CO-97: bundled into another service

Claim adjustment reason code 97 says the payment for this service is included in the payment for another service or procedure that has already been paid. With group code CO, the amount is the provider's responsibility and can't be billed to the patient.

On Medicare claims, the most common source is a National Correct Coding Initiative (NCCI) procedure-to-procedure edit: a published pair of codes that Medicare doesn't pay separately when both are billed for the same patient on the same day by the same provider. A CO-97 can also come from a global surgical package, where a service is included in a surgery's payment.

Each NCCI edit names a column 1 code (the one that is paid) and a column 2 code (the one that is denied when both are billed), plus a modifier indicator:

CMS publishes these edits quarterly, and the practitioner table runs to well over a million pairs.

For a pair with indicator 1, Medicare pays both codes when the services were distinct: a different session, a different site or organ, a separate incision, or a separate time period. That is shown with modifier 59, or with the more specific X modifiers:

• XE: a separate encounter
• XS: a separate structure or organ
• XP: a separate practitioner
• XU: an unusual, non-overlapping service

A modifier is a statement that the services were distinct. It must be supported by the documentation. Adding it to every claim to get past the edit is exactly what payers audit for.

Manual therapy (97140) and therapeutic activities (97530) on the same day are an NCCI pair with a modifier indicator of 1. Medicare pays both only when they were performed in separate, distinct time intervals, with the right modifier on the column 2 code and documentation that shows the separate time for each.

Without the modifier, one line is denied as CO-97. With the modifier but without documentation of separate intervals, the payment is at risk on review.

• Check every same-day pair against the current NCCI table before the claim goes out.
• Know which pairs can never be cleared (indicator 0), so nobody spends time on them.
• For indicator 1 pairs, decide whether the services were genuinely distinct, and use the most specific modifier the note supports.
• Make the documentation show it: separate times, sites or sessions.

• Indicator 0: the denial stands. Fix the habit that produced it.
• Indicator 1, services were distinct and documented: correct the claim with the right modifier through your contractor's reopening process, or appeal with the note.
• Indicator 1, services were not distinct: the denial is correct. Billing both was the error.

This guide is general information, not legal or billing advice. Always check the current NCCI tables and your payer's own rules.