In the world of medical billing, claim denials can be frustrating for both healthcare providers and patients. Among the many denial codes used by insurance companies, Denial Code 97 is one of the most common. This code means that the insurance payer believes the service provided is not covered or considered part of another service already paid for. In other words, the payer sees the billed service as “included” in the primary procedure and therefore not eligible for separate reimbursement.
What Does Denial Code 97 Mean?
Denial Code 97 simply indicates that the benefit for the service is included in the payment for another service or procedure. This usually happens when two related procedures are billed together, and the payer decides that one of them is already covered under the main code.
For example, if a doctor performs a comprehensive examination and also bills separately for a consultation on the same day, the insurance company may deny the consultation, stating that it is part of the main exam. This denial ensures that payers don’t pay twice for overlapping services.
Common Reasons for Denial Code 97
Several issues can trigger this type of denial, and understanding them can help prevent future claim rejections.
- Bundled Services:
Sometimes, multiple procedures are bundled together under one code. If a provider bills each procedure separately, the payer may deny the additional services under Code 97. - Incorrect Use of Modifiers:
Modifiers are crucial in billing because they tell the payer that a procedure was distinct or performed under different circumstances. If the correct modifier (like -59 or -25) isn’t used when needed, the claim may be denied. - Duplicate Billing:
If the same service is billed more than once for the same patient on the same date, the payer will deny it, claiming it’s already included in a previous payment. - Non-Covered Services:
Some insurance plans simply don’t cover certain services. If a provider bills for a non-covered service, the claim will be denied with code 97. - Incorrect Coding or Documentation:
A mismatch between diagnosis codes and procedure codes can also lead to this denial. The payer may determine that the service isn’t medically necessary or that the documentation doesn’t support separate billing.
How to Fix Denial Code 97
When you receive a denial with Code 97, it’s not the end of the road. The key is to analyze the reason for denial, correct any errors, and resubmit the claim if appropriate.
- Review the Explanation of Benefits (EOB):
The EOB or remittance advice will explain why the service was denied. Check for bundling, incorrect coding, or missing modifiers. - Check for Modifier Errors:
If the denial occurred because the payer believes the service is part of another procedure, review whether a modifier should have been added. For instance, if two procedures were truly separate, use modifier -59 (Distinct Procedural Service) or -25 (Separate E/M Service). - Review Documentation:
Make sure your medical records clearly show why the additional service was necessary and distinct. Good documentation supports your appeal and can lead to claim approval. - Submit an Appeal:
If you believe the denial was incorrect, you can file an appeal. Include supporting documentation, such as chart notes, operative reports, or coding guidelines that prove the service should be billed separately. - Educate Your Billing Team:
Regular staff training on correct coding and modifier use can prevent these denials from happening in the first place.
Real-World Example
Let’s say a patient visits a doctor for both a routine physical exam and a separate medical issue like back pain. The provider bills for both an E/M code for the back pain and a preventive exam code. The payer denies one service with denial code 97, claiming that both are part of the same visit.
However, if the provider includes modifier 25 to show that the evaluation for back pain was significant and separate from the preventive exam, the claim may be paid upon resubmission.
Preventing Denial Code 97 in the Future
The best way to deal with denials is to prevent them. Here are a few proactive steps:
- Always review payer policies and understand which procedures are bundled.
- Use correct and up-to-date CPT and ICD-10 codes.
- Ensure documentation supports all billed services.
- Apply the correct modifiers when appropriate.
- Conduct internal audits to identify recurring issues.
Staying current with coding rules and payer policies saves time and reduces revenue loss.
The Impact of Denial Code 97 on Revenue
Frequent denials under Code 97 can affect a provider’s cash flow and slow down payments. Reworking denied claims takes time, and delays in reimbursement can strain financial operations. By addressing the root cause and implementing better billing practices, healthcare providers can protect their revenue cycle and maintain smooth operations.
Final Thoughts
Denial Code 97 is one of the most common and avoidable claim denials in medical billing. It usually means the service billed is bundled with another or not separately payable. Understanding how this code works helps medical billers, coders, and healthcare providers take the right steps to prevent future denials.
With accurate coding, strong documentation, and proper use of modifiers, most Code 97 denials can be resolved quickly. Staying proactive ensures faster claim approvals, fewer rejections, and a healthier revenue cycle for your practice.
