Denial codes can be confusing and time-consuming to navigate, but understanding their meaning is crucial for effective revenue cycle management. In this article, we’ll tackle what the CO-97 denial code is, why it appears, and how to resolve it.
What Does CO-97 Denial Code Mean?
The CO-97 denial code is a common issue in medical billing that signifies a service isn’t separately payable because its cost is already included in the payment for another previously processed procedure or service. In simpler terms, CO-97 means that the payer considers the denied service as bundled into another service for which payment has already been made.
For instance, if a patient undergoes a procedure that includes various components, such as preoperative care and surgical services, the insurance company may bundle these services into one payment. Any attempt to bill separately for a service included in this bundle could result in a CO-97 denial.
You might want to check out our article about the CO-197 to see additional examples of bundling scenarios.
An Example of CO-97 Denial Code
Let’s break this down with a practical example:
Imagine a patient undergoing knee replacement surgery. The procedure involves several steps: anesthesia, the surgery itself, and postoperative monitoring. When the claim is submitted, the insurance company reviews the billing and identifies that the anesthesia cost is included in the payment for the surgical procedure. As a result, the claim for anesthesia services is denied with the CO-97 denial code.
Step-by-step, this scenario looks like:
- The provider submits separate claims for the surgery and anesthesia.
- The insurance payer processes the claim and identifies that anesthesia is bundled into the surgical procedure payment.
- The claim for anesthesia is denied with the CO-97 denial code.
This example illustrates why understanding bundling rules is critical to avoid unnecessary denials.
Why Does Denial Code CO-97 Happen?
Denial Code CO-97 happens when services are considered bundled under payer rules. Payers often create bundling guidelines to simplify payments and avoid paying twice for services that are part of a single procedure.Some common reasons for CO-97 denials include:
- Submitting separate claims for bundled services: This happens when a provider unknowingly bills for a service already included in a procedure.
- Coding errors: Using incorrect codes or failing to follow the payer’s specific billing guidelines can lead to CO-97 denials.
- Failure to review payer policies: Payers often update their bundling rules, and staying informed is critical to submitting accurate claims.
How to Resolve Denial Code CO-97
Addressing CO-97 denials requires a structured approach. Here are actionable steps to resolve and prevent these denials:
- Review the denial notice. Start by carefully reviewing the denial notice to understand the payer’s rationale.
- Examine bundling guidelines. Check the payer’s bundling rules to confirm whether the denied service is part of another procedure’s payment.
- Submit a corrected claim. If an error was made, submit a corrected claim with the appropriate procedure code to align with bundling rules.
- Appeal if necessary. If you believe the denial is incorrect, file an appeal with supporting documentation, such as medical records and a detailed explanation of why the service should be payable.
Additionally, here are some tips for preventing CO-97 denials:
- Stay updated on payer policies: Regularly review updates to bundling guidelines from your payers.
- Invest in staff training: Make sure your billing team understands coding best practices and payer-specific rules.
- Conduct internal audits: Periodically review claims to identify and address potential bundling issues before submission.
How Adonis Helps With Denial Codes (Including CO-97)
Facing denial codes like CO-97 can be daunting, but Adonis streamlines the process with advanced automation and data-driven insights. Here’s how Adonis can help:
- Automated claim verification: Adonis guarantees that claims are compliant with payer bundling rules before submission, reducing the likelihood of CO-97 denials.
- Real-time denial tracking: With real-time tracking, your team can quickly identify and address denial codes, minimizing delays in payment.
- Comprehensive reporting: Gain valuable insights into denial trends to pinpoint recurring issues and implement corrective measures.
- Seamless appeals management: Adonis simplifies the appeals process by organizing necessary documentation and providing step-by-step guidance for resolution.
With Adonis, healthcare organizations can save time, reduce errors, and improve revenue outcomes. For more insights, have a look at how Adonis addresses other denial codes like CO-197, CO-29, and CO-177.
Ready to Simplify Your Denial Management? Denial codes don’t have to be a barrier to your revenue goals. With our automated solutions, your team can focus on delivering quality care while ensuring accurate and timely reimbursements.Explore Adonis today to take control of your denial management process and optimize your revenue cycle.
