Electronic medical records cannot be attached to an electronic claim. These instructions will show how to input the PWK segment in a claim to indicate Medical reports or any attachments are being forwarded by fax or mail to the payer.
- Within the visit information indicate the following in the Box 19 field: PWK*M1*BM (This indicates Medical Record Attachment is being mailed)
- Attached is a listing of all the codes that will be listed in the first field after PWK* (the asterisk needs to be after each code as shown above in the example)
- The second code will indicate if the attachments are mailed or faxed:
- BM (By Mail)
- FX (Faxed)
Do not place an asterisk after this code.
The ACN number is the patient's account number and visit number combined which is programmed in the electronic claims module, this is not required to be indicated in Box 19 of the visit screen.
Code Description:
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 Payor)
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 vitalsigns) 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
Providers that wish to use the PWK process to submit additional documentation will be required to use a specially designed cover sheet, which will be provided by the servicing MAC. Providers should contact their MAC for details on how/where to obtain the cover sheet. These cover sheets are required to be completely and accurately filled out or they will be manually returned.