PWK

Claim Supplemental Information

Pos: 155	Max: 10
Detail - Optional
Loop: 2300	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

AS

Admission Summary

Description: A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital

B2

Prescription

B3

Physician Order

B4

Referral Form

CT

Certification

DA

Dental Models

Description: Cast of the teeth; they are usually taken before partial dentures or braces are placed

DG

Diagnostic Report

Description: Report describing the results of lab tests x-rays or radiology films

DS

Discharge Summary

Description: Report listing the condition of the patient upon release from the hospital; it usually lists where the patient is being released to, what medication the patient is taking and when to follow-up with the doctor

EB

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

Description: Summary of benefits paid on the claim

MT

Models

NN

Nursing Notes

Description: Notes kept by the nurse regarding a patient's physical and mental condition, what medication the patient is on and when it should be given

OB

Operative Note

Description: Step-by-step notes of exactly what takes place during an operation

OZ

Support Data for Claim

Description: Medical records that would support procedures performed; tests given and necessary for a claim

PN

Physical Therapy Notes

PO

Prosthetics or Orthotic Certification

PZ

Physical Therapy Certification

RB

Radiology Films

Description: X-rays, videos, and other radiology diagnostic tests

RR

Radiology Reports

Description: Reports prepared by a radiologists after the films or x-rays have been reviewed

RT

Report of Tests and Analysis Report

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

Paperwork is available at the provider’s site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at his or her request.

BM

By Mail

EL

Electronically Only

EM

E-Mail

FX

By Fax

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’. Can be used when PWK02 equals ’AA’ if the Provider wants to send a document control number for an attachment remaining at the Providers office.

C

ID

1/2

Situational

Code

Name

AC

Attachment Control Number

Description: Means of associating electronic claim with documentation forwarded by other means

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.

C

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

Not recommended

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 PWK segment is required if there is paper documentation supporting this claim. The PWK segment should not be used if the information related to the claim is being sent within the 837 ST-SE envelope.
2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another functional group e.g., 275) rather than by paper. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.
3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is available upon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA in PWK02 to convey this specific use of the PWK segment. See element note under PWK02, code AA.

Example:

PWK*AS*BM***AC*DMN0012~