PR-249: Claim Identified as Readmission

What Does PR-249 Mean?

CARC 249 signals that the payer identified the hospital admission as a readmission — meaning the patient was readmitted within a defined window (typically 30 days) of a prior discharge. Under readmission reduction policies, the payer may reduce or deny payment for the second admission.

This code is most commonly associated with Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with excess readmissions for specific conditions including heart failure, acute myocardial infarction, pneumonia, COPD, hip/knee replacement, and coronary artery bypass graft surgery. Commercial and Medicaid payers have also adopted similar readmission policies.

Not all readmissions are preventable or related to the initial stay. A readmission for a completely unrelated condition, an unavoidable complication, or a planned return should not trigger this reduction. The key to resolving CARC 249 is determining whether the readmission was genuinely related and preventable, or whether it should be treated as a distinct admission warranting separate payment.

How to Resolve

Evaluate whether the readmission was clinically justified, and if so, appeal with comprehensive documentation.

1. Review the readmission circumstances Examine the clinical details of both the initial admission and the readmission. Determine whether the readmission was for the same condition, a related complication, or a completely unrelated medical issue.
2. Check the payer's readmission policy Review the payer's specific readmission policy, including the readmission window, targeted conditions, and any exceptions for planned readmissions or unrelated conditions.
3. Gather clinical documentation Compile discharge summaries from both admissions, clinical notes, diagnostic reports, and any evidence that appropriate discharge planning was implemented during the first stay.
4. Submit a clinical appeal File a formal appeal with documentation demonstrating the readmission was medically necessary, clinically distinct from the prior admission, or not preventable. Reference the payer's readmission criteria and explain why the case does not meet their definition of a preventable readmission.
5. Request peer-to-peer review If the written appeal is denied, request a peer-to-peer review with the payer's medical director to discuss the clinical merits of the readmission.
6. Implement discharge planning improvements Regardless of the appeal outcome, review your discharge planning processes for this patient's condition to reduce future preventable readmissions.

Also Filed As

The same CARC 249 may appear with different Group Codes:

Related Denial Codes