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 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
01999 15999 17999 19499 20999 21089 21110 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 66983 66987 66988 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 78429
78430 78431 78432 78433 78434 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 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 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 0571T
0572T 0573T 0574T 0575T 0581T 0582T 0583T 0584T
0585T 0586T 0587T 0591T 0592T 0593T 0594T 0599T
0609T 0610T 0611T 0612T 0613T A0999 A4290 A4563
A4640 A4641 A4642 A4648 A4650 A9501 A9504 A9508
A9509 A9516 A9517 A9526 A9527 A9529 A9532 A9536
A9542 A9543 A9544 A9545 A9546 A9547 A9550 A9553
A9554 A9557 A9559 A9561 A9562 A9563 A9564 A9566
A9567 A9570 A9571 A9572 A9582 A9584 A9586 A9597
A9598 A9699 A9999 C1823 C9399 D2999 D5899 D6199
D7999 D9999 E1399 J0120 J0400 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 J2797 J2910
J2950 J3010 J3303 J3305 J3310 J3398 J3400 J3472
J3490 J3591 J7170 J7199 J7309 J7315 J7629 J7799
J7999 J9044 J9118 J9219 J9999 L7510 L8499 L8604
L8608 L8679 L8699 L9900 Q0507 Q0508 Q0509 Q2028
Q2035 Q2036 Q2038 Q2039 Q3001 Q4050 Q4051 Q4103
Q4112 Q4116 Q4118 Q4125 Q4126 Q4128 Q4130 Q4134
Q4135 Q4136 Q4138 Q4140 Q4142 Q4143 Q4145 Q4146
Q4147 Q4149 Q4150 Q4153 Q4155 Q4157 Q4159 Q4161
Q4163 Q4164 Q4165 Q4167 Q4168 Q4169 Q4175 Q4179
Q4182 Q4183 Q4184 Q4185 Q4188 Q4190 Q4209 Q4210
Q4191 Q4192 Q4193 Q4198 Q4200 Q4202 Q4203 Q4204
Q4211 Q4212 Q4214 Q4215 Q4216 Q4217 Q4220 Q4221
Q4228 Q4229 Q4230 Q4232 Q4233 Q4235 Q4236 Q4237
Q4238 Q4239 Q4240 Q4241 Q4242 Q4245 Q4247 Q4248
Q4249 Q4250 Q4255 Q9953 Q9954 Q9962 V2785 V2799
V5299              

Modifiers

22 24 52 53 55 62 66 73 74 77 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).

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.




Last Updated: 01/14/2022