How To Fix Denial Code 97 | Common Reasons, Next Steps & How To Avoid It

Denial Code 97 means that the benefit for a particular service is already included in the payment or allowance for another service or procedure that has already been adjudicated. This denial code indicates that the insurance company will not make an additional payment for the service because it is already covered under a different code. In this article, we will explore the description of denial code 97, common reasons for its occurrence, next steps to resolve it, how to avoid it in the future, and provide examples of denial code 97 cases.

2. Description

Denial Code 97 is a specific Claim Adjustment Reason Code (CARC) that signifies that the benefit for a particular service is already included in the payment or allowance for another service or procedure that has already been adjudicated. This means that the insurance company has already made a payment for a related service, and therefore, will not provide additional reimbursement for the service associated with denial code 97. The 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) can be referenced to obtain more information about the specific service and its payment status.

2. Common Reasons

The most common reasons for the occurrence of denial code 97 are:

1. Incorrect Billing: Denial code 97 may occur when a service is mistakenly billed separately when it should have been included as part of another service or procedure. This can happen due to coding errors or a lack of understanding of the insurance company’s billing guidelines.
2. Unbundling of Services: Sometimes, healthcare providers may unbundle services that should be billed together as a single procedure. This can lead to denial code 97 as the insurance company considers the individual services to be already covered under a different code.
3. Duplicate Billing: If a service is billed multiple times for the same patient and the same date of service, denial code 97 may be triggered. The insurance company will only reimburse for the service once, and any duplicate claims will be denied.
4. Incorrect Coding: Inaccurate coding of services can result in denial code 97. If the service is coded incorrectly or does not match the description of the service provided, the insurance company may deny the claim.

3. Next Steps

To resolve denial code 97, the following steps can be taken:

1. Review the Claim: Carefully review the claim that was denied under denial code 97. Check for any errors in coding, billing, or bundling of services that may have led to the denial.
2. Identify the Related Service: Determine which service or procedure the denied service is related to. This can be done by referring to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if available.
3. Correct the Billing: If the denial was due to incorrect billing or unbundling of services, correct the billing by ensuring that the related service is included as part of the primary service or procedure. Make any necessary adjustments to the claim and resubmit it for reimbursement.
4. Address Duplicate Billing: If the denial was a result of duplicate billing, identify the duplicate claims and remove them from the submission. Ensure that only one claim is submitted for the service.
5. Verify Coding Accuracy: Double-check the coding of the service to ensure that it accurately reflects the description of the service provided. Make any necessary corrections to the coding and resubmit the claim.
6. Contact the Insurance Company: If there is still confusion or disagreement regarding the denial, contact the insurance company’s provider support. Discuss the specifics of the claim and seek clarification on the reasons for the denial. This communication can help resolve any misunderstandings and provide guidance on how to proceed.

4. How To Avoid It

To avoid denial code 97 in the future, healthcare providers can take the following steps:

1. Understand Billing Guidelines: Familiarize yourself with the insurance company’s billing guidelines and policies. Ensure that services are billed correctly and in accordance with the guidelines to prevent denials.
2. Review Coding Practices: Regularly review and update coding practices to ensure accuracy. Stay updated with the latest coding guidelines and ensure that services are coded appropriately.
3. Implement Quality Checks: Establish quality checks in the billing process to catch any errors or discrepancies before claims are submitted. This can include double-checking codes, verifying service descriptions, and reviewing claims for completeness.
4. Train Staff: Provide training to billing and coding staff to ensure they are knowledgeable about the insurance company’s policies and procedures. Regularly update their knowledge to keep up with any changes in billing guidelines.

5. Example Cases

Here are two examples of denial code 97:

• Example 1: A healthcare provider submits a claim for a surgical procedure. However, the claim also includes a separate charge for a related diagnostic test that should have been bundled with the surgical procedure. The insurance company denies the diagnostic test charge under denial code 97, as it is already covered as part of the surgical procedure.
• Example 2: A provider submits a claim for a comprehensive office visit that includes various services such as laboratory tests and vaccinations. However, the provider mistakenly bills each service separately instead of bundling them together. The insurance company denies the individual service charges under denial code 97, as they are already covered as part of the comprehensive office visit.

Source: Claim Adjustment Reason Codes