PWK

Additional Service Information

Pos: 155	Max: 10
Detail - Optional
Loop: 2000F	Elements: 5

Ref

Id

Element Name

Req

Type

Min/Max

Usage

PWK01

755

Report Type Code
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code

M

ID

2/2

Required

Code

Name

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

48

Social Security Benefit Letter

55

Rental Agreement

Use for medical or dental equipment rental.

59

Benefit Letter

77

Support Data for Verification

A3

Allergies/Sensitivities Document

A4

Autopsy Report

AM

Ambulance Certification

AS

Admission Summary

AT

Purchase Order Attachment

Use for purchase of medical or dental equipment.

B2

Prescription

B3

Physician Order

BR

Benchmark Testing Results

BS

Baseline

BT

Blanket Test Results

CB

Chiropractic Justification

CK

Consent Form(s)

D2

Drug Profile Document

DA

Dental Models

DB

Durable Medical Equipment Prescription

DG

Diagnostic Report

DJ

Discharge Monitoring Report

DS

Discharge Summary

FM

Family Medical History Document

HC

Health Certificate

HR

Health Clinic Records

I5

Immunization Record

IR

State School Immunization Records

LA

Laboratory Results

M1

Medical Record Attachment

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

P4

Pathology Report

P5

Patient Medical History Document

P6

Periodontal Charts

P7

Periodontal Reports

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

QC

Cause and Corrective Action Report

QR

Quality Report

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

PWK02

756

Report Transmission Code
Description: Code defining timing, transmission method or format by which reports are to be sent
Industry: Attachment Transmission Code

O

ID

1/2

Required

Code

Name

AA

Available on Request at Provider Site

This means that the paperwork is not being sent with the request at this time. Instead, it is available to the UMO (or appropriate entity) on request.

BM

By Mail

EL

Electronically Only

Use to indicate that the attachment is being transmitted in a separate X12 functional group.

EM

E-Mail

FX

By Fax

VO

Voice

Use this for voicemail or phone communication.

PWK05

66

Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
This data element is required when PWK02 DOES NOT equal “AA” or “VO”. The requester can use it when PWK02 equals “AA” if the requester wants to send a document control number for an attachment remaining at the Provider’s office.

X

ID

1/2

Situational

Code

Name

AC

Attachment Control Number

PWK06

67

Identification Code
Description: Code identifying a party or other code
Industry: Attachment Control Number
Required if PWK02 equals BM, EL, EM or FX.

X

AN

2/80

Situational

PWK07

352

Description
Description: A free-form description to clarify the related data elements and their content
Industry: Attachment Description
This data element is used to add any additional information about the attachment described in this segment.

O

AN

1/80

Situational

1.

P0506 - If either PWK05,PWK06 is present, then all are required

1.

PWK05 and PWK06 may be used to identify the addressee by a code number.

2.

PWK07 may be used to indicate special information to be shown on the specified report.

3.

PWK08 may be used to indicate action pertaining to a report.

Notes:

1. This PWK segment is required if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop. This PWK segment should not be used if
a. the 278 request (ST-SE) supports this information in its segments and data elements, or
b. the 278 request (ST-SE) does not support this information and the needed information pertains to the health care services review and not to a specific service.
2. This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
3. The requester can also use this PWK segment to identify paperwork that is held at the provider’s office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Refer to Section 2.2.5 for more information on using this PWK segment.

Example:

PWK*OB*BM***AC*DMN0012~