PWK

Additional Service Information

Pos: 155

Max: 10

Detail - Optional

Loop: 2000F

Elements: 5

User Option (Usage): Situational

To identify the type or transmission or both of paperwork or supporting information

Element Summary:

	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

Report Justifying Treatment Beyond Utilization Guidelines

Drugs Administered

Treatment Diagnosis

Initial Assessment

Functional Goals

Plan of Treatment

Progress Report

Continued Treatment

Chemical Analysis

Certified Test Report

Justification for Admission

Recovery Plan

Social Security Benefit Letter

Rental Agreement

Use for medical or dental equipment rental.

Benefit Letter

Support Data for Verification

Allergies/Sensitivities Document

Autopsy Report

Ambulance Certification

Admission Summary

Purchase Order Attachment

Use for purchase of medical or dental equipment.

Prescription

Physician Order

Benchmark Testing Results

Baseline

Blanket Test Results

Chiropractic Justification

Consent Form(s)

Drug Profile Document

Dental Models

Durable Medical Equipment Prescription

Diagnostic Report

Discharge Monitoring Report

Discharge Summary

Family Medical History Document

Health Certificate

Health Clinic Records

Immunization Record

State School Immunization Records

Laboratory Results

Medical Record Attachment

Nursing Notes

Operative Note

Oxygen Content Averaging Report

Orders and Treatments Document

Objective Physical Examination (including vital signs) Document

Oxygen Therapy Certification

Pathology Report

Patient Medical History Document

Periodontal Charts

Periodontal Reports

Parenteral or Enteral Certification

Physical Therapy Notes

Prosthetics or Orthotic Certification

Paramedical Results

Physician's Report

Physical Therapy Certification

Cause and Corrective Action Report

Quality Report

Radiology Films

Radiology Reports

Report of Tests and Analysis Report

Renewable Oxygen Content Averaging Report

Symptoms Document

Death Notification

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

1/2

Required

Code

Name

By Mail

Electronically Only

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

E-Mail

By Fax

Voice

Use this for voicemail or phone communication.

PWK05

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 �VO�.

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. The UMO can use this PWK segment on the response to request additional information that applies to the service(s) requested in this Service loop. If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO can use this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
2. Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
3. This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
4. This PWK segment should not be used if
a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.
b. the 278 request (ST-SE) does not support this information and the needed information pertains to all the services requested and not to a specific service. Use the PWK segment at the Patient level (Loop 2000C or Loop 2000D) if requesting medical necessity information that applies to all the services requested
Refer to Section 2.2.5 for more information on using this segment.

Example:

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