Insurance deny the claim with CO 97 denial code, when procedure code is inclusive with the other procedure code billed or another service for the same patient that has already been billed and adjudicated.
Let us learn some of the following medical terms for decoding the above denial:
Global Days: Certain follow up cares or post-operative services after the surgery performed within the global time period will not be paid and will be denied with denial code CO 97 as this is inclusive and part of the surgical reimbursement.
Global time period:
1) Major surgery – 90 days and
2) Minor surgery – 10 days.
Inclusive denial in Medical billing:
When we receive CO 97 denial code, we need to ask the following question to rectify the problem and take an appropriate action:
- First check, the procedure code denied is inclusive with the primary procedure code billed on the same service by the same physician on the same day.
- If not, check whether that procedure code had been billed within the global period after a surgical procedure performed by the same physician and denied with CO 97 denial code.
Questions need to ask with representative of the claims department for CO 97 denial code (Inclusive/bundle/exclusive with primary procedure code):
- Get the denial date and reason for the denial
- Check to which primary procedure code it is inclusive/bundle/exclusive.
- Next verify in application whether appropriate modifier appended or not.
- If already appropriate modifier appended, then request rep to reprocess the procedure code. If not appended then check whether we can resubmit the claim as corrected claim along with appropriate modifier. Check with medical coding team for appropriate modifier.
- Get timely filing limit to resubmit corrected claim, claim number and Cal reference number.
Questions need to ask with representative of the claims department for CO 97 denial code (Inclusive/bundle/exclusive with surgery code (Global period)):
- Get the denial date and reason
- Check to which previously paid surgery code (DOS and CPT code) it is inclusive.
- Next check the global period and verify the same.
- Finally verify in the application whether it is same diagnosis code billed for both previously paid surgery code and inclusive denial date of service. If it is same diagnosis code then will take client approval (Provider) for adjustment.
- If diagnosis code is different, then check whether you can resubmit the claim with appropriate modifier. Check with coding team for appropriate modifier.
- Get timely filing limit to resubmit corrected claim along with appropriate modifier, claim number and Cal reference number.
Assume doctor has performed the following repairs for the patient who fell from a step ladder and reported the claim with CPT code 12044 and 12004 for the following wound repairs.
- Intermediate repair to the arm of 8.9 cm.
- Simple repair to the foot of 9.6 cm.
In this case insurance has paid the primary procedure code 12044 and denied the procedure code 12004 with CO 97 denial code.
Answer: As per the medical coding guidelines, when more than one classification of wounds is repaired, we have to list the more complicated as the primary procedure code and less complicated as the secondary procedure code along with modifier 59. If not reported with modifier 59 the less complicated CPT code will be denied with CO 97 denial code.
In this case more complicated procedure code is 12044 (Intermediate repair; 8.9 cm) and less complicated procedure code is 12004 (Simple repair; 9.6 cm) and claim should be reported along with modifier 59 as follows for reimbursement of both the CPT’s.
12044 and 12004*59.