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:
Questions need to ask with representative of the claims department for CO 97 denial code (Inclusive/bundle/exclusive with primary procedure code):
Questions need to ask with representative of the claims department for CO 97 denial code (Inclusive/bundle/exclusive with surgery code (Global period)):
Examples:
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.
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