Best Ways for Billing Teams to Handle CO-97 Denials Efficiently
Reduce claim denials with proven strategies to handle CO-97 efficiently. Help billing teams improve accuracy, and boost revenue cycle success.
Denial management is among the most challenging tasks in medical billing that requires billing teams to deal with day in day out. CO-97 is one of the denial codes which seem to be prevalent across the various specialties and practice sizes. Such refusals delay the flow of cash, overburden the work of the administration, and cause misunderstandings between providers and payers. Every billing team that would like to have a healthy revenue cycle must understand how to manage them effectively.
This article spells out all that billing teams should know, including the knowledge of the denial code and prevention of future incidents.
What CO-97 Denial Code Means for Billing Teams
The CO-97 denial code is used when insurance payers consider a service or procedure to be covered in another service that has already been billed. To put it in simple terms, the payer feels that the billed service cannot be separately payable since it is included with a primary procedure.
It means the advantage of this service is part of the payment or allowance of another service or procedure that has already been adjudicated. With such a denial by the billing teams, it indicates that the claim was not denied due to the fact that the service was not necessary, but because the payer does not allow separate reimbursement of the service.
To billing staff at practices of all sizes, receipt of CO-97 is an indicator to become more cautious of reviewing the coding practices, bundling policies, and payer-specific policies.
Common Reasons Behind CO-97 Denials in Medical Billing
This denial has several reasons why it comes up on a remittance advice. Improper unbundling of services is the most prevalent reason. This occurs when a coder charges two procedures as two distinct codes when payer policies state that they need to be billed together under a single code.
The other cause is that there is no modifier. Certain procedures are liable to be billed separately, and only when the appropriate modifier is appended to the claim. In the absence of such a modifier, the services are automatically lumped together and a CO-97 denial is provided.
Other common triggers are lack of medical necessity documentation, duplicate billing, and improper use of add-on codes. Billing teams have to keep up with National Correct Coding Initiative (NCCI) edits which determine which codes can or cannot be billed together. The disregard of such edits is one of the main reasons as to why this denial has been continuously repeated on claims.
How CO-97 Affects Revenue Cycle Management Processes
Once this denial makes its way into the revenue cycle, the effect of this denial is rippled throughout various departments. The billing team has to pause and check the claim, conduct a research on the reason of denial and decide on whether to appeal the claim or write off the sum. This is time and resource consuming and could be utilized in a more productive manner elsewhere.
Recurring incidences also have an influence on the overall denial rate of a practice, which is one of the key performance indicators in revenue cycle management. High denial rate is an indicator of low billing efficiency and may result into shortage of cash flow. Payers can also be able to flag practices that have recurrent patterns to further review.
Financially, every unresolved CO-97 situation will constitute lost or stalled revenue. In the long run, these sums accumulate substantially. This is the reason why billing teams need to consider any case as a priority task instead of letting it lie in the system without being resolved.
Steps Billing Teams Must Take After CO-97 Denials
The initial thing to do upon this denial is to carefully examine the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). This will inform the billing team on which service was rejected and the exact reason why it was rejected.
The team is then supposed to pull the original claim and compare it with the bundling rules and NCCI edits of the payer. In the event that the denial was made in error, then a powerful appeal must be made. In the event of being valid, the claim ought to be amended and either re-filed or entered into the system.
All denials of CO-97 should be recorded in a denial tracking log by the billing teams. This assists in determining the trends with time. When the same procedure continues to produce this reaction, it is an indication of a systemic problem in the coding or billing process that needs to be rectified as soon as possible.
It is also important to communicate with the clinical team. There are cases where the documentation made by the provider does not justifiable to separate billing. A collaborative effort with the providers to enhance the quality of documentation can go a long way in ensuring that this form of denial is reduced in the future.
How to Appeal CO-97 Denials With Supporting Documentation
To be appealing, it is necessary to be clear and evidence-based. The billing group should collect all the pertinent paperwork prior to filing the appeal. It consists of the original claim, the EOB, the clinical notes, the operative reports, and any payer policy documents supporting separate reimbursement.
In the appeal letter, it must be clearly stated why the service qualifies to be reimbursed separately. It must refer to certain payer policies, CPT code guidelines, and relevant modifiers. In case a missing modifier triggered CO-97, the corrected claim with the proper modifier must be resubmitted as soon as possible.
The filing is an important aspect within the appeal process. The majority of payers have very tight deadlines, and failure to comply with them means that the practice will lose the right to be reimbursed in full. The internal deadline set by billing teams should be earlier than the deadline put in place by the payer to enable the billing teams to have enough time to thoroughly review and submit the bills.
It is also important that follow-ups are done on appeals submitted. All the cases that have been appealed should be monitored and those which have not been resolved should be brought to high levels within a specific period.
Preventing CO-97 Denials Through Better Prior Authorization Practices
It is always better to prevent than cure. Among the most efficient ones, there is the improvement of the previous authorization procedures. The billing team is required to ensure that they know what services are covered and whether the payer needs bundled billing of those services.
Educating staff is also a significant factor. Coders and billing personnel are required to remain abreast of the most recent NCCI edits, CPT code updates as well as payer specific bundling policies. Internal audits and regular training sessions can significantly reduce the percentage of CO-97 on returned claims.
Another intelligent move is to use billing software, which has inbuilt claim scrubbing applications. Such tools identify possible triggers prior to submission, which will provide an opportunity to the team to fix errors in advance. Review of claims in advance minimizes the possibility of such a denial ever getting to the payer.
Effective communication among coders, billers, and providers is necessary. By making all people aware of the regulations surrounding bundling and separate billing, the number of errors and rejection of claims will decrease.
CO-97 Denial Trends Billing Teams Should Monitor Regularly
One of the smarter things that a billing team can get used to is tracking trends in denial. Surveillance of CO-97 trends across weeks and months will show what procedures, providers or payers are causing the greatest issues within the practice.
Billing teams are advised to create regular denial reports with their practice management system. These reports can be used to determine whether the problems are grouped in one particular department, tied to one particular payer, or tied to one particular set of procedure codes.
After identifying the trends, teams can come up with specific solutions. As an example, when the claims submitted to a specific payer have this denial repeatedly, the billing workflows with that payer can be revised. Reactive denial management is converted into a strategic and measurable process through proactive monitoring.
Dissemination of trend reports to practice managers and providers also creates accountability and helps to enhance continuous improvement throughout the entire organization.
Best Tools Billing Teams Use to Reduce CO-97 Denials
Technology contributes significantly in the management and reduction of such denials effectively. Billing teams can identify, categorize, and resolve more CO-97 cases more quickly and with greater accuracy by using practice management systems with built-in denial management modules.
Claim scrubbing software compares each claim to payer rules and NCCI edits then submits it. This minimizes the chances of making mistakes due to bundling mistakes or omission of modifiers. A lot of these tools are also updated on a regular basis to reflect any recent changes in the payer policies.
Denial management dashboards provide billing managers with real time access to volumes, trends, and resolution status. This assists the teams to prioritize the amount of work and nothing is missed.
There are also some practices that outsource medical billing services that specialize in denial resolution. These partners introduce specialized skills and up-to-date information on payer-specific regulations, which is particularly beneficial to smaller practices with a limited internal base.
How Billing Care Solutions Streamlines CO 97 Appeals?
Billing Care Solutions makes sure there is no room left for speculation with every CO-97 denial. First, we will conduct an audit on your rejected claim to uncover the real cause of the rejection. Then, our staff will collect all the needed documentation such as fee schedule and patient medical records. Letters appealing the denial will be written, mentioning the particular payer contract in which your case is stated. Our software will ensure that we monitor every denial from the time of submitting the appeal till the time the payment arrives. Let us handle the complexity of the appeal process for you.
Conclusion
To effectively deal with these denials, knowledge, process discipline, and the appropriate tools are needed. Billing teams that identify the root causes of CO-97, follow a systematic response process, appeal with well-documented appeals, and invest in preventive strategies will experience significant improvements in revenue cycle performance. By working hard, and ensuring that the right support system is in place, any billing team can limit the effects of this denial and take steps to safeguard the long-term financial wellbeing of their practice.
