CO-97 denial code
The payer counts this service as already paid for inside another service it processed.
“The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. …”
Start 01/01/1995 · Last modified 07/01/2017 · X12 adjustment reason code list
What it usually means in behavioral health
Per diem programs are the big one. Under many contracts, individual therapy, group, or testing during an IOP, PHP, or residential day is part of the per diem, so a separate professional claim gets CO-97.
Outpatient psychotherapy with an E/M visit on the same day is another: the psychotherapy has to be billed with the correct add-on code, not as a standalone service.
Common causes
- A service billed separately that the contract includes in the per diem
- Psychotherapy with E/M billed as a standalone code instead of the add-on
- Incidental services billed alongside the primary service
Correct and resubmit, or appeal?
Check the contract. If it carves the service out of the per diem, or allows separate billing, appeal with the contract language. Otherwise the adjustment is correct, and billing rules should stop separate billing.
What to do
Read the contract's per diem inclusions and carve-outs.
Check that same-day psychotherapy with E/M uses the add-on codes.
Appeal with the contract clause if the service is separately payable; otherwise fix the billing rule.
Often seen with
- N19
- N20
- M80
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