Dealing with claim denials is a frustrating but unavoidable part of medical billing. This guide provides a clear, actionable plan to understand, fix, and prevent denials related to Claim Adjustment Reason Code (CARC) 97, also known as group code CO 97.
A 97 denial indicates an inclusive denial. This means the payer believes one or more of the billed services are already included in the payment for another service on the same claim. The payer considers these services bundled. Think of it like a prix fixe menu—you pay one price for the appetizer, entrée, and dessert, not for each item individually.
Why Does a 97 Denial Occur?
Several factors can lead to a 97 denial:
Bundling Rules: The most frequent cause. Payers bundle services they deem inherently related, such as pre-operative care, the surgical procedure, and post-operative visits. Billing for each separately often results in a 97 denial.
Incorrect Coding: Using an overly specific code when a more comprehensive bundled code exists can trigger the denial.
Duplicate Billing: Accidentally billing for the same service twice is another common reason.
Resolving a 97 Denial: A Step-by-Step Guide
Review the Remittance Advice (RA): This document explains the denial. Identify the specific denied service and the related, paid service.
Investigate the Bundling Rules: Refer to the payer’s specific bundling guidelines, usually available on their website or through provider relations. Determine if the payer considers the denied service bundled with the paid service.
Correct the Billing: Depending on the situation, you may need to:
Remove the denied code: If it’s truly bundled.
Use a modifier: To indicate the service was distinct or medically necessary despite appearing bundled. Modifiers should be used judiciously and only when appropriate. Research is crucial to select the right modifier.
Bill with the correct bundled code: If the initial coding was too specific.
Resubmit the Claim: Include all necessary supporting documentation, such as medical records and procedure notes, to justify the services.
Know Your Payers’ Policies: Familiarize yourself with each payer’s unique bundling rules. Ongoing research is important as these rules can change.
Utilize Coding Software: Invest in quality coding software that alerts you to potential bundling issues before submission.
Communicate with Payers: Contact payers directly with coding or bundling questions. Building a relationship with payer representatives can be beneficial.
Consider Pre-authorization: For services potentially subject to bundling, pre-authorization can confirm coverage and prevent future denials.
Troubleshooting Persistent Denials
If the denial persists after these steps:
Analyze the 835 Healthcare Policy Identification Segment: Your Electronic Remittance Advice (ERA) may offer more specific denial details.
Contact the Payer: Request clarification on the denial.
Appeal the Denial: Provide comprehensive documentation supporting the medical necessity and distinct nature of the denied service. A well-crafted appeal often overturns denials.
Consult a Billing Expert: If needed, seek expert advice to navigate complex denials.
Additional Tips for Preventing Denials
Regular Training: Continuous training for your billing staff on current coding guidelines and payer policies is essential.
Internal Audits: Periodically review your billing processes to identify patterns and address recurring issues.
Resources and Further Information
While this guide provides a thorough overview, continuous learning is vital in the ever-changing landscape of medical billing. Consulting reliable resources can significantly reduce denials and improve your revenue cycle management.
By understanding and proactively addressing the nuances of the 97 denial code, you can significantly improve your billing efficiency, minimize revenue loss, and ensure your practice receives appropriate reimbursement for the services provided. While the information presented here is based on current best practices, ongoing research and changes in payer policies may impact future interpretations of denial codes. Staying informed and adaptive is key to navigating the complexities of medical billing.
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