Denial Code CO-97 is more than just a frustrating rejection from payers—it's a critical factor that can directly impact your clinic's financial health. As a physical therapist, understanding and effectively managing CO-97 denials is essential to ensure you get paid for the services you provide and maintain the smooth operation of your practice.
What is Denial Code CO-97?
Denial Code CO-97 indicates that a claim has been denied because the service is considered included in the allowance of another service or procedure already adjudicated. Simply put, the payer believes that the procedure you billed for was part of another service that has already been paid, so no additional payment is warranted.
Why Does CO-97 Matter?
Repeated CO-97 denials can lead to significant financial losses, increased administrative workload, and a negative effect on patient satisfaction. Mastering the intricacies of CO-97 is essential to safeguarding your revenue cycle and ensuring your practice thrives.
Deconstructing a CO-97 Denial: What Went Wrong and How to Fix It?
Example:
- Initial Billing:
- CPT 97110: Therapeutic Exercise
- CPT 97140: Manual Therapy
- CPT 97530: Therapeutic Activities
- CPT 97150: Group Therapy
- Outcome: CPT 97530 (Therapeutic Activities) was denied under CO-97 because the payer considered it part of the service covered by CPT 97110 (Therapeutic Exercise).
- Remedy:
- Step 1: Review the denial reason on the Explanation of Benefits (EOB) to confirm the bundling issue.
- Step 2: Consult payer guidelines to determine if a modifier is necessary to unbundle the services.
- Step 3: Resubmit the claim with the appropriate modifier, such as Modifier 59, which indicates that CPT 97530 was a distinct and separate service from CPT 97110.
- Corrected Billing:
- Result: The claim was paid after resubmission with the correct modifier.
Actionable Steps: How to Address a CO-97 Denial
- Analyze the Denial: Carefully review the EOB or Remittance Advice (RA) to understand the exact reason for the denial.
- Gather Documentation: Collect all relevant documentation that supports the service provided, including clinical notes, previous claims, and payer guidelines.
- Correct and Resubmit: Make necessary corrections, such as adding appropriate modifiers or adjusting the claim based on the documentation, and then resubmit the claim.
- Follow-up: Keep track of the resubmitted claim and be prepared to appeal if the denial persists.
Correct Modifier Usage
Using the correct modifiers is crucial in preventing CO-97 denials because they help clarify the context in which services were provided, ensuring that each service is appropriately reimbursed. Misapplication or omission of modifiers is a common cause of denials, so thorough knowledge and accurate application are essential for maximizing reimbursements.
Here's a list of commonly used modifiers that can help address and prevent CO-97 denials in physical therapy billing:
- Modifier 59 (Distinct Procedural Service): Indicates that a procedure or service was distinct or independent from other services performed on the same day. Used to bypass the National Correct Coding Initiative (NCCI) edits when services that are usually bundled are performed separately.
- Modifier GP (Services Delivered Under an Outpatient Physical Therapy Plan of Care): Applied to indicate that services were provided as part of a physical therapy plan of care.
- Modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Healthcare Professional): Used when a procedure or service is repeated by the same provider on the same day.
- Modifier 25 (Significant, Separately Identifiable Evaluation and Management [E/M] Service by the Same Physician on the Same Day of the Procedure or Other Service): Indicates that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service beyond the usual pre-and post-operative care.
- Modifier KX (Requirements Specified in the Medical Policy Have Been Met): Indicates that the therapy cap has been met and that the services provided meet the necessary criteria for continued payment.
Proactive Prevention: Avoiding CO-97 Denials
- Pre-Claim Submission Checklist:
- Verify that all services are coded correctly and that appropriate modifiers are used.
- Double-check for potential bundling issues before submitting the claim.
- Ensure that documentation supports all services billed.
- Training and Best Practices:
- Regularly train your billing staff on the latest coding guidelines and payer policies.
- Implement best practices for documentation to avoid denials.
- Technology and Tools:
- Utilise advanced billing software that flags potential coding errors before submission.
- Leverage claim scrubbing tools that check for bundling issues and incorrect modifiers.
Conclusion: Protect Your Practice’s Revenue with Expert Denial Management
Denial Code CO-97 can be a significant challenge, but with a thorough understanding of its implications and proactive measures, you can protect your practice's financial health and focus on what truly matters—patient care. By mastering the proper use of modifiers, ensuring accurate documentation, and staying vigilant with claim submissions, you can minimize the risk of denials and ensure that your services are fully reimbursed.
Take Action with SPRY
Navigating the complexities of medical billing and denial management can be overwhelming, but you don’t have to do it alone. SPRY’s advanced physical therapy software is designed to streamline your billing process, flag potential errors before they occur, and ensure your practice gets paid for the hard work you do. Our platform integrates seamlessly with your existing workflows, offering you peace of mind and freeing up time to focus on patient care.
Ready to see how SPRY can revolutionize your billing and revenue cycle management? Schedule a demo today and take the first step toward a more profitable and efficient practice.
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