation should make note and include documentation with any claim submitted in the future for the service(s). 

CARC
RARC
251 — The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
N233 — Incomplete/invalid operative note/report
251 — The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
N705 — Incomplete/invalid documentation
252 — An attachment/other documentation is required to adjudicate this claim/service
M23 — Missing Invoice
252 — An attachment/other documentation is required to adjudicate this claim/service
M29 — Missing operative/note/report
252 — An attachment/other documentation is required to adjudicate this claim/service
N706 — Missing Documentation

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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