Denial code 97 means that the benefit for a particular service has already been included in the payment or allowance for another service or procedure that has already been processed. In other words, the insurance company has already accounted for the cost of this service within the payment made for another related service. To get more information about this denial, you can refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) in the claim's electronic remittance advice, if it is available.
Common causes of code 97 are:
- The service or procedure for which the claim was submitted is already included in the payment or allowance for another service that has been processed and paid.
- The healthcare provider may have mistakenly submitted a separate claim for a service that is already bundled or included in another procedure.
- The claim may have been submitted for a service that is considered a component or integral part of another procedure, and therefore, not eligible for separate reimbursement.
- The healthcare provider may have failed to properly identify the bundled services or procedures in the claim submission, leading to the denial.
- The payer's adjudication system may have automatically identified the duplication or bundling of services and denied the claim accordingly.
- The denial may also occur if the healthcare provider did not follow the specific billing guidelines or coding rules set by the payer for bundled services.
It is important for healthcare providers to review the payment policies and guidelines provided by the payer to ensure accurate billing and avoid denials related to code 97.
Ways to mitigate code 97 include:
- Conduct thorough documentation: Ensure that all services and procedures are accurately documented in the patient's medical record. This includes clearly indicating the necessity and distinctiveness of each service provided.
- Verify coverage and benefits: Before providing any service, verify the patient's insurance coverage and benefits. This will help identify if the service is already included in another payment or allowance.
- Communicate with payers: Establish open lines of communication with insurance payers to clarify any potential overlaps or conflicts in payment. This can help prevent denials based on code 97.
- Use correct coding: Accurately assign appropriate codes for each service rendered. This includes using modifiers when necessary to indicate the distinctiveness of the service.
- Implement effective billing practices: Ensure that billing processes are efficient and accurate. Double-check claims before submission to minimize the chances of denials based on code 97.
- Stay updated with payer policies: Regularly review and stay updated with payer policies and guidelines. This will help you understand any specific requirements or restrictions related to code 97.
- Educate staff: Provide comprehensive training to your staff on proper coding and billing practices. This will help minimize errors and ensure compliance with payer requirements.
- Monitor and analyze denials: Continuously monitor and analyze denial trends related to code 97. This will help identify any recurring issues and allow for targeted improvements in your revenue cycle management processes.
By implementing these strategies, healthcare providers can mitigate denials associated with code 97 and improve their revenue cycle management.
The steps to address code 97 are as follows:
1. Review the claim details: Carefully examine the claim to ensure that the service or procedure in question is indeed included in the payment or allowance for another service that has already been adjudicated.
2. Verify the adjudication: Double-check the adjudication of the claim to confirm that the related service or procedure has been processed and paid.
3. Analyze the payment/allowance: Compare the payment or allowance received for the related service or procedure with the one being questioned. Ensure that the payment/allowance adequately covers the service in question.
4. Investigate any discrepancies: If there are discrepancies between the payment/allowance received and the service in question, investigate further to identify any potential errors or issues.
5. Consult relevant documentation: Review any relevant documentation, such as the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if available. This can provide additional guidance or clarification on how to address the code.
6. Take appropriate action: Based on the findings of your review and investigation, take the necessary action to address the code. This may involve resubmitting the claim with additional documentation or appealing the denial if you believe it was incorrect.
7. Document the process: Keep a record of the steps taken to address the code, including any communication with payers or additional documentation submitted. This documentation will be useful for future reference or if further action is required.
By following these steps, healthcare providers can effectively address code 97 and work towards resolving any payment or allowance discrepancies related to services or procedures that have already been adjudicated.