Denial codes / CO-97
CO-97 denial: meaning, fix & appeal letter template
Payer bundled this service into another one.
What it means
Official CARC 97 descriptionThe benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
The payer treats this service as part of another service it already paid — typically an NCCI procedure-to-procedure edit or a global surgical package. Appeal only when the service was separate and distinct and the edit allows a modifier.
Common causes
- NCCI procedure-to-procedure edit with no distinct-service modifier
- E/M on the same day as a procedure without modifier -25
- Service inside a global surgical period without -24/-58/-78/-79
- Payer bundling policy stricter than NCCI
- Modifier used but documentation didn't support it
How to fix it
- Check the NCCI PTP edit pair and its modifier indicator (0 = never separately payable, 1 = modifier allowed)
- If modifier indicator is 1 and the service was distinct, add -59/-XE/-XS/-XP/-XU or -25 as appropriate
- Check the global period and use -24/-58/-78/-79 when they apply
- Confirm documentation shows a separate site, session, or significant separate E/M
- Resubmit corrected, or appeal if the original modifier was correct
Appeal or corrected claim?
Corrected claim if a modifier was missing; appeal if it was correct. If the edit has a modifier indicator of 0, the service is not separately payable — don't appeal. Otherwise, add the correct modifier and resubmit, or appeal with documentation showing the service was distinct.
What to attach
- Procedure/operative note showing separate site, session, or incision
- E/M documentation showing a significant, separately identifiable service (for -25)
- NCCI edit lookup showing modifier indicator 1
- Payer bundling policy excerpt
CO-97 appeal letter template
Replace every [BRACKETED] field. Remove any optional paragraph that doesn't apply.
[PRACTICE NAME] [ADDRESS] · [PHONE] · NPI [NPI] · TIN [TIN] [DATE] [PAYER NAME] Attn: Appeals / Provider Disputes [PAYER APPEALS ADDRESS] Re: Request for Reconsideration — Claim [CLAIM NUMBER] Patient: [PATIENT NAME] Member ID: [MEMBER ID] DOB: [DOB] Date of Service: [DOS] CPT: [CPT CODE] Billed: [AMOUNT] Denial: CO-97 — The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Dear Appeals Reviewer, We request reconsideration of the denial of the above claim. The above service was denied with CARC 97 as included in the allowance for CPT [PRIMARY CPT]. CPT [DENIED CPT] was a separate and distinct service [performed at a separate anatomic site / during a separate session / as a significant, separately identifiable E/M]. The NCCI procedure-to-procedure edit for [CPT PAIR] carries a modifier indicator of 1, permitting separate payment with an appropriate modifier. Modifier [MODIFIER] was appended, and the enclosed [NOTE] dated [DATE] documents [SUPPORTING DETAIL]. Based on the enclosed documentation, we request that [PAYER NAME] overturn this denial and reprocess the claim for payment in accordance with the member's benefits and our participation agreement. Enclosures: - Procedure/operative note showing separate site, session, or incision - E/M documentation showing a significant, separately identifiable service (for -25) - NCCI edit lookup showing modifier indicator 1 - Payer bundling policy excerpt Please contact [CONTACT NAME] at [PHONE] or [EMAIL] with any questions. Sincerely, [NAME], [TITLE] [PRACTICE NAME]
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