What CO‑97 usually signals
CO‑97 commonly appears when a payer considers a service “included” in the payment for another service already processed. Operationally, your goal is to decide quickly:
- Correct & resubmit (wrong coding/modifier)
- Appeal (distinct service but not recognized)
- Prevent next time (documentation/template fixes)
Decision tree (use this before you waste time)
| Question | If YES | If NO |
|---|---|---|
| Was it truly separate/distinct? | Proceed to edits/modifier + documentation proof | Likely non-payable separately → adjust workflow |
| Are you allowed to override with modifier (per edits/payer policy)? | Add modifier only if supported + resubmit/appeal | Educate + update claim rules; avoid rebilling separately |
| Does the note explicitly prove distinct service? | Appeal with narrative + cite note elements | Fix templates: prompt providers to document distinct work |
Non-obvious move: Create a “bundling patterns” sheet for your specialty (top 5). Train staff once/month. This prevents 80% of repeats.
Documentation prompts (so the appeal is easy)
Bundling appeals fail when the note is vague. Add prompts to your templates so it’s obvious the work was distinct:
- Separate diagnosis/indication for the distinct service
- Separate procedure note elements when applicable
- Time/location/laterality if relevant
- Clear statement: “Performed as a distinct service due to…”
Even if you don’t appeal, these prompts prevent future issues by aligning documentation with billing reality.
Prevention system (stop repeats)
- Add a bundling check to your clean-claim checklist.
- QA sample top bundling codes weekly until stable.
- When CO‑97 occurs, log it with: CPT pair, payer, note gap, fix made.
Implementation checklist (copy/paste)
- Choose the KPI you want to move.
- Implement one workflow change (SOP + checklist).
- QA sample 10 items/day for 5 days.
- Publish a 1‑page weekly report: KPI, blockers, next action.
Educational resource only — not legal/medical/billing advice.