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September 25, 2012

Paperwork (PWK) Implementation: Submitting Additional Documentation with Electronic Claims

Effective October 1, 2012, PWK segment of the X12N version 5010 will be implemented. When paper documentation or attachments are necessary to support the electronically submitted claim, trading partners should identify the documentation using the PWK Segment at the claim level (Loop 2300) or line level (Loop 2400). The PWK segment will allow documentation to be submitted for an initial claim. The documentation will be imaged to be available while the claim is being processed.

Electronic Claim Requirements (Loop 2300 & Loop 2400)

In PWK segment claim level (Loop 2300) or line level (Loop 2400), use the following data elements to identify that a paper attachment is forthcoming:

PWK 01 (Attachment Report Type Code – Required) – Values are listed below:

CODE DEFINITION
03 Report Justifying Treatment Beyond Utilization Guidelines
04 Drugs Administered
05 Treatment Diagnosis
06 Initial Assessment
07 Functional Goals
08 Plan of Treatment
09 Progress Report
10 Continued Treatment
11 Chemical Analysis
13 Certified Test Report
15 Justification for Admission
21 Recovery Plan
A3 Allergies/Sensitivities Document
A4 Autopsy Report
AM Ambulance Certification
AS Admission Summary
B2 Prescription
B3 Physician Order
B4 Referral Form
BR Benchmark Testing Results
BS Baseline
BT Blanket Test Results
CB Chiropractic Justification
CK Consent Form(s)
CT Certification
D2 Drug Profile Document
DA Dental Models
DB Durable Medical Equipment Prescription
DG Diagnostic Report
DJ Discharge Monitoring Report
DS Discharge Summary
EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer)
HC Health Certificate
HR Health Clinic Records
I5 Immunization Record
IR State School Immunization Records
LA Laboratory Results
M1 Medical Record Attachment
MT Models
NN Nursing Notes
OB Operative Note
OC Oxygen Content Averaging Report
OD Orders and Treatments Document
OE Objective Physical Examination (including vital signs) Document
OX Oxygen Therapy Certification
OZ Support Data for Claim
P4 Pathology Report
P5 Patient Medical History Document
PE Parenteral or Enteral Certification
PN Physical Therapy Notes
PO Prosthetics or Orthotic Certification
PQ Paramedical Results
PY Physician's Report
PZ Physical Therapy Certification
RB Radiology Films
RR Radiology Reports
RT Report of Tests and Analysis Report
RX Renewable Oxygen Content Averaging Report
SG Symptoms Document
V5 Death Notification
XP Photographs

PWK 02 (Report Transmission Code – Required) – Values are listed below:

BM By Mail
FX By Fax

PWK 05 (Identification Code Qualifier – Required with PWK02) – Values are listed below:

AC Attachment Control Number

PWK 06 (Identification Code – Required with PWK02) – PWK06 is a value assigned by the provider to uniquely identify the documentation to be mailed or faxed. The maximum field length is 50.

Additional Documentation Information

The PWK Fax/Mail Cover SheetPDF that you will used to submit the unsolicited additional documentation is available on the Forms page of our website.

All fields of the cover sheet should be completed. No modification may be made to this cover sheet. CGS will return PWK cover sheets with missing or inaccurate information. We will not return any documentation that accompanies a rejected PWK cover sheet. PWK documentation should not be submitted prior to submission of the claim. If the PWK segment is completed and additional documentation is needed for adjudication of the claim, we will allow 7 calendar 'waiting' days (from the claim date of receipt) for the documentation to be faxed or 10 calendar 'waiting' days for mailed documentation.

Claims submitted with a PWK segment that would not otherwise suspend for review and/or additional development will be processed in accordance with our established procedures and will not be held for the 7- or 10-day waiting period.

  1. Faxing unsolicited documentation is entirely voluntary

    Under current claim processing rules, if CGS determines that additional information is needed to complete proper adjudication of a claim (for instance, due to an audit), we will send you a development letter requesting additional documentation. This process will not change. If you believe your claim may result in a development request, we suggest (but do not require) that you fax documentation to accompany your initial electronic claim in order to expedite claim processing time.

  2. The NTE (note) segment is still a valid option

    Faxing unsolicited documentation is not always the best option for including additional claim information. The NTE (note) segment of an electronic claim is currently available for you to include notes and information that may be important for the proper adjudication of the claim. If you can use the NTE segment instead of the faxing documentation, we encourage you to do so.

  3. Do not fax unsolicited documentation unless CGS has specifically indicated it is needed

    Medicare rules and regulations require that you keep certain documentation on file in order to support the medical necessity and justification of your claims (medical records, progress notes, etc.); however, you are not required to submit this documentation with your claims. We encourage you to only submit supporting claim documentation when you believe it may be required in order to correctly process your claim. Examples of when it might be appropriate to fax additional documentation along with your initial claim include, but are not limited to:

    • Claims containing unlisted procedures (Not Otherwise Classified (NOC) procedures)
    • Claims that include CPT modifier 22 or 53
    • Claims requiring invoice information
    • Claims for co-surgery, assistant surgery, or team surgery (only when the code being submitted has an indicator in the Medicare Physician Fee Schedule Database (MPFSDB) signifying that supporting documentation for medical necessity for co-surgery, assistant surgery or team surgery)
  4. Faxing of documentation does not guarantee that CGS will review the submitted paperwork.

    When processing your claims, we may look for additional information in the NTE segment in order to complete your claim; however, submitting information in the NTE segment or faxing documentation does not mean that we will always review the information. We will only review your additional information when it is needed in order to properly process payment. For instance, if a claim is submitted with a modifier that precludes payment for the service, the claim will be denied and we will not review additional supporting documentation.

We are pleased to be able to provide you with this new option for submitting documentation. Should you have questions regarding this process, please contact our Provider Contact Center at 1.866.276.9558.

Additional resources:

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