Nearly 17% of in-network claims were rejected by HealthCare.gov insurers in 2021.Put otherwise, 48.3 million of the 291.6 million in-network claims were rejected. That’s a significant loss of income. It is reported by some insurers that almost 50% of in-network claims are denied! It goes without saying that one of the main causes of your practice’s resource depletion and the subsequent obstacles to effective revenue cycle management is claim denials. Denials not only reduce the output of your team but also slow down the flow of funds into your company by postponing payments.
What Are Denial Codes?
To determine the reasons for totally or partially rejecting a healthcare claim, insurance companies utilize denial codes. Denial codes give detailed justifications for a claim’s rejection, enabling medical providers and billing specialists to comprehend the reasons behind the denial and take the necessary steps to address the problem. Both patients and providers benefit from denial codes since they offer transparency and understanding about claim rejections.
What is Denial Code CO 97?
A vital function of the CO 97 Denial Code in medical billing is to indicate that a process or service is not eligible for an independent payment. When a service’s benefit is included in the allowance or payment for another service that has already been decided, Denial Code CO 97 is triggered. To put it another way, there is no separate payment for the service or procedure. When a provider invoices a procedure code that includes another procedure code, that is one example. A CO 97 code could be generated if these procedures are carried out on the same day by the same supplier.
Some common examples:
These are some additional typical instances of services that are typically bundled with other services. The ensuing items are not chargeable independently:
- getting blood samples while the patient is being seen.
- Moving, transporting, or working with a specimen from the clinic to the lab.
- Services connected to surgery that are performed during the post-operative phase include evaluation and management. Minor surgery recovery times typically last 10 days. Generally, major procedures take ninety days.
- if your practice is open twenty-four hours a day, using after-hours codes.
Common reasons or causes for code 97:
- The claim was filed for a service or treatment that had been covered by the payment or allowance for an additional service that had previously been paid for and processed.
- It’s possible that the medical professional filed a false claim for a service that was already combined or incorporated into another procedure.
- It is possible that the service for which the claim was filed was deemed essential or a component of another procedure and was not qualified for reimbursement on its own.
- The denial may have resulted from the healthcare provider’s incorrect identification of the packaged procedures or treatments in the claim submission.
- It’s possible that the payer’s evaluation system immediately recognized the service bundling or duplication and rejected the claim as a result.
- The refusal could also happen if the healthcare provider did not adhere to the payer’s particular coding or billing specifications for bundled services.
In order to guarantee correct billing and prevent code 97 denials, healthcare practitioners should carefully go over the payer’s payment policies and standards.
Possible Solutions for Denial Code CO 97:
Although services are typically packaged with other services, there are situations in which they may be paid separately, leading to the need for remedies for rejection Code CO 97. The actions to take are as follows:
- To begin, find out which procedure code is included, bundled, or mutually exclusive. After that, you’ll know what to do.
- After determining which procedure code is in doubt, speak with the coding team to find out if the claim may be resubmitted with the application of a suitable modifier. You have the right to file a complaint with the help of your medical files if you believe the claim has been unfairly refused even though it was previously billed with the proper modifier.
- Speaking with the claims department and posing the following queries to them regarding the rejected claim is frequently beneficial:
- When did you get the claim?
- When was the assertion rejected?
- Which process code was combined, exclusive, or inclusive?
- Does this require a suitable modifier?
- If so, obtain the relevant modification and submit your claim again with the necessary information.
- If the answer is no, find out the address, fax number, and appeal limit so you can challenge the claim.
- Make sure you have both the call reference number and the claim number.
Conclusion:
Resolving coding problems can be responsible for up to 81% of claim rejections. The nice part is that there is a way to prevent the typical medical billing denials. Your medical practice can effectively operate as a claims-handling specialist with careful data verification, good patient data collection, and reliance on