How do I fix or resolve code 97?

Identify the primary service that the payer bundled the denied service into by reviewing the ERA for the companion code and any NCCI edit indicators. Determine whether the denied service is truly a component of the primary service per CPT guidelines, NCCI edits, or the payer's published bundling policy. If the service is genuinely bundled, write off the denied amount as a contractual adjustment — no further action is needed. If the service was distinct and separately reportable (e.g., a separately identifiable E&M with modifier 25, or a distinct procedure with modifier 59), submit a corrected claim or appeal with the appropriate modifier and supporting documentation. Include the operative note, office note, or time-based documentation that justifies the separate reporting of the service.

97Denial CodeGeneral Adjustment

Code 97

Problem Description

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Root Cause

The benefit for the service billed is included in the payment or allowance for another service already adjudicated on the same claim or a companion claim. This is common with bundled services — for example, pre- and post-operative visits included in a global surgical package, E&M services bundled into an infusion code, or diagnostic imaging included in an interventional procedure. The payer applies National Correct Coding Initiative (NCCI) procedure-to-procedure edits or payer-specific bundling rules to deny the component service as separately payable.

Resolution Steps

1Identify the primary service that the payer bundled the denied service into by reviewing the ERA for the companion code and any NCCI edit indicators.
2Determine whether the denied service is truly a component of the primary service per CPT guidelines, NCCI edits, or the payer's published bundling policy.
3If the service is genuinely bundled, write off the denied amount as a contractual adjustment — no further action is needed.
4If the service was distinct and separately reportable (e.g., a separately identifiable E&M with modifier 25, or a distinct procedure with modifier 59), submit a corrected claim or appeal with the appropriate modifier and supporting documentation.
5Include the operative note, office note, or time-based documentation that justifies the separate reporting of the service.

EHR Documentation Note

Claim denied 97 — benefit included in another service payment; verified NCCI bundling rules, applied appropriate modifier if separately reportable, or wrote off as contractual adjustment.

Preventative Action

Run NCCI edit checks in the practice management system before submission and train coders on global package, incidental, and mutually exclusive code bundling rules to prevent unnecessary appeals.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.