Services and Circumstances That Require Additional Documentation

Published 07/07/2022

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/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 87154 87299
87483 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 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 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 A9562 A9563 A9564 A9566 A9567
A9570 A9571 A9572 A9582 A9584 A9586 A9597 A9598
A9699 A9999 C1823 C1824 C9399 D2999 D5899 D6199
D7999 D9999 E1399 G0308 G0309 J0120 J0400 J0475
J0715 J0735 J0833 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 J9118 J9219 J9999
L7510 L8499 L8604 L8608 L8679 L8699 L9900 Q0507
Q0508 Q0509 Q2028 Q2035 Q2036 Q2038 Q2039 Q3001
Q4050 Q4051 Q4103 Q4116 Q4118 Q4125 Q4126 Q4128
Q4130 Q4134 Q4135 Q4136 Q4138 Q4140 Q4142 Q4143
Q4145 Q4146 Q4147 Q4149 Q4153 Q4157 Q4159 Q4161
Q4163 Q4164 Q4165 Q4167 Q4175 Q4179 Q4182 Q4183
Q4184 Q4190 Q4191 Q4193 Q4198 Q4200 Q4202 Q4204
Q4209 Q4211 Q4214 Q4216 Q4220 Q4221 Q4228 Q4229
Q4236 Q4237 Q4238 Q4239 Q4240 Q4241 Q4242 Q4248
Q4249 Q4250 Q4255 Q9953 Q9954 Q9962 V2785 V2799
V5299              

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).

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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