CO-97: Benefit included in payment for another adjudicated service
CO-97 means the payer considers the benefit for this service included in the payment or allowance for another service or procedure that has already been adjudicated. It is a bundling adjustment, not an exact-duplicate denial.
Common Causes
- A component service was billed separately from a more comprehensive procedure
- An NCCI procedure-to-procedure edit applies to the code pair
- The service is included in a global surgical or other bundled payment
- The payer applied a plan-specific bundling or multiple-procedure rule
- Distinct services were documented but an appropriate supported modifier was omitted or reported incorrectly
How to Diagnose CO-97 Before You Resubmit
CO-97 is different from CO-18. CO-18 identifies an exact duplicate claim or service. CO-97 says the benefit for one service is included in payment for another service. Treating CO-97 as a duplicate can cause staff to miss valid bundling corrections or submit an unnecessary replacement claim.
- 1Which other service or procedure did the payer adjudicate on this claim or encounter?
- 2Does an NCCI procedure-to-procedure edit, global package, multiple-procedure rule, or payer policy explain the adjustment?
- 3Was the denied line a component of the more comprehensive service?
- 4Were the services distinct by encounter, anatomical site, session, lesion, or practitioner?
- 5Does the documentation clearly support that distinction?
- 6Does the applicable edit permit a modifier, and which modifier does the payer require?
- 7Did the payer calculate the allowance correctly under the contract?
How to Resolve CO-97
- 1Identify the other adjudicated service or procedure into which the payer bundled this line
- 2Review the remittance codes, payer policy, contract, and applicable NCCI edit
- 3Confirm whether the services were truly separate based on the medical record, date, site, encounter, and practitioner
- 4If the bundling is correct, post the contractual adjustment according to practice policy
- 5If the services are distinct and the edit permits a modifier, submit a supported corrected claim or appeal under payer instructions
- 6If the payer applied the bundling rule incorrectly, appeal with the code-pair policy and documentation
Worked example
What CO-97 Looks Like in a Real Work Queue
- Scenario
- A claim contains a comprehensive procedure and a component service on the same date. The payer pays the comprehensive code and adjusts the component line with CO-97.
- Interpretation
- The payer is saying the component's value is already included in the allowance for the comprehensive service. This is not evidence that the same claim was submitted twice.
- Next step
- Check the current NCCI and payer edit for the code pair. If the component was integral, post the contractual adjustment. If it was a genuinely distinct service and the edit permits separate reporting, confirm that the record supports the correct modifier before submitting a corrected claim or appeal.
How to Prevent CO-97 Denials
- Check current NCCI and payer-specific bundling edits before claim submission
- Document separate encounters, sites, sessions, lesions, or practitioners clearly when relevant
- Use modifier 59 or an X{EPSU} modifier only when the record supports a distinct service and the edit permits it
- Audit recurring CO-97 adjustments by code pair and payer instead of treating every line as a duplicate
CO-97 Frequently Asked Questions
Is CO-97 a duplicate denial?
No. CO-18 is the common exact-duplicate code. CO-97 indicates that payment for the service is included in the allowance for another adjudicated service or procedure.
Should staff automatically add modifier 59 to fix CO-97?
No. A modifier should be used only when the services were distinct, the documentation supports that distinction, and the applicable edit and payer policy permit separate reporting. Adding a modifier solely to bypass an edit creates compliance risk.
Can a practice bill the patient for CO-97?
Do not transfer the balance based only on CO-97. Review the contractual-obligation group code, payer contract, remittance, patient notices, and applicable law. A correctly bundled contractual adjustment is generally not a new patient charge.
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