Denial Code CO-97
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present
Why CO-97 Happens, Common Root Causes
Service is bundled into the payment for another procedure billed on the same date of service. CO-97 fires when a National Correct Coding Initiative (NCCI) edit, payer-specific bundling rule, or global surgical package consumes the line. • NCCI Procedure-to-Procedure (PTP) edit, the column 2 code is bundled into the column 1 code • Service falls within a 0/10/90 day global surgical period for an earlier procedure • E/M billed on the same day as a minor procedure without modifier 25 • Lab panel components billed individually instead of using the panel code • Payer-specific bundling beyond NCCI (UHC has 200+ proprietary bundles, Anthem similar)
How to resolve a CO-97 denial
CO-97 appeals win when documentation supports a separate identifiable service. Attach: • Two separate progress notes if the second service was distinct (or one note with clearly delineated sections) • A modifier 25 (E/M with procedure) or 59 / X{EPSU} (distinct procedural service) addition with a corrected claim, NOT a written appeal • NCCI lookup printout showing the edit was bypassable (modifier indicator 1) and your modifier rationale If the edit is NCCI Modifier Indicator 0 (absolute bundling), the code combination cannot be unbundled regardless of clinical justification. Do not appeal those, fix the coding for next time.
Recommended action: submit a corrected claim
This denial is a data, coding, or documentation issue. Fix the specific problem (read the paired RARC codes for CO-16; check NCCI bundling for CO-97; recalculate units for CO-151; etc.) and resubmit as a corrected claim — frequency code 7 on UB-04 or the Resubmission Code field on CMS-1500. A corrected claim typically resolves faster than a written appeal and does not consume your appeal windows.
Corrected claim cover letter
Use this cover letter when resubmitting a corrected claim (not an appeal). Mark the claim with the correct resubmission code (UB-04 frequency 7, or the CMS-1500 Resubmission Code field) so the payer processes it as a correction rather than a duplicate.
[Your Practice Letterhead] [Date] [Payer Name] Claims Department [Payer Address] Re: Corrected Claim Submission, Denial Code CO-97 Patient: [Patient Name] Member ID: [Member ID] Original Claim Number: [Original Claim Number] Date of Service: [DOS] To Whom It May Concern: The above claim was returned with denial code CO-97 (The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present). We are submitting a corrected claim to address the identified issue. Correction summary: [Describe the specific correction — e.g., added modifier 59, corrected rendering NPI, added prior authorization number, corrected place of service code, updated units for J-code.] This corrected claim should replace the original submission. Please reprocess with the corrections noted above. Sincerely, [Provider Name or Billing Manager] [NPI / TIN] [Contact Phone] --- A corrected claim is a resubmission with data corrections, not an appeal. Mark the claim with the correct resubmission indicator: frequency code 7 for UB-04 institutional claims, or the Resubmission Code field on CMS-1500 professional claims. Most payers accept corrected claims within 60-90 days of the original adjudication. Verify the payer's current corrected-claim submission rules before sending.
🛡 Preventing CO-97 Denials
Run NCCI edits in your scrubber BEFORE submission, all major clearinghouses include this. Train coders on global period rules (0/10/90 day) and the specific minor-procedure list. Audit your modifier 25 and 59 usage quarterly, both are top OIG audit targets and an unsupported modifier on appeal puts the entire claim at risk. Subscribe to the NCCI Quarterly Update Bundle from CMS, payers adopt new edits within 60-90 days.
CO-97 FAQ
What does denial code CO-97 mean? +
Denial code CO-97 indicates: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This falls under Contractual Obligations (provider writes off).
Can I appeal a CO-97 denial? +
Through a corrected claim, not a traditional written appeal. Identify the specific issue (from the RARC codes paired with CO-16, or the bundling analysis for CO-97), correct the claim, and resubmit with the appropriate corrected-claim frequency code. Corrected claims typically have faster turnaround than written appeals.
Can I bill the patient for a CO-97 denial? +
Generally no. CO (Contractual Obligation) denials are between you and the payer under your contract. Billing the patient for CO-adjusted amounts usually violates your participating provider agreement. Review your specific contract terms before billing.
How do I prevent CO-97 denials? +
Run NCCI edits in your scrubber BEFORE submission, all major clearinghouses include this. Train coders on global period rules (0/10/90 day) and the specific minor-procedure list. Audit your modifier 25 and 59 usage quarterly, both are top OIG audit targets and an unsupported modifier on appeal puts the entire claim at risk. Subscribe to the NCCI Quarterly Update Bundle from CMS, payers adopt new edits within 60-90 days.
What are the common root causes of CO-97? +
Service is bundled into the payment for another procedure billed on the same date of service. CO-97 fires when a National Correct Coding Initiative (NCCI) edit, payer-specific bundling rule, or global surgical package consumes the line. • NCCI Procedure-to-Procedure (PTP) edit, the column 2 code is bundled into the column 1 code • Service falls within a 0/10/90 day global surgical period for an earlier procedure • E/M billed on the same day as a minor procedure without modifier 25 • Lab panel components billed individually instead of using the panel code • Payer-specific bundling beyond NCCI (UHC has 200+ proprietary bundles, Anthem similar)
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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