Claim adjustment reason code
CO-97: Included in the payment for another service
CO-97 means: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not.
Read the group code before you act on this
97 is the reason. The CO in front of it is the group code, a separate field on the remittance, and it is the one that decides who owes the money: CO means contractual obligation — the payer says the amount is not billable to anybody, and it is written off unless the denial itself is overturned. You may not bill the patient. What the other group codes mean.
What causes CO-97?
- A genuine NCCI bundling edit where the codes should not be billed together
- A separately identifiable service billed without modifier 25 or modifier 59
- A global surgical period the payer believes is still running
- An unrelated service performed on the same day as a procedure
How do you fix a CO-97 denial?
- Check the NCCI edit pair and whether a modifier is permitted to break it — some pairs allow it and some do not, and billing a modifier on a pair that does not allow one is a compliance problem, not a shortcut
- Where modifier 25 applies, the documentation must show a separately identifiable evaluation, not just the same visit described twice
- For global period denials, confirm the surgery date and whether the service was related. Modifier 24 or 79 may apply
- Appeal with the operative note or the visit note, not with a letter asserting the codes are different
Can CO-97 be prevented?
This is where coding knowledge pays for itself. The wrong answer costs the claim, and the wrong shortcut costs more than that.
A denial like this one is the recurring cost that medical billing outsourcing is built to take off your desk — a dedicated seat working the queue instead of it waiting for whoever has a free hour.
Who does this work
A medical coding seat at $2,500 per seat per month works this queue full time, during your business hours, inside your own system. Every call is logged with the payer reference number and the outcome, and every Friday you get it in writing.
What leaving it costs
Working a denied claim costs $57.23 per denied claim in administrative time (source) — before any of it is recovered, and whether or not it ever is.
Payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment (source), so the reason one sits is rarely that nobody knows how to work it. Put your own denial count in.
Questions
What does denial code CO-97 mean?
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. In plain terms: The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not.
What causes CO-97?
A genuine NCCI bundling edit where the codes should not be billed together. A separately identifiable service billed without modifier 25 or modifier 59. A global surgical period the payer believes is still running. An unrelated service performed on the same day as a procedure.
How do you fix a CO-97 denial?
Check the NCCI edit pair and whether a modifier is permitted to break it — some pairs allow it and some do not, and billing a modifier on a pair that does not allow one is a compliance problem, not a shortcut. Where modifier 25 applies, the documentation must show a separately identifiable evaluation, not just the same visit described twice. For global period denials, confirm the surgery date and whether the service was related. Modifier 24 or 79 may apply. Appeal with the operative note or the visit note, not with a letter asserting the codes are different.
Can CO-97 be prevented?
This is where coding knowledge pays for itself. The wrong answer costs the claim, and the wrong shortcut costs more than that.
Is CO-97 the same as PR-97?
Same reason, different group code. The number 97 is the reason: The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not. The prefix says who carries the amount. CO means contractual obligation — the payer says the amount is not billable to anybody, and it is written off unless the denial itself is overturned. PR-97 is the same reason assigned to patient responsibility — the payer says the amount is owed by the patient, and it is billed to them. Read the prefix before the number: it decides whether you appeal, write off, or bill the patient.
What is the difference between CO-97 and CO-96?
CO-97: The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not. CO-96: The plan does not cover this service at all. Distinct from medical necessity, which is an argument about evidence. They are different reasons that happen to sit next to each other in the list, and they are worked differently — CO-97 is worked at the edit pair, with a modifier only where the record supports one; CO-96 is appealed with clinical documentation.
Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.
Last updated 2026-09-14. This is operational guidance drawn from payer remittance practice, not legal, coding or reimbursement advice. Payer-specific rules vary and change; confirm against the payer’s own policy before acting on a specific claim.
Other denial codes
- CO-234 — Procedure not paid separately
- CO-107 — Related or qualifying claim not identified
- CO-18 — Exact duplicate claim or service
- CO-B10 — Allowed amount reduced — a component of the procedure was already paid
- CO-4 — Procedure code inconsistent with the modifier
- CO-231 — Mutually exclusive procedures
- What a missed revalidation actually costs
- How to find payer underpayments nobody is looking for
- The five reasons certified payroll comes back rejected
Next step
Is CO-97 one of the denials costing you most?
Send a ninety-day denial report and an aged AR summary, with no patient identifiers. Within two working days you get a written summary of which denial reasons are costing you most and what is recoverable.
Or write to ops@softhomeglobal.com