Claim denials are one of the most significant barriers to efficient revenue cycle management. Denials not only require additional resources and time for reprocessing, but they also slow down your practice’s cash flow by delaying payment. Statistics show that around $262 billion in medical claims get denied initially, but even worse, more than 60% of those claims do not get reworked, which means that’s a lot of money down the drain.
The good news – it is possible to drastically decrease denials and manage denials that do happen efficiently. And one of the best things your practice can do is familiarize yourself with some of the most common denial codes. We have been looking at some of the most common ones, and today we are digging into denial code CO 97.
Denial Code CO 97 – Procedure or Service Isn’t Paid for Separately
Denial Code CO 97 occurs because the benefit for the service or procedure is included in the allowance or payment for another procedure or service that has already been adjudicated. Basically, the procedure or service is not paid for separately. This may involve a procedure code that’s inclusive with another procedure code that was performed by the same provider on the same day. It may also related to E&M services that are billed within the global period after a surgical procedure and are not payable separately.
Some common examples of services that are usually bundled into other services and not separately payable include:
- Collecting a blood specimen that is usually done during the patient encounter, and therefore is not considered to be separately payable.
- Special transfer, conveyance, or handling of a specimen to the laboratory from the doctor’s office usually is not separately payable, since this kind of “extra” care is considered in the payment fee schedules already in place.
- E/M services done within the post-operative period of a surgery that are related to that surgery are not payable separately. For minor surgeries this is usually 10 days, and it is usually 90 days for major surgeries. (NOTE: for major surgeries, insurances that follow Medicare guidelines also include the pre-operative visit the day before the surgery date, as well.)
- Using extended hours codes (after-hour codes) usually is not going to be separately payable if your practice operates 24-hours daily.
Potential Solutions for Denial Code CO 97
In some cases, there are some solutions for denial Code CO 97 because there are times when services may be billed separately, even if they are usually bundled with another service. Steps to follow include:
- Start out by checking to see which procedure code is mutually exclusive, included, or bundled. Then you’ll know how to proceed.
- Once you know which procedure code is in question, talk to the coding team to see if there is an appropriate modifier that can be used so you can resubmit the claim.
- If the claim was already billed using an appropriate modifier and you feel the claim has been incorrectly denied, then you have the option to appeal the claim with the support of your medical records.
- It is often useful to talk to the claims department and ask them some questions
about the denied claim, including:
- When was the claim received?
- When was the claim denied?
- Which procedure code was inclusive, mutually exclusive, or bundled
- Is there an appropriate modifier needed?
- If yes, get the appropriate modifier and resubmit your claim as a corrected claim.
- If no, ask about the appeal limit, address, and fax number so you can appeal the claim.
- Ensure you have the claim number and the call reference number as well.
The Use of Appending Modifier 59
According to CMS, you can’t separately report a procedure or service as a separate procedure if it is performed in the same patient encounter as an additional procedure in an anatomically related area using the same surgical approach, orifice, or skin incision. However, if the procedure or service is distinct from or unrelated to the major service or procedure, then you can code a separate procedure independently. That’s where modifier 59 comes into play. It can be used to represent a different patient encounter, session, surgery or procedure, different organ system or site, separate lesion, separate area or injury or injury, or separate excision/incision.
However, not all National Correct Coding Initiative (NCCI) code pairs have the ability to be unbundled with the use of a modifier. Code pair edits that have a “0” modifier indicator are not permitted to be unbundled. It is essential for coders to recognized when the separate procedure is integral to the comprehensive service or procedure being billing since NCCI edit tables don’t always incorporate those separate services or procedures.
Questions to Ask Before Separately Coding Separate Procedures
To avoid having claims denied for claim denial code CO 97, it is essential to ask some key questions before you separately code a separate service or procedure. Questions you should ask include:
- Question #1 – Is this separate procedure or service a component of another major service or procedure?
- Question #2 – Is the separate service or procedure independently performed?
- Question #3 – Is the separate service or procedure unrelated to the major service or procedure?
- Question #4 – Is this separate procedure considered distinct?
- Question #5 – Is this separate service or procedure performed on the contralateral or ipsilateral side, same orifice/incision, and same organ?
If you answered “yes” to any of the above questions, then it may be possible to bill the procedure or service separately.
Learning more about common claim denials helps equip your practice to prevent denials that can negatively impact your practice’s bottom line. At Coronis Health, we specialize in improving efficiency and revenue for medical practices. To discover how we can help you boost your bottom line, prevent denials, and even increase practice efficiency, contact us for more information today.