Originally Published: February 12, 2014
Revised: September 29, 2020
The PWK Segment
When submitting claims to the DME MAC, you have the option of mailing, faxing or using esMD to send documentation to accompany your electronically-submitted DMEPOS claims. This is accomplished through the use of what is called the PWK (paperwork) segment. The PWK process works like this:
- Submit an electronic claim, making sure to complete the PWK segment. NOTE: See the Electronic Claim Requirements (Loop 2300 & Loop 2400) section below for additional claim submission instructions.
- After the claim has been accepted by CEDI, complete the PWK Fax/Mail/esMD Cover Sheet.
- Mail, fax, or send via esMD with the PWK Fax/Mail /esMD Cover Sheet all necessary documentation.
- We will process the claim and will refer to your submitted PWK documentation (if necessary for proper claim adjudication).
When considering whether or not to use the PWK segment, please keep the following tips in mind:
- Use of the PWK segment is entirely voluntary
You are not required to use the PWK segment in any circumstance; it is entirely voluntary. Under current claim processing rules, if a Medicare contractor determines that additional information is needed to complete proper adjudication of a claim (for instance, due to an audit), then the contractor 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, then it may be a good idea to include the documentation through the PWK process in order to expedite claim processing time. - The NTE (note) segment is still a valid option
Using the PWK segment is not always the best option for including additional claim information. The NTE (note) segment of an electronic claim is also available for you to include notes and information that may be important for the proper adjudication of the claim. Use of the PWK segment results in additional processing time due to the waiting period required for us to receive your mailed/faxed documentation. If you can use the NTE segment instead of the PWK segment, we encourage you to do so. - Do not send PWK documentation unless 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 (detailed written orders, proof of delivery, etc.); however, you are not required to submit this documentation with your claim. We encourage you to only submit supporting claim documentation when you believe we require it in order to correctly process your claim. - Use of the PWK segment does not guarantee that the DME MAC will review the submitted paperwork
When processing your claims, we may look for additional information in the NTE segment or the PWK segment in order to complete your claim; however, use of the NTE segment or PWK segment does not mean that we will always review the information. We only look at your additional information when needed in order to properly process payment. For instance, if a claim is submitted with a modifier that precludes payment for the item, the claim will deny without our claim processors looking at the NTE or PWK segments. - Do not use PWK for submitting Reopenings, Redeterminations, or any other type of requests
Using PWK is NOT an acceptable form of submission for Reopenings, Redeterminations, or other types of requests. Additionally, if you attempt to send documentation for use with a pending reopening or redetermination request via PWK, our reopening or redetermination analysts will not be able to access the information, and therefore your documentation will not be factored into the determination of your request.
If you need help filing a Reopening or Redetermination request, refer to the Reopenings and/or Appeals pages on our website.
Electronic Claim Requirements (Loop 2300 & Loop 2400)
In the claim level PWK segment (Loop 2300) or line level segment (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:
Code | Definition |
---|---|
BM | By Mail |
FX | By Fax |
EL | Electronically using esMD via X12 275 |
FT | File Transfer using esMD via XDR |
PWK 05 (Identification Code Qualifier – Required with PWK02) – Values are listed below:
Code | Definition |
---|---|
AC | Attachment Control Number |
PWK 06 (Identification Code – Required with PWK02)
PWK06 is a value assigned by the supplier to uniquely identify the documentation to be mailed or faxed. This is the attachment control number (ACN). The ACN must match the CAN on the PWK cover sheet. The maximum field length is 50.
Related Information
- MLN Matters Article MM7306
- MLN Matters Article MM10397
- DME MAC Jurisdiction C Supplier Manual, Chapter 6