CO 97 – The benefit for this service is included in the payment or allowance for another service or procedure that has already been
Insurances will deny the procedure code as CO 97. Basically, the procedure or service is not paid for separately. This may involve a procedure code that’s inclusive with another procedure code that was performed by the same provider on the same day. It may also related to E&M services that are billed within the global period after a surgical procedure and are not payable separately.
Some common examples of services that are usually bundled into other services and not separately payable include:
Collecting a blood specimen that is usually done during the patient encounter, and therefore is not considered to be separately payable.
Special transfer, conveyance, or handling of a specimen to the laboratory from the doctor’s office usually is not separately payable, since this kind of “extra” care is considered in the payment fee schedules already in place.
E/M services done within the post-operative period of a surgery that are related to that surgery are not payable separately. For minor surgeries this is usually 10 days, and it is usually 90 days for major surgeries. (NOTE: for major surgeries, insurances that follow Medicare guidelines also include the pre-operative visit the day before the surgery date, as well.)
Using extended hours codes (after-hour codes) usually is not going to be separately payable if your practice operates 24-hours daily.
Solutions for Denial Code CO 97:
In some cases, there are some solutions for denial Code CO 97 because there are times when services may be billed separately, even if they are usually bundled with another service. Steps to follow include:
- Start out by checking to see which procedure code is mutually exclusive, included, or bundled. Then you’ll know how to proceed.
- Once you know which procedure code is in question, talk to the coding team to see if there is an appropriate modifier that can be used so you can resubmit the claim.
- If the claim was already billed using an appropriate modifier and you feel the claim has been incorrectly denied, then you have the option to appeal the claim with the support of your medical records.
- It is often useful to talk to the claims department and ask them some questions
about the denied claim, including:
- When was the claim received?
- When was the claim denied?
- Which procedure code was inclusive, mutually exclusive, or bundled
- Is there an appropriate modifier needed?
- If yes, get the appropriate modifier and resubmit your claim as a corrected claim.
- If no, ask about the appeal limit, address, and fax number so you can appeal the claim.
- Ensure you have the claim number and the call reference number as well.