No matter how much of a medical billing expert you might be, you will have claims denied. Denied claims are a hassle, causing delays, an extra dent in resources, and unnecessary financial setbacks.
Every year, $262 billion are denied in medical claims, and sadly, 90% of these denials are preventable. The key is to understand the denial code triggered by the payer. One of the most common of these codes is denial code 97.
In this guide, we will explain what causes the CO 97 denial code, how to prevent it, and what to do to resolve it.
Denial Code CO 97 – Description
Payers use the CO 97 denial code to indicate that the claim was adjudicated and paid for a previously performed and related procedure or service. Therefore, the provider is not eligible for a separate payment for the second rendered service or procedure.
It means that if two medical procedures were performed on the same day (where the second procedure is related to the first procedure), the provider is only allowed to bill for the primary procedure.
Denial Code 97: Real-World Examples
Here are some real-world examples to help you better understand code 97:
Colonoscopy with Biopsy
You performed a colonoscopy for a patient to diagnose potential colon cancer. However, during it, you also identified a suspicious polyp and removed it for biopsy. Now, if you submit a claim charging for coloscopy with CPT code 45380 and biopsy with CPT code 49321, the insurance payer may trigger the CO 97 denial code.
The reason behind this denial here is simple – biopsy is a significant part of the colonoscopy procedure for diagnostic purposes, so charging separately for it is not warranted.
Dressing Change with Wound Debridement
You have a patient with a chronic wound that requires regular dressing changes, and during it, you may clean and remove dead tissue, i.e., debridement from the wound. If you charge for dressing change with CPT code 97597, 97598, or 97602 and wound debridement with CPT code 11012, the payer may trigger denial CO 97 on the latter charge.
The CO 97 denial code reason here is that debridement is a necessary service performed during dressing change for chronic wounds. Besides, CPT codes 97597, 97598, or 97602 cover the cost of wound debridement.
X-ray with Two Views
One of your patients requires an X-ray because of suspected pneumonia. As a result, the radiographer took two X-ray images from the anterior-posterior (front) and lateral (side). Thus, you decided to bill for both views separately with CPT code 71045 (which is for single view) when you should have used CPT code 71046 for two views, CPT code 71047 for three views, or CPT code 71048 for four or more views. This wrong coding may result in denial code CO 97.
Other Common Examples of CO 97
Some other common scenarios that may result in CO 97 denial code are as follows:
- Charging separately for a blood specimen results in denial 97 because it is a primary requirement of a patient encounter.
- Within a surgery’s post-operative period, charging for evaluation and management (E/M) services separately can result in CO 97 denial. For minor surgeries, this period is 10 days, and for major surgeries, it is 90 days.
- You cannot charge for extended hour codes if your practice operates around the clock.
Common Causes of CO 97 Denial Code
Some common reasons for the payer to trigger a denial code 97 are as follows:
Separately Billing Bundled Procedures
If a provider primarily performs a radical mastectomy to remove a malignant lesion but also removes other cysts in the process, then the cyst removal will not be billed separately. It is because the provider is already billing for a more extensive procedure – radical mastectomy (removal of the entire breast and axillary adipose tissue) with the CPT code 19307. So, minor lesions or cyst removal for the same breast will be bundled into 19307 instead of getting separately coded as CPT 19120.
Simply speaking, if a separate charge is generated for a bundled service due to misidentification or lack of knowledge about codes by the medical billers, then the CO 97 denial code will be issued.
Billing Related E/M Services
The payment for surgery encompasses all services related to the surgery during the post-operative period (global period). This timeframe ranges between 0 and 10 days for minor surgeries and 0 to 90 days for major surgeries.
Evaluation and management (E/M) services during this period include patient visits, follow-up, wound care, removal of stitches, or lab tests and should not be billed separately. However, if they are, the denial code 97 is triggered.
Duplication of Services
Most government and private insurance payers use automated systems to adjudicate claims. If the system recognizes a duplication of services or procedures performed on the same patient by the same provider on the same day, the system tags the claim with a CO 97 denial code. In this case, denial 97 indicates that the provider is billing the same service or procedure multiple times.
Coding Errors
A submitted claim is flagged with the denial code 97 when the medical billing staff uses inaccurate codes to bill the services or procedures. It can happen when the procedural codes for two separate services are used when a bundled code already exists for the two services in the CPT coding sheets. Similarly, non-compliance to the payer’s unique coding guidelines for bundled services can also initiate a denial 97.
Preventive Strategies for Denial Code CO 97
You can consider these preventive strategies to proactively mitigate the CO 97 denial code.
Review the Documentation
A thorough review of the claim submission form and all the supporting documents is advisable to avoid denial code 97. During the revision, ensure that the procedural codes used match the patient’s medical record and will not be categorized as a duplication of services. You can also use modifiers to explain the necessity and specify the distinctiveness of each procedure.
Educate and Train the Staff
Employees handling medical billing should get adequate training regarding the coding best practices to avoid denial code 97. The latest coding guidelines should be at their fingertips, and they should be able to use the correct codes and modifiers easily when needed.
Moreover, they should constantly be updated about changes in governmental rules and regulations to ensure compliance.
Use Auto-Coding Software
The risk of coding errors increases with manual coding, especially when you file dozens of medical claims daily. In such a case, there is a need for automated billing software to point out errors, give real-time suggestions, autocorrect minor coding errors, and provide valuable feedback. Investing in such automation tools minimizes denials and prevents the loss of revenue.
Stay Updated on New Coding Guidelines
Procedural codes like CPT, assigned by the American Medical Association (AMA), are updated annually. Coding errors and resulting denials usually occur when the billing staff uses outdated codes instead of the most recent ones. Hence, keeping up with the new coding guidelines is essential to avoid the CO 97 denial code.
Outsource Coding to Professionals
Medical coding and the creation of superbills can be a stressful and time-consuming process. If done wrong, it could trigger a denial, similar to denial code 97. You can outsource medical coding to professional billing companies to avoid the hassle and secure your accurate collections.
Their team includes certified professional coders (CPCs) who are well-versed in the latest coding guidelines and can easily tell if a separately performed procedure already exists as part of a bundled service.
Denial Code CO 97 Management & Resolution
Receiving a denial code is not an ideal situation, but it is not one to panic, either. There are ways to address the CO 97 denial code.
Step 1- Review the Denial Letter
The first and foremost step is to thoroughly read the denial letter and understand the reason behind CO 97. The letter contains information such as the procedures for which the payments were denied, whether the payer has paid an adjusted amount for the rendered services, and the last date for filing an appeal.
This denial letter can be used as a framework to identify the root cause of denial code 97 and rework the claim for accurate reimbursements.
Step 2 – Cross-Check the Procedural Codes Used
Next, re-examine the submitted claim carefully. Cross-check the CPT codes, HCPCS codes, and their modifiers against the services performed. If separate codes were used to bill two related procedures, check if a bundled code exists to describe them both.
Step 3 – Communicate to Investigate Discrepancies
Speak to your staff to confirm if the claim was approved and reimbursement was received for the primary procedure. Check the payment receipt to verify if the amount covers the secondary procedure.
Step 4 – Rework the Claim
If the reimbursement does not cover the expenses of both procedures, rework the claim for resubmission. Correct all inaccuracies in procedural codes, especially if the denial code 97 was caused by the missing bundle code. Or correct any duplications in the performed procedures. For example, you can use appropriate modifiers to distinguish between two services and bill them separately.
Step 5 – Collect Supporting Documents
Gather all the supporting documents like clinical notes and operative reports to justify medical necessity for multiple procedures and their separate billing.
Step 6 – Resubmit or Appeal
After you have reworked the claim and corrected the coding errors or inconsistencies in the documents, you can resubmit the claim. In some cases, healthcare providers must create a new claim for rightful reimbursement.
If you disagree with the CO 97 denial code and have sufficient documentation to justify separate billing of the rendered procedures, you can file an appeal with the required documents.
Step 7 – Follow Up
It may take a while for the payer to review your new claims or appeals. Hence, you should track the status of your claim or appeal on the payer’s portal and contact them over a call or via email to follow up on the progress of your payments.
Step 8 – Document the Process
We recommended that you document the denial management process. If the payer refuses to overturn the denial code 97, you can re-appeal the verdict with the help of these documents.
Bottom Line
The frequent occurrence of the CO 97 denial code can decrease a healthcare organization’s cash flow and lead to serious financial challenges. It is usually triggered when two related services are coded and billed separately instead of bundled under one CPT code. Such errors can be avoided through accurate coding, staff training, automated billing, and outsourcing.
If you have received a denial code 97 and are unsure how to resolve it, consider using professional denial management services for quick reversals and rightful reimbursements.
