Denial Code CO 97

Denial Code CO 97 – The benefit for the service or procedure is inclusive/bundled in the allowance/payment for another service/procedure that was already adjudicated.

Insurance company deny a service or procedure with the denial code CO 97 for the following reasons:

• Inclusive
• Bundled

Inclusive/Incidental

Procedure code is a part of another procedure code (usually surgical procedure code) will be denied as inclusive/incidental.

It is related to E&M services that are billed within the global period after a surgical procedure performed and those E & M will not be reimbursed as insurance company will deny with denial code CO 97 as this is inclusive and part of the surgical reimbursement.

Global period:

• 90 days for Major surgery
• 10 days for Minor surgery

For example:

Consider surgery code 27220 performed on 09/18/2023 and billed to insurance and received a payment. Later E&M services performed i.e., CPT 99213 on 10/01/2023 within a global period and submitted a claim to insurance company for reimbursement.

Here insurance company will pay the surgery code CPT 27220 and deny the E&M service CPT 99213 with denial code CO 97 – The benefit for the service or procedure is included in the allowance/payment for another service/procedure that was already adjudicated. It means E&M service is inclusive with surgery code and insurance will not make separate payment for the E&M services within a global period of surgery performed.

In inclusive denial, if we verify the medical records with denied CPT with paid surgery code the diagnosis code will be same.

Following steps taken when procedure code denied as Inclusive:

• First check, the CPT code denied is inclusive with which primary CPT code and also verify is it billed on the same service by the same physician on the same day.
• Next check whether that procedure code had been billed within the global period after a surgical procedure performed by the same physician with same dx code and denied with CO 97 denial code.
• Verify application to see whether appropriate modifier appended to the procedure code. If not appended any modifier, then append the appropriate modifier and resubmit the claim as corrected claim.
• If valid modifier is already appended and denied, then finally you have option to appeal the claim with medical records.

Bundled

Often, certain CPT’s are bundled with other CPT code due to their integral nature and those procedure will be denied as bundled.

For example:

Consider a heart surgery performed for a patient. Before performing the heart surgery treatment, provider will give anesthesia. When the claim billed with separate code for heart surgery and a separate code for anesthesia.

In this case insurances might deny the anesthesia procedure code as its bundled with the heart surgery CPT code, deeming it unnecessary to bill separately.

Following steps taken when procedure code denied as Bundled:

• Whenever we have received the denial Code CO 97 – The benefit for the service or procedure is bundled in the allowance/payment for another service/procedure that was already adjudicated, first step is to verify to which CPT this procedure code is bundled. Whether that denied procedure code is bundled with same claim CPT or with the other DOS CPT of the patient.
• Next step is to verify whether denied CPT submitted with any modifier. If submitted with modifier then check the same with representative, there are possible that rep can send those denied CPT back for reprocessing.
• If CPT submitted without modifier, then check with rep can we add appropriate modifier and resubmit the claim as corrected claim?
• If yes, then get the timely filing limit for corrected claim and corrected claim mailing address.
• If no, then get the appealing address, time frame to appeal the claim, appeal fax#
• If appeal withheld, then assign the claim to client for further action (probably write off).

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)