One of the most important things is checking coding before submission, check once, check twice, or if possible, then check with any software if the coding is correct, if the documents are according to the insurance update policy.
Denial code 97 basically means “you won’t get paid separately for this service because its cost is already included in another service or procedure that was already processed and paid.”
But don’t worry, this denial is fixable
Here in this blog, we will discuss co 97 denial code description, the top causes, and a proven step-by-step process to help you understand Code 97 and prevent revenue loss.
What is Denial Code 97 and Why Does It Happen
Denial Code 97 means the insurance company is not paying for a service because they believe it is already included in another service that was billed and paid for. In simple words, they are saying, “This is part of something else, so we won’t pay for it again.”
This usually happens when two or more services are closely related and are normally done together. Insurance companies follow rules like bundling guidelines that group certain procedures into one payment. If those services are billed separately, one of them may get denied with a co97 denial code.
One of the most common reasons for this denial is unbundling. This implies that a provider charges different codes, although they are supposed to be charged as one combined service. The other cause is the absence or misplaced modifiers. Modifiers are little codes that are affixed at the end, and they explain why a service is to be paid separately. The claim can be refused in case they are not used properly.
It may also occur because of mere errors, such as duplicate billing or inadequate documentation. Unless it is indicated clearly on the record that the services were distinct and required, the payer will not make an additional payment.
Example of a Claim Denied with CO-97
Let’s say a patient comes in for a visit and also gets a minor procedure done on the same day.
- 99213 – Office visit
- 17000 – Destruction of skin lesion
In many cases, the assessment (99213) is viewed as a component of the procedure (17000). Thus, 99213 can be denied by the insurance with the denial code co 97 because it is already part of the procedure payment. However, when the visit was independent and medically necessary, it can be added that it should be paid separately by adding a modifier -25 to 99213. Otherwise, the system presupposes that the two services are in a single package.
This denial is significant to understand since it influences payment directly. Otherwise, it may result in a loss of income even if the work has been performed.
Common Causes Behind Denial Code 97
There are a few common reasons why this denial shows up. They are mostly minor billing or coding problems that can be resolved when you are aware of where to find them.
1. Unbundling of services
Billing separate codes for services that are usually included in one main procedure
2. Missing or incorrect modifiers
Not adding modifiers like -25 or -59 when the service should be treated as separate
3. Duplicate billing
Billing the same or an almost similar service more than once in a day.
4. Lack of clear documentation
Notes do not clearly show that both services were needed and done separately
5. Coding errors
With the help of the combinations of codes that insurance companies combine in one payment.
If these points are checked carefully before submitting claims, many co 97 denial code cases can be avoided. This is especially important for practices handling workers compensation billing service, where billing rules can be strict and small mistakes can lead to repeated denials
Step-by-Step Process to Fix Denial Code 97
When you get this denial, don’t rush to rebill. The approach explained below works across different specialties, including mental health billing services, where bundling issues are also common.
Follow a clear process so you don’t repeat the same mistake and lose money again.
Step 1: Review the denial details carefully
Check the EOB or ERA and confirm its co-97 denial code. Look for any remark codes that explain why it was bundled.
Step 2: Find the root cause
See which service it was grouped with. Check if it was truly part of another procedure or if it should have been billed separately. Also, review NCCI edits and payer rules.
Step 3: Correct coding or add the right modifier
If the service was separate, fix the claim by adding the correct modifier (like -25 or -59). If it was wrongly coded, update the CPT codes properly.
Step 4: Resubmit the corrected claim
Send the claim again with proper coding and attach supporting documents (notes, reports, or a short explanation if needed).
Step 5: Follow up on the claim
Don’t leave it after resubmitting. Verify the status in 10-14 days and make a move in case it is once again denied.
This step-by-step approach will not only allow you to retrieve payment but will also decrease the possibility of receiving the same denial in the future.
How Outsourcing Helps Prevent CO-97 Denials
A trained outsourcing billing team is aware of how to code checks, claim review, and make small mistakes before it becomes a denial. Outsourcing firms adhere to new payer regulations and coding policies; they can easily identify problems such as bundling errors or missing modifiers.
For instance, when they deal with codes such as 99203 CPT code, they ensure that the service is charged properly and backed with the correct documentation. This reduces the chances of claims getting grouped or denied under CO-97. They also conduct regular audits, billing software accuracy, and a denial pattern tracker. When an issue recurs, they do not correct the individual claims; they correct the root of the issue.
Outsourcing can also contribute to an increase in your total revenue flow in the long run, as opposed to the reduction in CO-97 denials. It saves time, reduces rework, and enables your staff to spend more time attending to patients rather than pursuing payments.
