No one likes to see a denied claim from an insurance payer. A denied claim is lost or delayed revenue for your practice. Nearly 65% of denied claims are never reworked by providers. Not only do you have to adhere to strict state-specific coding and audit guidelines, but you must also evaluate medical documents and physician notes to ensure claims are not under or over-coded. In this article, we shared common reasons for CO 97 denial code and how to resubmit the claim with added information.
CO 97 Denial Code: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
You can reach the claims department with the following questions for the above denial code:
- Claim received date
- Claim denied date
- May I know to which procedure code and DOS it is inclusive/bundled/mutually exclusive?
- Check whether appropriate modifier is required?
- If yes, check with coding team and add the appropriate modifier and resubmit the claim as corrected claim.
- If no, check the appeal limit, appeal address or fax# to appeal the claim.
Possible Reason for Denial
Denial indicates services billed may have already been submitted as part of another service billed for the same date of service (services were bundled). Some services may always be bundled into other services provided or not separately payable. Bundled services should be billed to Medicare only when a denial is needed for a secondary payer. Few examples as follows:
- E/M services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.
- Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.
- Extended hours codes/ common after-hour codes are not separately payable in a facility which operates 24-hours a day.
- Special handling, conveyance or transfer of a specimen to a laboratory from a physician’s office is not usually separately payable, as this type of “extra” care is considered within the payment fee schedules.
Rebill with Modifier
Sometime re-billing with Modifier can get paid for this service. If appropriate, resubmit your claim after appending a modifier and/or correcting your procedure code or other details on the claim. If these codes are coming under Inclusive category then go ahead and adjust the balance as Inclusive write off. If not, append with appropriate modifier and resubmit the claim as corrected claim for reimbursement.
Billing under Global Surgery
The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable. The Medicare approved amount for surgical and some therapeutic or diagnostic procedures includes payment for services related to the surgery and are not separately payable if performed within the global period.
Included services are Pre-operative visits; Intra-operative services; Complications following surgery; Post-surgery pain management; Anesthesia by the surgeon; Supplies; Miscellaneous services; and Post-operative visits.
Excluded services are Initial Evaluation & Management (E/M) service; Other physicians’ care; Unrelated visits/surgeries; Complications with return to operating room; Return to operating room; Unrelated Critical care; Staged/distinct procedures; and Diagnostic tests/procedures.
Verify Post-operative Period
- Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure.
- Access complete instructions for documenting and submitting CPT modifier 24 and 25
- If a modifier is applicable to the claim, apply the appropriate modifier, and resubmit the claim. Submit the corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial. Consider following modifiers
- Modifier 54: pre-and intra-operative services performed
- Modifier 55: post-operative management services only
- Modifier 56: pre-operative services only
- When a visit occurs on the same day as surgery with ‘0’ global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted
Researching and resubmitting denied claims can lead to long, frustrating hours trying to figure out why the claim was denied in the first place. The good news is that on average, 63% of denied claims are recoverable and nearly 90% are preventable. E2E Medical Billing Services can assist you in addressing these denials and recover the insurance reimbursement. For more information, feel free to call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com