Services and Circumstances That Require Additional Documentation

Published 09/23/2024

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 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 modifier begin with a numberic character and HCPCS codes and modifiers begin with an alpha character.

CPT® Codes

Table 1. CPT Codes.
Code Range 00000 – 09999

01999

0408T

0409T

0410T

0411T

0412T

0413T

0414T

0415T

0416T

0417T

0418T

Code Range 10000 – 19999
15999 17999 19499
Code Range: 20000 – 29999
20999 21089 21110
21299 21499 21899
22899 22999 23929
24999 25999 26989
27299 27599 27899
28899 29799 29999
Code Range: 30000 – 39999
30999 31299 31599
31899 32999 33999
36299 37501 37799
38129 38589 38999
39499 39599  
Code Range: 40000 – 49999
40799 40899 41599
41899 42299 42699
42999 43289 43499
43659 43999 44238
44799 44899 44979
45399 45499 45999
46999 47379 47399
47579 47999 49329
49659 49999  
Code Range: 50000 – 59999

50549

50949

51999

53899

54699

55559

55899

55970

55980

58578

58579

58679

58999

59897

59898

59899

 

 

Code Range: 60000 – 69999

60659

60699

64999

66983

66987

66988

66999

67299

67399

67599

67999

68399

68899

69399

69799

69949

69979

 

Code Range: 70000 – 79999

76120

76125

76496

76497

76498

76499

76999

77299

77399

77499

77799

78099

78199

78299

78399

78429

78430

78431

78432

78433

78434

78499

78599

78699

78799

78999

79999

Code Range: 80000 – 89999

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

87154

87299

87483

87798

87799

87899

87999

88099

88199

88299

88399

88749

89240

89398

 

Code Range: 90000 – 99999

90284

90399

90653

90654

90655

90656

90657

90660

90661

90669

90749

90899

90999

91299

92499

92700

93799

93998

94799

95199

95706

95707

95709

95710

95711

95712

95713

95714

95715

95716

95999

96379

96549

96999

97039

97139

97151

97152

97153

97154

97155

97156

97157

97158

97799

99082

99199

99429

99499

99600

 

Code Range: 0000T – 0999T

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

0563T

0567T

0569T

0570T

0571T

0572T

0573T

0574T

0575T

0581T

0582T

0583T

0584T

0585T

0586T

0587T

0591T

0592T

0593T

0594T

0598T

0599T

0600T

0601T

0609T

0610T

0611T

0612T

0613T

0730T

0737T

 

 

HCPCS Codes

Table 2. HCPCS Codes.
Code Range: A0000 – A9999

A0999

A2019

A4290

A4563

A4640

A4641

A4642

A4648

A4650

A9501

A9504

A9508

A9509

A9516

A9517

A9527

A9529

A9532

A9536

A9542

A9543

A9544

A9545

A9546

A9547

A9550

A9553

A9554

A9557

A9559

A9563

A9564

A9566

A9567

A9570

A9571

A9572

A9582

A9584

A9586

A9597

A9598

A9699

A9999

 
Code Range: C0000 – C9999
C1823 C1824 C1826
C9399    
Code Range: D0000 – D9999
D2999 D5899 D6199
D7999 D9999  
Code Range: E0000 – E9999
E1399
HCPCS Codes G0000 – G9999
G0308 G0309
Code Range: J0000 – J9999
J0120 J0400 J0475
J0665 J0715 J0735
J0883 J0945 J1060
J1094 J1130 J1170
J1230 J1330 J1435
J1457 J1710 J1725
J1729 J1810 J1890
J1990 J2180 J2278
J2320 J2650 J2795
J2797 J2910 J2950
J3010 J3303 J3305
J3310 J3398 J3400
J3472 J3490 J3590
J3591 J7170 J7199
J7309 J7315 J7629
J7799 J7999 J9044
J9057 J9219 J9999
Code Range: L0000
L7510 L8499 L8604
L8608 L8679 L8699
L9900    

Code Range: Q0000 – Q9999

Q0507

Q0508

Q0509

Q2028

Q2035

Q2036

Q2038

Q2039

Q3001

Q4050

Q4051

Q4116

Q4125

Q4130

Q4135

Q4136

Q4138

Q4140

Q4142

Q4145

Q4149

Q4153

Q4157

Q4159

Q4163

Q4165

Q4167

Q4179

Q4182

Q4183

Q4190

Q4193

Q4198

Q4200

Q4202

Q4204

Q4209

Q4211

Q4214

Q4216

Q4220

Q4228

Q4237

Q4240

Q4249

Q4250

Q4255

Q9953

Q9954

Q9962

 

Code Range: V0000 – V9999
V2785 V2799 V5299

CPT®/HCPCS Modifiers

Table 3. CPT/HCPCS Modifiers.
22 24 52 53 55 62 66 73 74 77 80 81 82 AS GM KX

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

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).

Table 4. Claim Adjustment Reason Codes.
CARC
RARC
251 — The attachment or other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
N233 — Incomplete or invalid operative note and/or report. 
251 — The attachment or other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim.
N705 — Incomplete or invalid documentation. 
252 — An attachment or other documentation is required to adjudicate this claim/service.
M23 — Missing Invoice.
252 — An attachment or other documentation is required to adjudicate this claim/service.
M29 — Missing operative, note and/or report.
252 — An attachment or other documentation is required to adjudicate this claim/service.
N706 — Missing documentation.

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