Insurances will deny the procedure code as CO 97 – The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated with the following reasons:

  • If procedure code billed is inclusive with another procedure code performed on the same day by the same provider.
  • E and M Services billed within the global period are not separately payable. It means the Evaluation and management services that are related to the surgery performed during the post-operative period will be denied as CO 97 – The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated. As the E and M services performed during the post-operative period are not separately payable.

Global period for minor surgery is 10 days and for major surgery is 90 days after the day of surgery performed.

  • If it’s a major surgery, insurances which follow Medicare guidelines will include the pre-operative visits the day before the day of surgery (One day pre-operative included).

Solutions for the denial code CO 97 – The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated:

  • First check to which procedure code it’s been included/bundled/mutually exclusive.
  • Then try to check with the coding team, whether you can submit the claim with an appropriate modifier.
  • If you have already billed the claim with an appropriate modifier and if you think insurance denied the claim incorrectly, then you have rights to appeal the claim along with supporting medical records.

You can reach the claims department with the following questions for the above denial code:

CO 97 – Claim denied as the benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated
1 Claim received date
2 Claim denied date
3 May I know to which procedure code and DOS it is inclusive/bundled/mutually exclusive
4 Check whether appropriate modifier is required?
* If yes If No
6 Check with coding team and add the appropriate modifier and resubmit the claim as corrected claim. Check the appeal limit appeal address or fax# to appeal the claim.
7 Claim# and Cal Reference#