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.
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 fax cover sheet or PWK fax cover sheet until the procedure code is available in eServices.
CPT®/HCPCS Codes
Note: CPT® codes and modifier begin with a numeric character and HCPCS codes and modifiers begin with an alpha character.
CPT® Codes
|
Code Range 00000 – 09999 |
|---|
|
01999 |
|
Code Range 10000 – 19999 |
||
|---|---|---|
|
15999 |
17999 |
19499 |
|
Code Range: 20000 – 29999 |
||
|---|---|---|
|
20999 |
21089 |
21110 |
|
21299 |
21499 |
21899 |
|
22899 |
22999 |
23929 |
|
24999 |
25999 |
26989 |
|
27299 |
27599 |
27899 |
|
28899 |
29799 |
29999 |
|
Code Range: 30000 – 39999 |
||
|---|---|---|
|
30999 |
31299 |
31599 |
|
31899 |
32999 |
33999 |
|
36299 |
37501 |
37799 |
|
38129 |
38589 |
38999 |
|
39499 |
39599 |
|
|
Code Range: 40000 – 49999 |
||
|---|---|---|
|
40799 |
40899 |
41599 |
|
41899 |
42299 |
42699 |
|
42999 |
43289 |
43499 |
|
43659 |
43999 |
44238 |
|
44799 |
44899 |
44979 |
|
45399 |
45499 |
45999 |
|
46999 |
47379 |
47399 |
|
47579 |
47999 |
49329 |
|
49659 |
49999 |
|
|
Code Range: 50000 – 59999 |
||
|---|---|---|
|
50549 |
50949 |
51999 |
|
53899 |
54699 |
55559 |
|
55899 |
55970 |
55980 |
|
58578 |
58579 |
58679 |
|
58999 |
59897 |
59898 |
|
59899 |
|
|
|
Code Range: 60000 – 69999 |
||
|---|---|---|
|
60659 |
60699 |
64999 |
|
66983 |
66987 |
66988 |
|
66999 |
67299 |
67399 |
|
67599 |
67999 |
68399 |
|
68899 |
69399 |
69799 |
|
69949 |
69979 |
|
|
Code Range: 70000 – 79999 |
||
|---|---|---|
|
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 |
|
Code Range: 80000 – 89999 |
||
|---|---|---|
|
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 |
|
|
Code Range: 90000 – 99999 |
||
|---|---|---|
|
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 |
|
Code Range: 0000T – 0999T |
||
|---|---|---|
|
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 |
|
|
HCPCS Codes
|
Code Range: A0000 – A9999 |
||
|---|---|---|
|
A0999 |
A4563 |
A4640 |
|
A4641 |
A4642 |
A4648 |
|
A4650 |
A9501 |
A9504 |
|
A9508 |
A9509 |
A9516 |
|
A9517 |
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 |
|
|
|
Code Range: C0000 – C9999 |
||
|---|---|---|
|
C1823 |
C1824 |
C9399 |
|
Code Range: D0000 – D9999 |
||
|---|---|---|
|
D2999 |
D5899 |
D6199 |
|
D7999 |
D9999 |
|
|
Code Range: E0000 – E9999 |
|---|
|
E1399 |
|
Code Range: G0000 – G9999 |
||
|---|---|---|
|
G0308 |
G0309 |
|
|
Code Range: J0000 – J9999 |
||
|---|---|---|
|
J0120 |
J0400 |
J0475 |
|
J0665 |
J0715 |
J0735 |
|
J0883 |
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 |
J9219 |
J9999 |
|
Code Range: J0000 – J9999 |
||
|---|---|---|
|
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 |
|
J9219 |
J9999 |
|
|
Code Range: L0000 |
||
|---|---|---|
|
L7510 |
L8499 |
L8604 |
|
L8608 |
L8679 |
L8699 |
|
L9900 |
|
|
|
Code Range: Q0000 – Q9999 |
||
|---|---|---|
|
Q0507 |
Q0508 |
Q0509 |
|
Q2028 |
Q2035 |
Q2036 |
|
Q2038 |
Q2039 |
Q3001 |
|
Q4050 |
Q4051 |
Q4116 |
|
Q4125 |
Q4130 |
Q4135 |
|
Q4136 |
Q4138 |
Q4140 |
|
Q4142 |
Q4145 |
Q4149 |
|
Q4153 |
Q4157 |
Q4159 |
|
Q4163 |
Q4165 |
Q4167 |
|
Q4179 |
Q4182 |
Q4183 |
|
Q4184 |
Q4190 |
Q4191 |
|
Q4193 |
Q4198 |
Q4200 |
|
Q4202 |
Q4204 |
Q4209 |
|
Q4211 |
Q4214 |
Q4216 |
|
Q4220 |
Q4221 |
Q4228 |
|
Q4237 |
Q4238 |
Q4239 |
|
Q4240 |
Q4241 |
Q4242 |
|
Q4249 |
Q4250 |
Q4255 |
|
Q9953 |
Q9954 |
Q9962 |
|
Code Range: V0000 – V9999 |
||
|---|---|---|
|
V2785 |
V2799 |
V5299 |
Important Note: While Palmetto GBA has made every attempt to identify all services that will require additional documentation, the above list is not all-inclusive due to the nature of health care and changes in coding and pricing requirements.
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 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 or service. |
M23 — Missing invoice. |
|
252 — An attachment or other documentation is required to adjudicate this claim or service. |
M29 — Missing operative, note or report. |
|
252 — An attachment or other documentation is required to adjudicate this claim or service. |
N706 — Missing documentation. |