- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
JK and J6 providers have the option of electronically submitting, mailing, or faxing documentation for electronically-submitted claims that require additional documentation for purposes of claim processing.
The provider will complete the PWK segment in loop 2300/2400 of the 837 professional and institutional electronic transactions to notify National Government Services they intend to send documentation for that claim.
- In segment PWK02 please identify method of documentation delivery:
- EL ‒ electronic submission
- BM ‒ mail submission
- FX ‒ fax submission
- The ACN must be entered into PWK06. ACN must match the ACN value sent in the X12 275 transaction.
NGS will only review additional documentation when it is necessary to process a claim. The circumstances listed here may require additional information which may be submitted utilizing the PWK segment:
- Surgical NOC Procedure Codes: A description of the NOC should be entered on the electronic claim in the comment field. If unable to adequately describe, an operative report is required. If multiple services are submitted, the information submitted should clearly indicate which service the NOC code applies.
- Nonsurgical NOC Procedure Codes: A detailed description of the procedure must be provided in the comment field.
- Drugs and Biologicals NOC Codes: An invoice is required for certain drugs/products. This may be entered on the electronic comment field. For NOC codes, a detailed description of the drug name and dosage must be provided in the comment field of the claim. If this is done, no separate attachment is required.
- Modifier 22 ‒ Unusual Services: Always attempt to explain the reason for the modifier 22 in the comment field. If you feel there is not enough space to sufficiently describe the reason, an operative report is required with a concise statement about how the service differs from the usual.
- Modifier 53 ‒ Discontinued Services: An operative report is required for surgical procedures if unable to explain in the claim comment. Colonoscopies are exempt from requiring documentation for a modifier 53.
- Modifier 62 ‒ Cosurgery: An operative report is required to demonstrate the medical necessity for two surgeons if the cosurgery indicator on the Medicare Fee Schedule Database is a 1, which is defined as: cosurgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.
Note: The operative report can be submitted as two separately signed reports from each surgeon or as one operative report which requires the signature from both surgeons - Modifier 66 ‒ Team Surgeons: An operative report is always required for the team concept.
- Modifier GM ‒ Ambulance Multiple Patients on One Ambulance Trip: Documentation to specify the particulars of a multiple patient transport. Documentation must include total number of patients transported at same time and MBI for each beneficiary.
- Claims submitted with procedure codes 21031, 21032, 21110, 30120, 30400, 30410, 30420, 30430, 30435, 30450, and 69300 require medical necessity documentation.
- Services submitted with AS, 80, 81 and 82 modifiers and the procedure code has an assistant surgery indicator of 0 require the operative notes. Assistant surgery indicator of 0 indicates the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
- Claims submitted with greater than five surgeries on the date of service.
Important reminders for PWK:
- Submit your documentation promptly. If documentation is not received or is received after the time frame has elapsed we will begin normal processing procedures which might include development for any necessary documentation.
- NGS will allow seven calendar days from the date we receive the claim for the documentation to be electronically transmitted or faxed; and we will allow ten calendar days from the receipt date of the claim for mailed documentation.
- Claims submitted with a PWK segment that would not otherwise suspend for review and/or require additional development, will process routinely without a waiting period.
- NGS medical review departments are only required to review unsolicited documentation when claim suspends for medical review edit/audit.
- Documentation is to be submitted only after the claim has been electronically submitted with the PWK segment completed. Do not submit documentation before submission of the claim.
- For mail and/or fax documentation submissions, the provider must complete the PWK fax/mail cover sheet that is provided on our website. Be sure to clearly write or type on the form, and complete every section. Incomplete or incorrectly filled out cover sheets will be returned to the provider.
- Fax number and mailing addresses are listed on the PWK fax/mail cover sheet.
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Reviewed 11/6/2023