PWK Submission Reminders

National Government Services has identified several issues with PWK submissions from providers. We are issuing this article as a notification to alert provider offices to systems and processes that you may have in place that are not necessary, thus wasting time, effort and budget on claim submissions.

As a reminder, PWK is not necessary to use for every claim submission. This process is only to be used when a claim requires documentation submission to justify the medical necessity based on medical policy, regulation or coding guidelines.

• When submitting PWK information providers are required to submit an ICN on the coversheet. It is mandatory to transmit the claim with the PWK segment fields and include the attachment control number. When the ICN and PWK segment fields are not identified with the submitted information a claim match cannot be identified for review. This may cause a denial and lead to an appeal that could be avoided. Note: Please be sure to place the cover sheet on top.
• PWK information is being submitted for claims that do not require supporting documentation. Submitting additional documentation via the PWK process when it is not necessary could be viewed as an abuse to the Medicare Program. Some specific items we receive PWK documentation that is not necessary are:
• • 93298 with G2066
  • Cystoscopy claims with one or two services and no special modifiers
  • Single line surgery claims without any special modifiers
  • E/M service alone
  • E/M service with an x-ray
  • Hip and knee replacement, hysterectomies, cardiac stress tests, cardiac catheterizations, duplex scans without any special modifiers
  • Hospital observation care
  • Nerve conduction studies with one or two services
• It is never appropriate to submit an entire patient chart for a single claim documentation submission. This is a violation of the Minimum Necessary rule of HIPAA Privacy. This could also lead to the claim being denied as a claims review nurse is not required to review an entire patient record to try and find the one piece of documentation that should have been submitted. Only send the operative note, procedure note, office note, etc. that was for the service in question. It is rare that the Part B claims team will ever need more than a few pages of documentation for the review of that claim.

To determine surgery services that may need additional documentation please review the Medicare Physician Fee Schedule Lookup tool. The MLN Booklet: How to Use the Searchable Medicare Physician Fee Schedule (MPFS) provides additional information about the tool.

Posted 4/14/2020