Denial Code 97 is a common yet often misunderstood reason code used by insurance payers. It reads:

“The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.”

This means the claim (or line item) has been bundled with another service, and no separate payment will be made. It’s not a refusal of the service itself but rather a denial of additional reimbursement because the billed service is considered part of a more comprehensive procedure.

In this article, we’ll break down what this denial means, why it happens, how to prevent it, and most importantly how to effectively handle Denial Code 97 to recover revenue and maintain billing compliance.

Understanding Denial Code 97

What It Means:

When a payer issues a denial with Reason Code 97, they’re saying:

• The billed CPT or HCPCS code was already included in another code on the claim.

• This additional code is not eligible for separate payment due to bundling policies (e.g., National Correct Coding Initiative – NCCI edits).

Example:
Billing both CPT 93000 (routine EKG with interpretation and report) and CPT 99213 (office visit) on the same day may lead to 97 denial if proper modifiers are not used or if the EKG was part of the evaluation and management (E/M) visit.

Common Scenarios Leading to Denial Code 97

Step 1: Review the EOB or ERA

• Carefully read the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA).

• Identify the denied code, the code it was bundled with, and any modifier or comments provided.

Step 2: Analyze CPT Coding Relationships

• Check whether the denied CPT code is bundled with another CPT using the NCCI Edits (check Column 1 and Column 2 edits).

• Determine if there is a modifier allowed to bypass the bundling.

Step 3: Review Clinical Documentation

• Does the documentation clearly support the necessity of both services performed independently?

• If yes, ensure that each service is distinct, separately identifiable, and well-documented.

Step 4: Apply Appropriate Modifiers

Depending on the service, apply a modifier when the service is separate and distinct this is a crucial step in accurate medical billing and coding services.

• Modifier -25: For E/M service performed on the same day as a minor procedure.

• Modifier -59: To show distinct procedural service.

• Modifiers -XS, -XE, -XP, -XU: More specific subsets of Modifier 59.

Important: Never use a modifier just to get payment. It must be supported by documentation.

Step 5: Resubmit or Appeal the Claim

• If a modifier was missing, correct the claim and rebill with the proper modifier.

• If a modifier was used correctly but still denied, submit an appeal with supporting documentation, such as:

  • Clinical notes

  • Procedure reports

  • Justification for separate service

Step 6: Educate Staff and Track Trends

• Flag these denial patterns in your revenue cycle system.

• Educate providers and coders on bundling rules and proper use of modifiers.

• Regularly audit claims to identify recurring errors.

Don’t Just Write Off 97 Denials

Too often, practices write off Denial Code 97 without investigation. This leads to avoidable revenue loss. Many of these claims are recoverable if:

• The services were truly distinct

• Documentation is solid

• Proper modifiers are applied

Even if the service was rightfully bundled, you may still be able to capture the full reimbursement by rebilling other codes or bundling smarter.

How to Prevent 97 Denial Code Issues

Use CCI Edits Tools

Before claim submission, check for potential bundling issues using the National Correct Coding Initiative (NCCI) edit checker.

Train Billing & Coding Teams

Ensure staff understands:

• Modifier usage (especially 25 and 59)

• Global surgical package rules

• Documentation standards

Use Billing Software Alerts

Use billing software that flags potential NCCI edit violations before submission.

Educate Providers

Make sure clinicians understand the documentation needed to justify separate services especially on the same day.

Example: Real-World Denial Code 97 Scenario

Claim Example:

• CPT 11721 (debridement of nails)

• CPT 99213 (E/M visit)

Outcome: CPT 99213 denied with Code 97.

Why? The payer considered the E/M part of the routine nail debridement.

Resolution: If documentation shows that a separate medical problem was addressed during the visit (e.g., diabetes review or ulcer care), add Modifier 25 to the E/M code and resubmit the claim with supporting notes.

Final Thoughts: Turning Denials into Opportunities

Denial Code 97 doesn’t always mean you’ve lost money t means you need to review your coding approach. Sometimes, it’s about knowing what to bundle and when to appropriately separate and code multiple services, especially in cases involving CPT Code 88305 and similar pathology procedures.

By:

• Understanding payer rules,

• Applying precise modifiers,

• And maintaining clean documentation,

you can reduce the frequency of 97 denials and recover reimbursement that might otherwise be left on the table.