Services and Circumstances that Require Additional Documentation

Published 09/23/2024

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

Table. CPT® Codes.
Code Range: 00000 – 09999
01999 0408T 0409T

0410T

0411T

0412T

0413T

0414T

0415T

0416T

0417T

0418T

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 o
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

90653

90654

90655

90656

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

Table 2. HCPCS Codes.
Code Range: A0000 – A9999

A0999

A2019

A4290

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

A9563

A9564

A9566

A9567

A9570

A9571

A9572

A9582

A9584

A9586

A9597

A9598

A9699

A9999

 
Code Range: C0000 – C9999
C1823 C1824 C1826
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

Q4190

Q4193

Q4198

Q4200

Q4202

Q4204

Q4209

Q4211

Q4214

Q4216

Q4220

Q4228

Q4237

Q4240

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).

Table 3. Claim Adjustment Reason Codes.
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.

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