What is Denial Code CO 97?

In 2021, an organization by the name of KFF found that HealthCare.gov insurers denied nearly 17% of in-network claims. In other words, out of almost 292 million in-network claims, there were roughly 48 million denied claims. That’s a lot of lost revenue.

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Claim denials are one of the most significant culprits when it comes to delayed payments.

While you won’t be able to say sayonara to claim denials all together, you can minimize the amount your practice receives. To do this efficiently and effectively, it is important for you and your team to understand some of the most frequently seen denial codes.

Today, let’s take a look at CO 97 and how understanding this code can save you money.

If you receive denial code CO 97, here are some things to keep in mind. The “CO” in this equation stands for “Contractual Obligation”. This means that the code is a contract between a healthcare provider and an insurance company. This is important for providers and insurance companies to figure out what services they will each be covering.

Denial Code CO 97 occurs because the benefit for the service or procedure provided is included in the payment for another procedure that has already been billed.

In simpler terms, the service provided is not paid for individually.

Here are some common examples of services that usually bundle with other services. The following are not separately payable:
1. Taking a blood sample during a patient encounter.
2. Transfer, conveyance, or handling of a specimen from the doctor’s office to the laboratory.
3. Evaluation and management services done within the post-op period of a surgery that are directly related to that surgery. The time period for minor surgeries is usually 10 days. For major surgeries, it's usually 90 days.
4. Using after-hour codes if your practice operates 24-hours daily.

Luckily, there are some solutions for denial code CO 97. That is because there are times when you can bill services separately, even if they bundle with another service.

Follow these steps to find out more:
1. Check to see which procedure code is mutually exclusive, bundled, or included.
2. Once you check for the procedure code, talk to the coding team. See if there is an appropriate modifier to use so you can resubmit the claim.
3. If the claim was already billed using the correct modifier, you still have the option to appeal the claim with support of medical records. Make sure you have the claim number and call reference number.

With nationwide staff shortages, landmark regulation, a shifting economy, and lack of standardization among payers, there is little room for error in collecting revenue. Figuring out how to reduce errors during your claims process is the best place to start. Utilizing clearinghouses can help you expedite your claims process by executing claim scrubbing and instantly flagging errors before sending to the payer.

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