CMS-1500 Workers Compensation Report Codes/Transmission Codes

CMS-1500 Box 19 Additional Claim Information

FOR WORKERS’ COMPENSATION: Required based on Jurisdictional Workers’ Compensation Guidelines.

When reporting Supplemental Claim Information, use the qualifier PWK for data, followed by the appropriate Report Type Code, the appropriate Transmission Type Code, then the Attachment Control Number. Do not enter spaces between qualifiers and data. The NUCC defines the following qualifiers used in 5010A1:


03Report Justifying Treatment Beyond Utilization
04Drugs Administered
05Treatment Diagnosis
06Initial Assessment
07Functional Goals
08Plan of Treatment
09Progress Report
10Continued Treatment
11Chemical Analysis
13Certified Test Report
15Justification for Admission
21Recovery Plan
A3Allergies/Sensitivities Document
A4Autopsy Report
AMAmbulance Certification
ASAdmission Summary
B3Physician Order
B4Referral Form
BRBenchmark Testing Results
BTBlanket Test Results
CBChiropractic Justification
CKConsent Form(s)
D2Drug Profile Document
DADental Models
DBDurable Medical Equipment Prescription
DGDiagnostic Report
DJDischarge Monitoring Report
DSDischarge Summary
EBExplanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
HCHealth Certificate
HRHealth Clinic Records
I5Immunization Record
IRState School Immunization Records
LALaboratory Results
M1Medical Record Attachment
NNNursing Notes
OBOperative Note
OCOxygen Content Averaging Report
ODOrders and Treatments Document
OEObjective Physical Examination (including vital signs) Document
OXOxygen Therapy Certification
OZSupport Data for Claim
P4Pathology Report
P5Patient Medical History Document
PEParenteral or Enteral Certification
PNPhysical Therapy Notes
POProsthetics or Orthotic Certification
PQParamedical Results
PYPhysician’s Report
PZPhysical Therapy Certification
RBRadiology Films
RRRadiology Reports
RTReport of Tests and Analysis Report
RXRenewable Oxygen Content Averaging Report
SGSymptoms Document
V5Death Notification


AAAvailable on Request at Provider Site
BMBy Mail

Example: PWK03AA12363545465

Source: CMS-1500 02/12 Instructions

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