CO 97 Denial Code

CO 97 denial code means that an insurance claim has been rejected because the number of times a specific medical service or procedure was billed exceeds the maximum allowed by the insurance company. In simpler terms, it’s like saying the insurance won’t cover the extra times that a particular medical action was done beyond what they consider acceptable.

Common reasons:

1. Inclusion of Service in Another Payment:

• The submitted claim may be denied because the service or procedure is already covered within the payment for another processed and paid service.

2. Mistaken Separate Claim Submission:

• The healthcare provider might have mistakenly submitted a separate claim for a service that is already bundled or included in another procedure.

3. Service Considered an Integral Part:

• The claim could be rejected if it’s for a service considered a component or integral part of another procedure, making it ineligible for separate reimbursement.

4. Failure in Identifying Bundled Services:

• Denial may result from the healthcare provider’s failure to correctly identify bundled services or procedures in the claim submission.

5. Automated Denial by Payer’s System:

• The payer’s adjudication system might automatically identify duplicated or bundled services, leading to the denial of the claim.

6. Non-compliance with Billing Guidelines:

• Denial may occur if the healthcare provider did not adhere to the specific billing guidelines or coding rules set by the payer for bundled services.

7. Unnecessary use of modifiers 59 and 79:

• Modifier 59 is used to indicate a distinct procedural service, while modifier 79 signifies an unrelated procedure performed during the postoperative period. If these modifiers are applied incorrectly, such as using them interchangeably or without proper justification, it can create confusion for payers. This may result in claims being denied with CO 97.

Avoiding Future Denial

1. Understand Payer Guidelines:
   1. Familiarize yourself with the billing guidelines and coding rules of the specific payer to ensure accurate and compliant claim submissions.
2. Use Correct Codes:
   1. Use the correct CPT (Current Procedural Terminology) codes and modifiers when submitting claims. Ensure that codes accurately represent the services provided.
3. Accordingly use modifiers 59 and 79:
4. Apply modifiers 59 and 79 as necessary. Failure to do so might result in encountering denial code CO 97.
5. Identify Bundled Services:
   1. Clearly identify and understand which services are bundled or included in others. Submit claims accordingly to prevent duplication.
6. Documentation:
   1. Maintain thorough documentation that supports the medical necessity of each service billed. Proper documentation can help in case of claim audits or reviews.
7. Training and Education:
   1. Train staff involved in billing and coding on the latest updates in coding guidelines. Regularly educate them to stay informed about changes in reimbursement policies.
8. Implement Technology Solutions:
   1. Utilize billing software or systems with built-in checks for bundling issues. Automated systems can help identify potential problems before claim submission.
9. Monitor Remittance Advice:
   1. Regularly review remittance advice from payers. Understand the reasons for any denials, including CO 97, and address the root causes promptly.
10. Communicate with Payers:
    1. Establish open communication channels with payers to clarify any uncertainties regarding their billing policies. Seek clarification before submitting claims.
11. Stay Informed:
    1. Stay informed about industry changes, coding updates, and payer policy changes. Regularly check for updates from relevant healthcare organizations and payers.
12. Internal Audits:
    1. Conduct periodic internal audits to identify and rectify potential issues. This proactive approach can help prevent denials.

Addressing the denial

Follow the procedure outlined in:

1. Take a moment to review the procedure code and identify if it falls under mutual exclusivity, bundling, or inclusion.
2. Engage with the coding team to discuss potential modifiers that could be applied for resubmitting the claim. Their expertise can offer valuable insights and assistance.
3. In cases where the claim was initially submitted with the correct modifier, consider the option of appealing the claim. Supporting documentation from medical records can strengthen your appeal.
4. Connect with the claims department in a collaborative manner. Seek additional information that could be beneficial for your appeal. Open communication can lead to a better understanding of the situation.

In conclusion, to resolve a CO 97 denial, you may need to adjust the claim by correcting the billed units or providing additional documentation to support the medical necessity of the services rendered. It’s advisable to communicate with the payer and thoroughly understand their billing guidelines to prevent future denials of this nature.

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