249Denial Code (CARC)Active
CO 249 Denial Code: Readmission Claim Denial Explained
Code 249 indicates that the claim was denied because it was identified as a readmission. This means the payer considers the service as a subsequent admission within a certain period after a previous discharge, which they don't reimburse separately. The claim will be marked with Group Code CO, meaning it's a contractual write-off.
Who Pays: Group Code Liability
With Group Code CO, the provider must write off the amount. This is a contractual obligation, so the patient cannot be billed for the denied amount under code 249.
Why Claims Get Code 249
- The patient was readmitted to the hospital shortly after discharge, triggering the readmission flag.
- The claim was submitted without addressing a prior related admission, leading to the readmission identification.
- The hospital's internal system did not catch the readmission status before billing.
- The payer's readmission policy criteria were met, but the claim was not bundled with the initial admission.
- The claim was submitted without necessary documentation to justify the readmission.
How to Fix & Resubmit
- Review the patient's admission history to confirm if the readmission determination is accurate.
- Check the payer's readmission policy to understand the criteria and timeframes that apply.
- Gather documentation that may support the medical necessity of the readmission if applicable.
- Contact the payer for clarification or reconsideration if you believe the readmission determination is incorrect.
- If justified, submit an appeal with supporting documentation explaining why the readmission should be covered.
Corrected Claim or Appeal?
For code 249, a formal appeal is warranted if the readmission was medically necessary and not related to the initial admission. A corrected claim is not applicable since this is a contractual adjustment.
Preventing Future 249 Denials
- Ensure thorough review of patient admission history before claim submission to identify potential readmissions.
- Educate the billing team on payer-specific readmission policies and timeframes.
- Implement a system alert for potential readmissions to be reviewed prior to claim submission.
- Ensure documentation is complete and justifies the necessity of any readmissions before billing.