PR-49 Denial Code: Routine or Preventive Exam Not Covered

PR-49 is a Claim Adjustment Reason Code that means the payer treated the service as a routine or preventive exam, or a test done along with one, that the patient’s coverage doesn’t pay for. The PR group code means the patient is responsible. On Medicare claims it usually means a routine physical, which Medicare excludes by law. (Primary sources: X12 Claim Adjustment Reason Codes · First Coast, Tips to prevent CARC PR 49 · 42 CFR 411.15)

Quick answer: PR-49 means the payer treated the visit or test as a routine or preventive exam it doesn’t cover. Medicare excludes routine physicals but covers the IPPE and the Annual Wellness Visit. If a covered visit was coded as a routine physical, or a payable diagnosis was left off, correct and resubmit. If it really was routine, the patient pays.

Part of our denial codes library. Written by Manikandan, a revenue cycle management specialist with more than 10 years of US medical billing experience. Last reviewed: 7 October 2026. Official code wording is quoted word for word from X12; Medicare rules link to their CMS or Medicare contractor source.

PR-49 denial code description (official X12 wording)

X12 Claim Adjustment Reason Code 49, verbatim:

“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.”

Source: X12 Claim Adjustment Reason Codes, checked 7 October 2026. Start: 01/01/1995 | Last Modified: 07/01/2017.

The code covers two things. One is the routine exam itself. The other is a diagnostic/screening procedure done in conjunction with it. So labs, an EKG or other tests ordered as part of a routine physical can deny with 49 too. The usage note tells you to read loop 2110 REF for the payer’s policy.

What PR-49 means in plain English

Each part of the code answers a different question:

• PR (Patient Responsibility) means the payer says the amount “may be billed to the patient or insured” (Medicare Claims Processing Manual, Ch. 22, §60.1).
• CARC 49 tells you why: the service was routine or preventive, and the coverage doesn’t include it.

For Medicare, the rule is in the regulations. 42 CFR 411.15(a) excludes “Routine physical checkups”. That means “Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury.” The rule lists exceptions for the screenings and preventive visits Medicare does cover. It’s a common denial: CARC 49 is fourth on First Coast’s list of the most common denials for April – June 2026 (First Coast, Top claim errors).

PR-49 vs PR-96, CO-50, PR-204 and CO-119

Code	Official X12 text (short)	What it tells you
49	“This is a non-covered service because it is a routine/preventive exam…”	Routine or preventive service the coverage doesn’t include
96	“Non-covered charge(s).”	Not covered, with the reason in a required remark code. See CO-96
50	“These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”	A covered type of service, but not necessary for this patient. See CO-50
204	“This service/equipment/drug is not covered under the patient’s current benefit plan”	The plan doesn’t include this benefit. See PR-204
119	“Benefit maximum for this time period or occurrence has been reached.”	A covered preventive visit billed too often

That last row matters for Medicare wellness visits. CMS limits the AWV to once in 12 months, and not within 12 months of an IPPE. Too-early claims get “messages indicating the patient reached the benefit maximum for the period.” That’s a frequency problem, not a routine-exam problem.

PR-49 vs CO-49 vs OA-49 vs PI-49

Group + 49	Who carries the amount	Can you bill the patient?	When you’ll typically see it
PR-49	Patient	Yes, if it was truly routine	The usual Medicare form. Noridian publishes it as “PR-49”
CO-49	Provider	No	The payer decided the provider is liable. Check your contract
OA-49	Neither group fits	Check the remark codes	Used “when no other group code applies” (CMS Ch. 22, §60.1)
PI-49	Payer-initiated reduction	No	Non-Medicare remits only. CMS lists just CO, OA and PR as valid on Medicare remittances

Remark codes that come with 49

RARC	Official X12 text	What it adds
N429	“Not covered when considered routine.”	The service was treated as routine
N111	“No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.”	Noridian lists it with PR-49
N567	“Not covered when considered preventative.”	The service was treated as preventive
N425	“Statutorily excluded service(s).”	Excluded by law, which is the Medicare basis for the routine physical exclusion

RARC wording is quoted from the X12 RARC list, checked 7 October 2026. Noridian JE Part B lists PR-49 with N111 and N429 (its page shows a shorter N111 wording than the current X12 text). Despite N111’s wording, the same Noridian page says “Items or services with this message have appeal rights.”

Where PR-49 shows up in the 835

Here’s a trimmed, illustrative example for a $240.00 preventive visit line:

SVC*HC:99397*240.00*0.00**1~
DTM*472*20260818~
CAS*PR*49*240.00~
LQ*HE*N429~

• CAS*PR*49*240.00 is the group code, reason code and adjusted amount. PR puts it on the patient.
• LQ*HE*N429 says the service was treated as routine.
• If the remit has a policy reference in loop 2110 REF, the payer’s policy is named there.

How to fix PR-49: decision path

1. Decide what the visit really was. A routine physical, a Medicare preventive visit (IPPE or AWV), a problem-oriented visit, or a mix? Read the documentation, not just the code billed.
2. Covered preventive visit coded as a routine physical? Recode it. CMS pays for “1 IPPE per lifetime if you provide it in the first 12 months after the patient’s Part B coverage starts” (HCPCS G0402). The AWV is G0438 for the first visit and G0439 after that, and “You can only bill G0438 or G0439 once in a 12-month period” (CMS AWV). First Coast: “If a covered preventive service was coded incorrectly, correct the code, and resubmit the claim.”
3. Was a problem treated? If the record supports a payable diagnosis, report it. First Coast: “If a payable diagnosis is indicated in the patient’s medical record, be sure to include the diagnosis, and resubmit the claim.” Noridian notes that “Diagnosis codes starting with the letter ‘Z’ are routine diagnosis.” It adds that claims “can be reopened with a more appropriate primary diagnosis.”
4. Problem visit on the same day as an IPPE or AWV? CMS may pay a “significant, separately identifiable, medically necessary” E/M visit billed with modifier 25 alongside an IPPE or AWV. It can’t be added to a routine physical Medicare doesn’t cover.
5. Resubmit only the corrected lines. First Coast: “Prevent a duplicate denial: Submit corrected line item(s) only.”
6. If it was truly routine, bill the patient. CMS says a routine physical is “Not covered” and “Patients pay 100% out of pocket” (CMS, Medicare Wellness Visits). For next time, see the GY modifier and voluntary ABN notes below.

Medicare and major payer notes

The routine physical exclusion. The Medicare Benefit Policy Manual starts with “Routine physical checkups” in its list of services that “are not covered.” It also lists eyeglasses, hearing aids and most immunizations. The exclusion covers exams done for employers too: “examinations required by third parties such as insurance companies, business establishments, or Government agencies” (CMS IOM 100-02, Ch. 16, §90).

What Medicare does cover. The same section lists exceptions, such as screening mammography, colorectal cancer screening tests, the IPPE and the AWV. First Coast puts it simply: Medicare “does cover certain preventive services.” Two of them are the IPPE and the AWV.

The GY modifier. First Coast says that for statutorily excluded services “you can append a GY modifier to the line item. The GY modifier indicates that the item or service is statutorily excluded or does not meet the definition of a Medicare benefit” (First Coast, PR 96 tips). Our GY modifier guide covers it in more detail.

ABNs. CMS says ABNs “are not required for care that is either statutorily excluded from coverage under Medicare (i.e. care that is never covered)” but encourages a voluntary one as a courtesy (CMS IOM 100-04, Ch. 30, §50.2.1).

Commercial and Medicare Advantage plans. These plans set their own preventive benefits and frequency rules. A PR-49 from them can mean the visit fell outside the plan’s preventive schedule or was billed with codes the plan treats as routine. Read the plan’s benefit summary and the loop 2110 REF policy. For the patient’s side of this, see our guide on being charged for an annual physical or screening colonoscopy.

Worked example (illustrative)

A Medicare patient who has had Part B for six years books an “annual physical”. The doctor reviews her history, updates her prevention plan and screening schedule, and completes a health risk assessment. She also has a new cough, which the doctor examines and treats. The visit is billed as 99397 with Z00.00, and it comes back CAS*PR*49*240.00 with LQ*HE*N429.

Reading it: 99397 is a routine preventive medicine code. Medicare excludes it. But the documented work matches an AWV, and the cough was a separate problem.

Fix: her last AWV was 14 months ago, so the practice replaces the line with G0439. The record supports a separate problem visit, so it adds an E/M code with modifier 25 and the cough diagnosis. It submits the corrected lines only. If the record had shown only a routine physical, PR-49 would stand. The patient would owe it.

Prevention: schedule Medicare patients for an AWV, not an “annual physical”, and check the last AWV date first.

PR-49 appeal or reopening request template

Use this when the claim should have been paid as a covered service, for example a payable diagnosis left off or a covered preventive visit coded wrong. Replace the bracketed text.

[Date]
[MAC or payer name] Reopenings / Redeterminations
[Address or portal reference]

Re: [Reopening / Redetermination] request, PR-49 [/ N429] denial
Patient: [Name]   Medicare/Member ID: [ID]
Claim number: [ICN / claim #]   Date(s) of service: [MM/DD/YYYY]
Provider: [Name, NPI]   Remit codes: PR-49, [N429 / N111]

Reason for request (check one):
[ ] The service treated a specific illness, symptom or complaint.
    Primary diagnosis should be [ICD-10-CM code], documented in
    the enclosed note.
[ ] The service was a covered [IPPE G0402 / AWV G0438 / G0439],
    billed in error as [code]. Last [IPPE/AWV]: [date or none].
[ ] Other: [explain].

Please reprocess line(s) [#].

Enclosed: remittance advice, claim copy, visit note.

[Name, credentials]  [Practice, NPI]  [Phone / email]

PR-49 prevention checklist

• Check the Part B start date and the last IPPE or AWV date before booking a “physical”.
• Use G0402, G0438 or G0439 for Medicare preventive visits that meet the requirements.
• Don’t bill routine preventive medicine codes to Medicare as covered services.
• Put the diagnosis for any problem treated first on that line.
• Add modifier 25 only for a separately identifiable, documented problem visit.
• Use GY for services you know are statutorily excluded.
• Offer a voluntary ABN for a routine physical so the patient knows the cost.
• Review commercial plans’ preventive schedules and frequency limits.

Related denial codes

• CO-96: non-covered charge, often with N425 for statutory exclusions.
• CO-50: not medically necessary.
• PR-204: not covered under the patient’s current benefit plan.
• PR-1, PR-2 and PR-3: deductible, coinsurance and copay.
• CO-119: the benefit maximum has been reached, such as an AWV billed too often.

FAQ

Sources

• X12, Claim Adjustment Reason Codes (CARC 49, 96, 50, 204, 119). CARC 49 Start 01/01/1995, Last Modified 07/01/2017. Accessed 7 Oct 2026.
• X12, Remittance Advice Remark Codes (N429, N111, N567, N425). Accessed 7 Oct 2026.
• First Coast Service Options, Tips to prevent CARC PR 49 (April 14, 2025)
• First Coast Service Options, Top claim errors, April – June 2026 (August 14, 2026)
• First Coast Service Options, Tips to prevent CARC PR 96 (February 16, 2026)
• Noridian JE Part B, Routine Service (last updated Apr 30, 2025)
• eCFR, 42 CFR 411.15, Particular services excluded from coverage
• CMS, Medicare Benefit Policy Manual (IOM 100-02), Ch. 16, §90 Routine Services and Appliances
• CMS, Medicare Wellness Visits, Initial Preventive Physical Exam and Annual Wellness Visit
• CMS, Medicare Claims Processing Manual (IOM 100-04), Ch. 30, §50.2.1 and Ch. 22, §60.1

Last reviewed: 7 October 2026 · This page is educational and doesn’t replace payer-specific instructions.