Understanding Denial Code 97
Denial code 97 signifies that the benefit for a specific service has already been encompassed within the payment or allowance for another service or procedure that has been processed previously. In essence, the insurance provider has already factored in the expense of this service within the payments made for another associated service. For further details regarding this denial, you may refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) in the electronic remittance advice of the claim, if accessible.
Frequent Reasons for CARC 97 (denial code 97)
Frequent reasons for denial code 97 include:
The service or procedure tied to the claim submitted is already factored into the payment or allowance for another service that has been completed and compensated.
The healthcare provider might have inadvertently submitted a separate claim for a service that is already part of another procedure.
The claim could have been presented for a service deemed a component or essential segment of a different procedure, thus ineligible for separate reimbursement.
The healthcare provider might not have correctly identified the bundled services or procedures during the claim submission, which resulted in the denial.
The payer’s adjudication system may have automatically flagged the duplication or bundling of services and denied the claim accordingly.
The denial might occur if the healthcare provider did not adhere to the specific billing guidelines or coding standards established by the payer for bundled services.
Healthcare providers should thoroughly examine the payment policies and guidelines offered by the payer to ensure pin-point billing and avert denials associated with code 97.
Strategies to Alleviate Denial Code 97
Strategies to alleviate code 97 involve:
Conducting diligent documentation: Ensure every service and procedure is accurately noted in the patient’s medical record, clearly showing the necessity and individuality of each service rendered.
Verifying coverage and benefits: Prior to delivering any service, confirm the patient’s insurance coverage and benefits. This assists in highlighting whether the service is already part of another payment or allowance.
Engaging with payers: Foster open communication with insurance payers to clarify any possible overlaps or conflicts regarding payments. This can assist in averting denials linked to code 97.
Utilizing proper coding: Assign the correct codes meticulously for each service provided, incorporating modifiers when necessary to denote the distinctiveness of the service.
Implementing efficient billing procedures: Confirm that billing practices are effective and accurate. Review claims carefully before submission to reduce the possibility of denials related to code 97.
Remaining informed on payer policies: Regularly assess and stay knowledgeable about payer policies and guidelines to understand specific requirements or restrictions concerning code 97.
Educating team members: Provide extensive training for your staff on proper coding and billing practices, which can diminish errors and guarantee adherence to payer demands.
Monitoring and evaluating denials: Persistently observe and appraise denial patterns associated with code 97. This aids in recognizing any persistent issues and facilitates targeted enhancements in revenue cycle management processes.
By executing these strategies, healthcare providers can lessen denials associated with code 97 and enhance their revenue cycle management.
Steps to Tackle Denial Code 97
The actions to tackle code 97 involve:
1. Review the claim specifics: Meticulously scrutinize the claim to ensure the service or procedure in question is indeed included in the payment or allowance for another service that has previously been adjudicated.
2. Confirm the adjudication: Cross-verify the adjudication of the claim to ascertain that the related service or procedure has been processed and compensated.
3. Evaluate the payment/allowance: Contrast the payment or allowance received for the related service or procedure with that which is under scrutiny. Ensure that the payment/allowance sufficiently covers the service in question.
4. Investigate any inconsistencies: If there are inconsistencies between the payment/allowance received and the disputed service, conduct a deeper investigation to uncover any potential errors or complications.
5. Refer to relevant documentation: Look over any pertinent documentation, such as the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if available. This can yield additional guidance or clarification regarding how to tackle the code.
6. Take necessary measures: Based on the outcomes of your review and investigation, implement the essential actions to address the code. This may involve resubmitting the claim with supplementary documentation or appealing the denial if you perceive it as erroneous.
7. Document the procedure: Maintain a record of the actions taken to address the code, comprising any interactions with payers or supplementary documentation submitted. This record will be valuable for future reference or should further action become necessary.