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:
REPORT TYPE CODES
| Code | Description |
|---|---|
| 03 | Report Justifying Treatment Beyond Utilization |
| 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 |
| A3 | Allergies/Sensitivities Document |
| A4 | Autopsy Report |
| AM | Ambulance Certification |
| AS | Admission Summary |
| B2 | Prescription |
| B3 | Physician Order |
| B4 | Referral Form |
| BR | Benchmark Testing Results |
| BS | Baseline |
| BT | Blanket Test Results |
| CB | Chiropractic Justification |
| CK | Consent Form(s) |
| CT | Certification |
| D2 | Drug Profile Document |
| DA | Dental Models |
| DB | Durable Medical Equipment Prescription |
| DG | Diagnostic Report |
| DJ | Discharge Monitoring Report |
| DS | Discharge Summary |
| EB | Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) |
| HC | Health Certificate |
| HR | Health Clinic Records |
| I5 | Immunization Record |
| IR | State School Immunization Records |
| LA | Laboratory Results |
| M1 | Medical Record Attachment |
| MT | Models |
| 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 |
| OZ | Support Data for Claim |
| P4 | Pathology Report |
| P5 | Patient Medical History Document |
| 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 |
| 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 |
TRANSMISSION TYPE CODES
| AA | Available on Request at Provider Site |
| BM | By Mail |
Example: PWK03AA12363545465
Source: CMS-1500 02/12 Instructions
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