Fix CO-97 bundled service denials fast. 89% success rate using Modifier 59. Step-by-step guide + appeal templates. Recover lost PT revenue today.
CO 97 means “The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.”
In simple terms, it means the procedure wasn’t paid because it's bundled with another code. But don’t worry, this denial is fixable. Below, we break down the top causes, step-by-step fixes, and sample remarks to help you appeal CO 97 effectively.
Denial Code CO-97 is used in medical billing to indicate that a claim has been denied because the billed service is considered part of another service that has already been processed. This means that the cost of the billed procedure is included in the payment for another related service, and therefore, no additional payment is warranted.
Understanding Denial Code CO-97 is crucial for physical therapy clinics and healthcare providers. It highlights the importance of accurately coding services to ensure proper reimbursement. Identifying when a service overlaps with another can help clinics avoid future denials and streamline their billing processes.
Example of a Claim Denied with CO-97
For instance, a physical therapy clinic submits claims for the following services on the same day:
In this case, the claim for CPT 97530 (Therapeutic Activities) is denied under CO-97, as the payer considers it part of the service covered by CPT 97110 (Therapeutic Exercise). To correct this, the clinic should resubmit the claim with Modifier 59 for CPT 97530 to indicate it is a distinct service. As a result, the claim is paid after resubmission with the appropriate modifier.
Understanding why your claim was denied under CO-97 is the first step toward fixing it—and preventing it from happening again. Let’s break down the most frequent culprits behind this frustrating denial code.
This happens when a procedure you’ve billed for is considered an inherent part of another procedure that was already paid. For example, if you bill separately for a post-op checkup that's typically bundled with a surgical code, it gets denied. Payers view this as double-dipping, even if you feel it should be billed separately. Unfortunately, if you don’t append the right modifier or prove it’s distinct, they won’t budge.
Ever heard the phrase “you already got paid for that”? That’s essentially what CO-97 means when dealing with bundled codes. Insurance companies bundle certain services together under a primary CPT code, and if your claim includes one of those “extras,” it gets flagged. If your claim doesn’t justify unbundling—with strong documentation or modifiers like 59 or XU—it’ll be denied every time.
Even a small coding error can cause a CO-97 denial. Let’s say you mistakenly used a code that looks like it should be separately billable—but it isn’t in that context. Or you left off a required modifier that would have clarified the claim. Coders and billers need to stay sharp here; payers don’t give second chances for sloppy submissions. One misplaced digit or incorrect code pairing, and the system will deny it automatically.
Bottom line? Mastering these common denial triggers can help you train your billing team, tighten up your claims process, and get paid faster.
Now that you know what causes CO-97 denials, here’s exactly how to handle them like a pro. Think of this as your five-step battle plan to fight back and recover revenue.
Don’t just skim the explanation of benefits (EOB) or electronic remittance advice (ERA). Read it thoroughly. Is the denial marked clearly under CO-97? Does it list any associated remark codes? Knowing precisely what the payer is flagging helps you avoid wasting time correcting the wrong part of your claim.
Once you’ve identified the issue, dig deeper. Was the service truly part of another billed procedure? Or was it a legitimate, separate service that simply lacked the right modifier or documentation? Consult the payer’s bundling policy, review NCCI edits, and check if a modifier like 59 or 25 was appropriate—but missing. It’s detective work, and details matter here.
If you discover that the service is indeed separate and was denied only due to a lack of distinction, append the correct modifier (often Modifier 59 or an X modifier). Be careful—misusing modifiers just to force payment can trigger audits. Only apply them if you're confident the service qualifies for separate reimbursement under payer guidelines.
Don’t just slap on a modifier and resend. Attach documentation, office notes, operative reports, or any supporting evidence that justifies the service as distinct. Some payers even prefer you include a short appeal letter or a comment box message explaining the correction.
After resubmitting, set a reminder to check claim status in 10–14 days. Many denials fall into limbo because no one checks whether the correction was accepted. If the payer still denies it, you may need to appeal with more detailed records or request a peer review.
By following these steps, you not only increase your chance of overturning CO-97 denials but also build a stronger internal workflow that reduces repeat errors and improves overall reimbursement.
SPRY empowers clinics to proactively prevent CO-97 denials by optimizing claims management and enhancing documentation accuracy. By automating critical processes and providing real-time error alerts, SPRY allows clinics to focus on delivering excellent patient care while safeguarding their revenue.
Optimized Claim Management
SPRY's automated scrubbing and real-time payer alerts work proactively to ensure claims accuracy, highlighting potential errors to prevent denials such as CO-97.
Streamlined Documentation
With SPRY Scribe’s automated and customizable SOAP notes, along with auto-select CPT and ICD codes, clinics can easily align documentation with payer standards, reducing errors tied to billing codes.
Integrated Insurance Verification
By integrating insurance data directly into the billing system, SPRY avoids duplicate entries and minimizes mistakes, ensuring cleaner claim submissions and reducing denial rates.
To learn more about how SPRY can streamline your operations and reduce the risk of claim denials, schedule a demo today!
Denial Code CO-97 indicates that a claim has been denied because the billed service is considered part of a previously processed service.
Claims are often denied under CO-97 due to bundled services, incorrect submissions for separate payments, or failing to follow billing guidelines related to previously adjudicated services.
To resolve a CO-97 denial, verify the relationships between the billed services, correct any coding errors, and consider adding appropriate modifiers to clarify the distinct nature of the services.
SPRY aids in preventing CO-97 denials through streamlined billing processes, automated documentation, and real-time error alerts, ensuring accurate claims submission.
Review the denied claim to identify the bundled services, correct the billing as necessary, and resubmit the claim with appropriate modifiers for re-evaluation by the payer
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