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

01999

15999

17999

19499

20999

21089

21110

21299

21499

21899

22899

22999

23929

24999

25999

26989

27299

27599

27899

28899

29799

29999

30999

31299

31599

31899

32999

33999

36299

37501

37799

38129

38589

38999

39499

39599

40799

40899

41599

41899

42299

42699

42999

43289

43499

43659

43999

44238

44799

44899

44979

45399

45499

45999

46999

47379

47399

47579

47999

48999

49329

49659

49999

50549

50949

51999

53899

54699

55559

55899

55970

55980

58578

58579

58679

58999

59897

59898

59899

60659

60699

64999

66983

66987

66988

66999

67299

67399

67599

67999

68399

68899

69399

69799

69949

69979

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

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

87299

87798

87799

87899

87999

88099

88199

88299

88399

88749

89240

89398

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

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

0599T

0609T

0610T

0611T

0612T

0613T

A0999

A4290

A4563

A4640

A4641

A4642

A4648

A4650

A9501

A9504

A9508

A9509

A9516

A9517

A9526

A9527

A9529

A9532

A9536

A9542

A9543

A9544

A9545

A9546

A9547

A9550

A9553

A9554

A9557

A9559

A9561

A9562

A9563

A9564

A9566

A9567

A9570

A9571

A9572

A9582

A9584

A9586

A9597

A9598

A9699

A9999

C1823

C9399

D2999

D5899

D6199

D7999

D9999

E1399

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

J3591

J7170

J7199

J7309

J7315

J7629

J7799

J7999

J9044

J9118

J9219

J9999

L7510

L8499

L8604

L8608

L8679

L8699

L9900

Q0507

Q0508

Q0509

Q2028

Q2035

Q2036

Q2038

Q2039

Q3001

Q4050

Q4051

Q4103

Q4112

Q4116

Q4118

Q4125

Q4126

Q4128

Q4130

Q4134

Q4135

Q4136

Q4138

Q4140

Q4142

Q4143

Q4145

Q4146

Q4147

Q4149

Q4150

Q4153

Q4155

Q4157

Q4159

Q4161

Q4163

Q4164

Q4165

Q4167

Q4168

Q4171

Q4175

Q4176

Q4179

Q4182

Q4183

Q4184

Q4185

Q4188

Q4190

Q4191

Q4192

Q4193

Q4198

Q4200

Q4201

Q4202

Q4203

Q4204

Q4209

Q4210

Q4211

Q4212

Q4214

Q4215

Q4216

Q4217

Q4220

Q4221

Q4222

Q4226

Q4227

Q4228

Q4229

Q4230

Q4232

Q4233

Q4234

Q4235

Q4236

Q4237

Q4238

Q4239

Q4240

Q4241

Q4242

Q4244

Q4245

Q4247

Q4248

Q4249

Q4250

Q4255

Q9953

Q9954

Q9962

V2785

V2799

V5299

Modifiers

22
24
52
53
55
62
66
73
74
77
GM
KX

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.




Last Updated: 09/08/2021