What is Claim Status 97?

Claim status 97, often referred to as denial code 97, signifies that payment for a particular service has already been included in another service that has already been processed and paid. This means the payer considers the service billed under code 97 to be an inherent or integral part of a larger, primary service for which reimbursement has already been provided.

This is a common denial code in medical billing and does not necessarily indicate that the service was not performed or medically unnecessary. Instead, it highlights an issue with how the service was billed in relation to other services rendered to the patient.

Understanding Denial Code 97

Denial code 97 typically arises when a healthcare provider bills for a service that the payer considers "inclusive" within another procedure. This often falls under bundling rules or global period guidelines established by payers and regulatory bodies. The payer's system identifies that the component service is already compensated as part of a more comprehensive code, leading to the denial of the individually billed service.

This type of denial necessitates a thorough review of the submitted claim, the Explanation of Benefits (EOB), and the payer's specific coding policies to understand why the service was deemed inclusive.

Common Scenarios Leading to Code 97 Denials

Several situations can trigger a claim status 97 denial:

• Bundled Services: Many procedures are comprised of multiple components. Payers use coding edits (like those from the National Correct Coding Initiative, or NCCI edits) to prevent separate billing for services that are typically performed together. For instance, an office visit on the same day as a minor procedure might be bundled into the procedure code, unless specific conditions allowing separate billing (e.g., with certain modifiers) are met.
• Global Surgery Periods: A global surgery package includes all necessary services normally furnished by a surgeon before, during, and after a procedure. This typically covers pre-operative visits, the surgical procedure itself, and post-operative care for a specific period (e.g., 10 or 90 days). Billing separately for routine follow-up care within this global period would result in a 97 denial.
• Ancillary Services and Supplies: Minor services, supplies, or tests that are integral to a larger procedure are often considered part of the primary service. For example, the cost of bandages or local anesthetic used during a minor surgery is typically bundled into the surgical procedure's reimbursement.
• Mutually Exclusive Procedures: In some cases, two procedures are considered mutually exclusive, meaning they cannot reasonably be performed at the same patient encounter. Billing for both could lead to one being denied as included in the other.

How to Address and Prevent Code 97 Denials

Receiving a 97 denial requires specific actions to resolve the claim and prevent future occurrences.

1. Review the Explanation of Benefits (EOB)

• Carefully examine the EOB or remittance advice to identify the primary service that the denied service was supposedly included in.
• Understand the specific reason provided by the payer, even if it's just "included in another service."

2. Understand Coding Guidelines

• Payer-Specific Policies: Research the payer's medical policies regarding bundling, global periods, and appropriate use of modifiers. These policies are often available on the payer's website.
• National Coding Initiatives: Familiarize yourself with NCCI edits, which are updated quarterly by the Centers for Medicare & Medicaid Services (CMS). These edits outline which codes are considered components of others. You can find more information on NCCI edits here.
• CPT® and HCPCS Level II Codes: Refer to the latest coding manuals for guidance on code definitions, bundling rules, and appropriate modifier usage.

3. Utilize Modifiers Appropriately

• If the service was truly separate and distinct from the primary service, despite appearing bundled, specific modifiers may be necessary. Modifiers provide additional information about the service rendered.
• Modifier 59 (Distinct Procedural Service): This is a widely used modifier to indicate that a service or procedure was distinct or independent from other non-E/M services performed on the same day. However, its use should be judicious and only when clinically appropriate and supported by documentation.
• X Modifiers (XE, XS, XP, XU): CMS introduced "X" modifiers as more specific alternatives to Modifier 59 for certain situations (e.g., separate encounter, separate structure, unusual non-overlapping service, or different practitioner).
• Modifier 25 (Significant, Separately Identifiable E/M Service): Used when an evaluation and management (E/M) service is performed on the same day as a procedure or other service by the same physician or other qualified health care professional.

4. Appeal if Necessary

• If, after review, you believe the service was indeed separate and should be reimbursed, gather all supporting documentation (medical records, operative reports, notes).
• Submit a clear and concise appeal explaining why the service should not be considered inclusive, referencing specific medical necessity and coding guidelines.

Summary of Claim Status 97

By meticulously reviewing claims and understanding the nuances of medical coding and payer policies, healthcare providers can effectively manage and reduce denials related to claim status 97.