How do I fix or resolve code 49?

Review the medical record to determine whether the visit was a routine/preventive exam or a problem-oriented visit with a specific chief complaint and medical necessity. If the visit was problem-oriented (not routine), correct the E&M code and diagnosis codes to reflect the medical necessity of the visit and resubmit the claim with the supporting documentation. If the visit was routine/preventive, verify whether the patient's plan covers preventive services under the ACA essential health benefits; if the plan is ACA-compliant, file an appeal citing the ACA preventive services coverage requirement. If the plan genuinely excludes routine preventive services, determine whether the patient signed a financial responsibility form or ABN acknowledging non-coverage; if so, bill the patient. If a diagnostic procedure was performed during the routine exam and was separately medically necessary, appeal with documentation supporting the diagnostic (non-routine) nature of the procedure and the medical necessity for it.

49Denial CodeGeneral Adjustment

Code 49

Problem Description

This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Root Cause

The service was denied because it is a routine/preventive exam or a diagnostic/screening procedure performed in conjunction with a routine/preventive exam, and the patient's plan does not cover routine preventive services. Some plans — particularly grandfathered plans, short-term plans, or certain HMO plans — exclude routine preventive exams from covered benefits. When a preventive service is billed, the payer denies it as non-covered. If a diagnostic or screening procedure was performed during the same visit as a routine exam, the payer may bundle the diagnostic service with the non-covered routine exam and deny both.

Resolution Steps

1Review the medical record to determine whether the visit was a routine/preventive exam or a problem-oriented visit with a specific chief complaint and medical necessity.
2If the visit was problem-oriented (not routine), correct the E&M code and diagnosis codes to reflect the medical necessity of the visit and resubmit the claim with the supporting documentation.
3If the visit was routine/preventive, verify whether the patient's plan covers preventive services under the ACA essential health benefits; if the plan is ACA-compliant, file an appeal citing the ACA preventive services coverage requirement.
4If the plan genuinely excludes routine preventive services, determine whether the patient signed a financial responsibility form or ABN acknowledging non-coverage; if so, bill the patient.
5If a diagnostic procedure was performed during the routine exam and was separately medically necessary, appeal with documentation supporting the diagnostic (non-routine) nature of the procedure and the medical necessity for it.

EHR Documentation Note

Claim denied 49 — routine/preventive exam non-covered; verified visit type in medical record, corrected to problem-oriented if applicable, or billed patient with ABN.

Preventative Action

Verify preventive service coverage during pre-visit eligibility checks and obtain ABNs for routine exams on plans that exclude preventive benefits before service delivery.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.