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Last Modified: 7/22/2018 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?
Routine examinations and related services are not covered.
A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.
Medicare does not cover diagnostic/screening procedures or evaluation and management (E/M) services for routine or screening purposes, such as an annual physical.
Before submitting the claim, refer to "Active, Future, and Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
Medicare does cover certain preventive services, including an Initial Preventive Physical Examination (IPPE) and an Annual Wellness Visit (AWV).
Click here for more information on covered preventive services, including coding and billing.
Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.
If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
If a covered preventive service was coded wrong, correct the code and submit the corrected claim.
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