Quick Explanation
Denial code 97 indicates that the payer has bundled the billed service into the payment of another primary procedure performed during the same encounter. Under CMS and National Correct Coding Initiative (NCCI) guidelines, certain minor or administrative services are considered integral components of a main procedure and cannot be reimbursed separately. To secure payment, providers must prove the service was clinically distinct or performed under circumstances that warrant unbundling.
Common Causes for 97
Denials with code 97 typically happen for the following specific reasons:
- Submitting a claim for a component service that is bundled into a primary procedure according to National Correct Coding Initiative (NCCI) edits.
- Omitting appropriate modifiers, such as Modifier 59 or Medicare's X{EPSU} modifiers, when services are clinically distinct and performed at separate anatomic sites or distinct sessions.
- Billing routine evaluation and management (E/M) services or minor procedures within the global surgical period of a major operation.
- Billing for routine supplies, local anesthesia, or administrative prep work that is already valued in the primary procedure's Relative Value Units (RVUs).
How to Prevent 97 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Integrate up-to-date NCCI edit software within your practice management system to scrub claims and flag bundled code pairs prior to submission.
- Ensure documentation clearly justifies the clinical independence of a service (different site, separate lesion, distinct encounter) before appending modifier 59 or X{EPSU}.
- Track global surgery periods (0, 10, or 90 days) to prevent billing routine post-operative care separately from the primary surgical package.
- Conduct regular internal coding audits on frequently bundled code pairs to align charge master configurations with current payer policies.
Appeal Letter Template for 97
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 97 - The benefit for this service is included in the payment/allowance for another service/procedure
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 97: "The benefit for this service is included in the payment/allowance for another service/procedure".
We are appealing the denial of the billed service under denial code 97, which indicates the service is bundled into the primary procedure. According to CMS National Correct Coding Initiative (NCCI) guidelines and AMA CPT instructions, services that are clinically distinct, performed at separate anatomical sites, or executed during different encounters on the same day are eligible for separate reimbursement. The attached medical documentation clearly demonstrates that the disputed service was performed on a separate anatomical site and represents a distinct clinical effort from the primary procedure. As such, the distinct nature of this service justifies separate payment, and we respectfully request that the denial be overturned and the claim be reprocessed for payment.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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