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.

When an insurance company denies a service or procedure with denial code CO 97 citing reasons such as “inclusive” or “bundled,” it means that the benefit of that particular service is already covered within the payment or allowance for another service or procedure that was previously adjudicated.

What is Inclusive or incidental?

The concept of inclusive or incidental procedures is critical for ensuring accurate reimbursement for services rendered. When a procedure code is deemed inclusive or incidental, it means that it is considered integral to another primary procedure code, typically a surgical procedure. As a result, any services billed using an E&M (Evaluation and Management) code within the global period following the surgical procedure will be denied by insurance companies. This denial is usually accompanied by denial code CO 97, indicating that the E&M service is part of the surgical reimbursement and therefore not eligible for separate reimbursement.

The global period, which dictates the timeframe during which related services are considered part of the primary procedure, varies depending on the complexity of the surgery. Major surgeries typically have a global period of 90 days, while minor surgeries have a global period of 10 days. During this period, any E&M services provided as part of the post-operative care are expected to be included in the overall reimbursement for the surgical procedure and are not reimbursed separately.

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.

When an insurance company denies an Evaluation and Management (E&M) service code within a global period of a surgery due to it being inclusive with the surgery code, it means that the insurance will not make a separate payment for the E&M service as it is already included in the payment for the surgery. This is denoted by 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.

In such cases, if medical records are verified, it will show that the diagnosis code for both the denied E&M service (CPT 99213) and the paid surgery code (CPT 27220) will be the same. This is because the E&M service provided within the global period of the surgery is considered part of the overall care associated with the surgery and is therefore not eligible for separate reimbursement from the insurance company

When a procedure code is denied as inclusive (denial code CO 97), it is essential to take the following steps to address the issue effectively:

• First, check the denied CPT code to see which primary CPT code it is considered inclusive with. Verify if it was billed on the same service by the same physician on the same day.
• Next, check if the procedure code was billed within the global period after a surgical procedure performed by the same physician with the same diagnosis code, and if it was denied with the CO 97 denial code.
• Verify if the appropriate modifier was appended to the procedure code. If no modifier was appended, add the correct modifier and resubmit the claim as a corrected claim.
• If a valid modifier was already appended and the claim was still denied, the final option is to appeal the claim with medical records to provide additional documentation supporting the necessity of the procedure.

By following these steps systematically, healthcare providers can effectively address denials related to inclusive procedure codes and improve their claims reimbursement success rates.

What is Bundled?

Bundled refers to the practice in healthcare where multiple services are typically performed together as part of a single comprehensive procedure, and reimbursement is consolidated for all components.

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 the scenario where a heart surgery is performed and anesthesia is provided as a separate service with distinct billing codes, insurance companies may deny the anesthesia code on the grounds that it is bundled into the heart surgery procedure and therefore considered unnecessary to bill separately.

When a procedure code is denied as bundled (denial Code CO 97), it is crucial to address the issue effectively by following these steps:

• When faced with a denial Code CO 97 indicating that the benefit for a service or procedure is bundled in the allowance/payment for another service/procedure that has already been adjudicated, the first step is to verify to which CPT this procedure code is bundled. It is crucial to determine whether the denied procedure code is bundled with the same claim CPT or with a different Date of Service (DOS) CPT for the patient.
• Next step is Verifying whether a denied CPT code was submitted with a modifier is essential in the revenue cycle management process. If a denied CPT code was indeed submitted with a modifier, it is critical to communicate with the insurance representative. There is a possibility that the representative can provide clarification or request resubmission of the denied CPT code for reprocessing
• If CPT code submitted without a modifier, it is imperative to verify with a representative if an appropriate modifier can be added to accurately reflect the service provided
• If it is feasible to add a modifier, the timely filing limit for a corrected claim and corrected claim mailing address should be obtained promptly. The claim should then be moved to the coding team for review and the addition of the suitable modifier
• In cases where adding a modifier is not feasible and the claim needs to be appealed, the appealing address, time frame for appeal, and appeal fax number will vary based on the specific insurance company involved. It is crucial to be aware of these variations and comply with the specific requirements of the insurance company to ensure a successful appeal process.
• If the appeal is withheld or unsuccessful, the claim should be assigned to the client for further action, which may involve considering writing off the claim.

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