Wiki Pr-49

[bradhamilton]

I apologize if this has been answered elsewhere -

I'm told by my in-house Medicare expert, that Dx in the range of 520-525 will cause a denial by Medicare of an E/M procedure (99201-215). She has shown me EOBs with the denial code PR-49.

I scratch my head over this regularly, because the "definition" for 49 states, "These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam". Now, I'm confused, because nowhere in this language is any reference to diagnoses; the key nouns in here are "exam" and "procedure".

Can someone explain this? My head hurts thinking about it. : - )

 

[RebeccaWoodward*]

This may be what she's referring to...

150 - Dental Services
(Rev. 1, 10-01-03)
B3-2136

"As indicated under the general exclusions from coverage, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered. “Structures directly supporting the teeth” means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process."

https://www.cms.gov/manuals/Downloads/bp102c15.pdf

 

[bradhamilton]

Thanks, that does explain it - I'll stay away from those Dx codes, *if* I can find something more suitable.