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Medical Billing Guide to CO-97 Denial Code

CO-252 Denial Code

The CO-97 denial code is one of the most recurring and financially impactful denial codes in medical billing. Whether it appears as denial code 97, co 97 denial code, or denial code CO 97, the outcome is the same payment is denied because the payer considers the service bundled or included in another service that has already been repaid. For healthcare providers, unresolved CO 97 denial code medical billing issues can lead to rising write-offs, increased rework, and reduced net revenue. This complete guide explains the CO-97 denial code description, clarifies the CO 97 denial code reason, discusses related codes such as PI-97 denial code, OA 97 denial code, and PR 97 denial code, and provides a clear, actionable CO 97 denial code solution with a strong focus on prevention and compliance.

Denial Code CO 97 Description

The Denial Code CO 97 description indicates that the payer has determined the billed service is included in the payment for another service or procedure that has already been processed and paid. In medical billing terms, this means the denied service is considered bundled and not eligible for separate repayment. The CO 97 denial code falls under contractual obligation, which requires the provider to adjust off the denied amount and prohibits billing the patient. This denial commonly occurs due to National Correct Coding Initiative (NCCI) edits, global surgical package rules, or missing or incorrect modifiers. In CO 97 denial code medical billing, understanding this description is critical because it helps billing teams quickly identify whether the denial should be written off, corrected with appropriate modifiers, or appealed with strong clinical documentation.

Types of 97 Denial Code

The 97 denial code can appear under different adjustment responsibility categories, and each type determines who is financially responsible for the denied amount and how the denial should be handled. Accepting these variations is essential for accurate follow-up and compliance in medical billing.

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CO-97 Denial Code (Contractual Obligation)

The CO-97 denial code is the most common type and indicates that the service is bundled or included in the payment for another already reimbursed service. Since it is a contractual obligation, the provider must write off the denied amount and cannot bill the patient.

PI-97 Denial Code (Provider Insurance)

The PI-97 denial code or PI 97 denial code means the denial occurred due to provider billing or coding errors, such as incorrect CPT combinations or missing modifiers. The responsibility lies with the provider, and the amount is not billable to the patient.

OA-97 Denial Code (Other Adjustment)

The OA 97 denial code is issued when the payer applies its own internal policies or coverage rules to determine that the service is inclusive. This type often requires payer-specific review to decide whether correction or appeal is appropriate.

PR-97 Denial Code (Patient Responsibility)

The PR 97 denial code is less common and indicates that, according to the patient’s benefit plan, the denied amount may be transferred to patient responsibility. This should be carefully reviewed to ensure it aligns with payer contracts and reporting guidelines. Each 97 denial code description reflects the same core issue bundled or inclusive services but the adjustment type determines the correct resolution path.

Watch Out for The Services That Can Trigger CO 97 Denial Code

Certain services and billing scenarios are specially prone to denial code 97 due to how payers apply bundling logic.

Recurring CO 97 Denials

High-Risk Services for CO-97 Denials

Evaluation and Management (E/M) Services

E/M services billed on the same date as a procedure are one of the most common CO 97 denial code reason triggers. Without proper documentation and modifier -25, payers assume the visit is included in the procedure payment.

Global Surgical Package Services

Post-operative visits, minor procedures, and related diagnostic services billed within the global period frequently result in co-97 denial code descriptions, as they are considered part of the surgical package.

Mutually Exclusive CPT Code Combinations

CPT codes that violate NCCI column 1/column 2 edits are often denied under denial code CO 97 unless a valid modifier such as -59 or X-modifiers is applied correctly.

Diagnostic, Imaging, and Laboratory Services

Bundled lab panels, radiology components, and professional/technical splits are common sources of CO 97 denial code medical billing denials.

CO-97 Denial

Duplicate or Overlapping Services

When multiple providers bill similar services for the same patient and date of service, payers often reimburse only one and deny the rest as inclusive under 97 denial code rules.

Appealing a CO-97 Denial

Appeals for denial code co 97 should only be submitted when documentation clearly proves the service was distinct, medically necessary, and separately identifiable. Strong appeals typically include detailed progress notes, operative reports, and explicit justification for modifier usage. Unsupported appeals increase payer scrutiny and delay resolution.

What Is CO 97 Denial Code in Medical Billing?

The CO 97 denial code in medical billing indicates that the payer has determined a billed service is already included in the payment for another service or procedure that has been processed and reimbursed. In other words, the payer considers the denied service bundled and not eligible for separate payment. This denial falls under contractual obligation, meaning the provider must adjust off the amount and is not permitted to bill the patient. The co-97 denial code is most commonly associated with CPT bundling rules, National Correct Coding Initiative (NCCI) edits, and global surgical package guidelines. Understanding how and why this denial is applied is critical for billing teams, as improper handling can lead to unnecessary write-offs and repeated denials.

Why Does the CO 97 Denial Code Happen?

The CO 97 denial code occurs primarily due to payer bundling logic and coding rule enforcement. One of the most common reasons is billing multiple CPT codes that are considered inclusive of one another according to NCCI edits. Another frequent cause is missing or incorrect modifiers that would otherwise indicate a service was distinct and separately identifiable. Additionally, services provided during a global surgical period are often denied under denial code 97 because the payer assumes they are part of the global package. Duplicate billing, overlapping services by multiple providers, and payer-specific policy limitations also contribute to CO 97 denial code reasons. In most cases, the denial is not due to lack of medical necessity but rather how the service was reported.

Modifiers That Help Prevent CO 97 Denial Code

Proper modifier usage plays a crucial role in preventing co 97 denial code issues. Modifier -25 is used to indicate a significant, separately identifiable Evaluation and Management (E/M) service performed on the same day as a procedure. Modifier -59 and the more specific X-modifiers help identify distinct procedural services that would otherwise be bundled. Modifier -51 is used to report multiple procedures performed during the same session. When applied correctly and supported by strong documentation, these modifiers clearly communicate to the payer that the service should be reimbursed separately, significantly reducing the risk of 97 denial code occurrences.

How the Global Period Affects Denial Code 97

The global surgical period is a major contributor to denial code 97 adjustments. Payers bundle post-operative visits, routine follow-ups, and certain related procedures into the global payment for surgery. When providers bill these services separately without meeting specific exceptions, the claims are often denied under CO 97 denial code. Services that may qualify for separate payment during the global period include unrelated procedures, complications requiring return to the operating room, or distinctly documented services supported by appropriate modifiers such as -24 or -79. A thorough understanding of global period rules is essential to avoid unnecessary CO 97 denial code medical billing write-offs.

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Tips to Prevent Recurring CO 97 Denials

Preventing recurring CO 97 denial code issues requires a proactive and structured approach. Regularly reviewing NCCI edits and payer-specific policies ensures CPT combinations remain compliant. Implementing pre-billing audits and claim scrubbing tools helps identify bundling conflicts before claims are submitted. Continuous education for providers and coding staff improves documentation quality and modifier accuracy. Additionally, analysing denial trends by payer and service type allows billing teams to identify root causes and implement long-term corrective actions. Consistent preventive measures significantly reduce repeated 97 denial code denials.

How to Fix CO 97 Denial Code Without Rebilling

Not every CO 97 denial code requires claim resubmission. In many cases, the denial is correct and should be posted as a contractual adjustment. When documentation clearly supports a separately identifiable service, the denial can often be addressed through an appeal rather than rebilling. Appeals should include detailed clinical notes, operative reports, and clear justification for modifier usage. If the denial is due to payer policy rather than coding error, rebilling may be ineffective and unnecessary. Knowing when to appeal, adjust, or write off a CO 97 denial code saves time, reduces rework, and improves overall revenue cycle efficiency.

How To Prevent CO-97 Denial In Future?

Prevention is the most effective CO 97 denial code solution. Reducing these denials requires a proactive and compliant billing strategy.

Accurate Modifier Application
Consistent use of modifiers such as -25, -59, -51, and X-modifiers significantly reduces co 97 denial code descriptions.

Routine Review of NCCI Edits
Keeping CPT combinations aligned with current NCCI edits helps prevent 97 denial code rejections before claims are submitted.

Pre-Billing Audits and Claim Scrubbing
Internal audits and automated claim scrubbers identify bundling conflicts early, reducing downstream denials.

Provider Documentation Education
Clear, detailed documentation supports coding accuracy and minimizes CO 97 denial code reason occurrences.

Denial Trend Analysis
Monitoring denial code 97 trends by payer, provider, and service type allows organizations to identify root causes and implement long-term fixes.

Final Thoughts

The CO-97 denial code description highlights the importance of coding accuracy, documentation quality, and payer policy compliance in modern healthcare billing. By fully understanding Denial Code CO 97 Description, addressing the underlying CO 97 denial code reason, and implementing a structured CO 97 denial code solution, healthcare organizations can reduce write-offs, improve clean claim rates, and strengthen overall revenue cycle performance.

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