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Last Modified: 7/22/2022 Location: FL, PR, USVI Business: Part B

Avoiding denial reason code PR 49 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?
This is a non-covered service because it is a routine or preventive exam, or a diagnostic/screening procedure done in conjunction with a routine or preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.
A: The denial was received, because the service is a routine or preventive exam, or diagnostic/screening procedure done in conjunction with a routine or preventative exam. Diagnostic/screening procedures and evaluation and management (E/M) services for routine or screening purposes, such as an annual physical, are not covered by Medicare.
Medicare does cover certain preventive services, including an Initial Preventive Physical Examination (IPPE) and an Annual Wellness Visit (AWV). Review preventive services for information on covered preventive services, including coding and billing.
If an error was made, make the necessary correction, and resubmit your claim.
If a payable diagnosis is indicated in the patient's medical record, correct the diagnosis, and resubmit the claim.
If a covered preventive service was coded incorrectly, correct the code, and resubmit the claim.
Prevent a duplicate denial: Submit corrected line item(s) only.
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