How To Fix Denial Code 249 | Common Reasons, Next Steps & How To Avoid It

Denial Code 249 means that a claim has been identified as a readmission. This denial code is used in conjunction with Group Code CO. In this article, we will provide a description of denial code 249, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 249 cases.

2. Description

Denial Code 249 is used to indicate that a claim has been identified as a readmission. This means that the patient has been discharged from a healthcare facility and has been readmitted within a certain timeframe. The denial code is typically accompanied by Group Code CO, which stands for Contractual Obligation. This code signifies that the denial is based on contractual agreements between the healthcare provider and the insurance company.

2. Common Reasons

The most common reasons for denial code 249 are:

1. Readmission Within Specified Timeframe: Denial code 249 is triggered when a patient is readmitted to a healthcare facility within a specified timeframe. Insurance companies often have policies in place that limit coverage for readmissions within a certain number of days after discharge. If a claim is submitted for a readmission that falls within this timeframe, it will be denied under code 249.
2. Missing or Incomplete Documentation: In some cases, denial code 249 may be issued due to missing or incomplete documentation. Insurance companies require thorough documentation to support the medical necessity of a readmission. If the necessary documentation is not provided or is incomplete, the claim may be denied.
3. Incorrect Coding: Incorrect coding can also lead to denial code 249. If the coding on the claim does not accurately reflect the reason for the readmission or the services provided, the claim may be denied.
4. Lack of Prior Authorization: Some insurance plans require prior authorization for readmissions. If the necessary prior authorization was not obtained before the readmission, the claim may be denied under code 249.

3. Next Steps

If you receive a denial with code 249, here are the next steps to resolve the issue:

1. Review the Claim: Carefully review the denied claim to understand the specific reason for the denial. Identify any missing documentation or coding errors that may have contributed to the denial.
2. Obtain Necessary Documentation: If the denial was due to missing or incomplete documentation, gather the necessary documentation to support the medical necessity of the readmission. This may include medical records, physician notes, and any other relevant documentation.
3. Correct Coding Errors: If the denial was a result of coding errors, correct the coding on the claim to accurately reflect the reason for the readmission and the services provided. Ensure that the coding aligns with the documentation and meets the requirements of the insurance company.
4. Submit an Appeal: If you believe the denial was issued in error or if you have resolved the issues identified in the denial, submit an appeal to the insurance company. Include any supporting documentation and a detailed explanation of why the denial should be overturned.
5. Follow Up: Follow up with the insurance company to track the progress of the appeal. Be prepared to provide any additional information or documentation that may be requested.

4. How To Avoid It

To avoid denial code 249 in the future, consider the following tips:

1. Understand Insurance Policies: Familiarize yourself with the insurance policies of the patients you serve. Be aware of any limitations or requirements related to readmissions, including specified timeframes and prior authorization.
2. Obtain Prior Authorization: If prior authorization is required for readmissions, ensure that the necessary authorization is obtained before admitting the patient. This will help prevent denials based on lack of prior authorization.
3. Thorough Documentation: Maintain thorough and accurate documentation for all patient encounters, including readmissions. Document the medical necessity of the readmission and provide detailed notes to support the services provided.
4. Accurate Coding: Ensure that coding is accurate and reflects the reason for the readmission and the services provided. Regularly train coding staff to stay updated on coding guidelines and best practices.

5. Example Cases

Here are two examples of denial code 249:

• Example 1: A patient is discharged from a hospital and readmitted within 30 days for a related condition. The claim for the readmission is denied under code 249, as it falls within the specified timeframe for readmissions.
• Example 2: A patient undergoes a surgical procedure and is discharged. However, due to complications, the patient is readmitted to the hospital within 10 days. The claim for the readmission is denied under code 249, as it falls within the specified timeframe for readmissions.

Source: Claim Adjustment Reason Codes