Can CO-97 denials be appealed?

Yes, CO-97 denials can be appealed or resolved via corrected claim within the payer's filing window (typically 30 days). Average industry overturn rate is 35%.

CO-97 Coding & Modifiers Medium Severity

CO-97: Benefit Included in Another Service / Bundled Procedure

Benefit included in another service / bundled procedure (NCCI edit)

Appealable?

Yes — Standard

Avg Recovery Rate

35%

Filing Window

~30 Days

Common RARCs

N519, M15

1. What Does Denial Code CO-97 Mean?

The payer bundled this procedure into another primary procedure billed on the same encounter under CMS National Correct Coding Initiative (NCCI) edits or commercial bundling rules.

2. Top Root Causes for CO-97

Most CO-97 rejections trace back to one of the following billing or clinical discrepancies:

Billing comprehensive and component codes together without modifier

Evaluation & Management (E/M) service bundled into a minor surgical procedure on same DOS

Separate anatomic sites treated but billed without unbundling modifiers (e.g. -59, -XS)

3. Resolution Checklist for CO-97

Interactive Checklist

Step through these concrete audit items before submitting a corrected claim or filing a formal appeal:

Check CMS NCCI Procedure-to-Procedure (PTP) edits to verify if modifier is allowed (Indicator 1)

If modifier is allowed and services were separate and distinct, append Modifier 59 or X{EPSU}

Verify documentation clearly demonstrates separate lesions, separate anatomical sites, or distinct sessions

Resubmit as corrected claim with modifier and supporting operative report

4. Appeal Strategy & Letter Template

If NCCI edit modifier indicator is 0, the services can never be billed together. If indicator is 1, appeal with documentation proving the services occurred at separate anatomic sites or separate encounters on the same day.

Subject: Appeal for Bundled Procedure (CO-97) with Modifier Justification
Claim: [Claim ID] | DOS: [DOS] | Primary CPT: [Primary CPT] | Bundled CPT: [Secondary CPT]

We request unbundling reconsideration for CPT [Secondary CPT]. As documented in the attached operative report (Page 2), this service was performed at a completely separate anatomical site ([Describe Site]) distinct from the primary procedure. We appended Modifier [59/XS] in accordance with NCCI guidelines and request independent reimbursement.

How ClaimCure Prevents CO-97 Automatically

Rather than reacting to CO-97 on post-adjudication 835 ERAs weeks after service, ClaimCure's pre-submission 4-bucket scrubber audits claims in real-time before electronic dispatch:

Integrate automated NCCI PTP edit checks into pre-submission claim scrubbers
Train coding staff on appropriate modifier 25 and 59 utilization criteria

Try ClaimCure Claim Scrubber Free →

Free Appeal Toolkit

Get the CO-97 Resolution Kit

Download our customized appeal checklist, CMS citation references, and payer timely filing matrix for CO-97.

Work Email

Practice / Company Name

Practice Size

HIPAA-compliant. Zero PHI collected.

Related Denial Codes

CO-16 Missing Information or Billing Error

CO-4 Service Inconsistent with Policy/POS

CO-45 Charge Exceeds Fee Schedule

CO-151 Payment Adjusted / Downcoded E/M