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CARC 97 · CO-97

CARC 97 Denial: The benefit for this service is included in the payment/allowance for another s… — How to Fix and Appeal

QuickIntell editorial content · Legacy registry date · Review not verified

Updated

TL;DR

CARC 97 (X12 The benefit for this service is included in the payment/allowance for another service/procedure that has alre…). CARC 97 is a bundling denial — the payer is saying the service you billed is considered part of another service it already paid.

Official X12 description

“The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.”

Source: X12 Claim Adjustment Reason Codes. The X12 External Code Lists are the single authoritative source for every CARC descriptor — always verify against the current release before building a claim-scrub rule.

What CARC 97 actually means

CARC 97 is a bundling denial — the payer is saying the service you billed is considered part of another service it already paid. The most common drivers are NCCI Procedure-to-Procedure (PTP) edits, the global surgical package, E/M-bundled-with-a-procedure rules, and payer-specific bundling policies. When two services are genuinely distinct, a distinct-procedural-service modifier (59, XE, XS, XP, XU) or modifier 25 on an E/M solves the problem — provided documentation supports the distinction.

Common root causes

  • NCCI PTP edit between two codes billed on the same date without the override modifier.
  • Service falls inside the global surgical period of an earlier surgery (0-, 10-, or 90-day global).
  • E/M billed on the same day as a minor procedure without modifier 25 and documentation of a separately identifiable E/M service.
  • Payer-specific bundling edit (e.g., commercial-payer bundling of ancillary services into a visit rate).

Prevention checklist

  • Run NCCI PTP and MUE edits at charge entry — ideally at order entry where the clinician can adjust.
  • Educate clinicians on modifier 25 documentation: the E/M must be a significant, separately identifiable service from the procedure.
  • Track global-period dates in the PM system so post-op visits route to the correct no-charge status automatically.
  • Maintain a payer-specific bundling-policy library for commercial payers whose rules diverge from CMS/NCCI.

Appeal strategy — step by step

Most CARC 97 denials clear faster with the right remediation than with a formal appeal. Work the steps in order and escalate only when a lower-effort path has been ruled out.

  1. 1If services were genuinely distinct, submit a corrected claim with the appropriate modifier (25 for E/M, 59 or X{EPSU} for distinct procedure) and the documentation supporting the distinctness.
  2. 2For NCCI edits, confirm the column-2 code is unbundlable — Modifier Indicator 1 allows an override; Modifier Indicator 0 does not.
  3. 3For global-package disputes, include the op note showing the current service is unrelated to the prior surgery (consider modifier 24, 58, 78, or 79 as appropriate).
  4. 4Cite the specific section of the payer's bundling policy or the NCCI Policy Manual when the distinction hinges on policy language.
Sample appeal-letter language for CARC 97
[Provider letterhead] Re: Appeal of CARC 97 — Claim #{claim_number} Member: {member_name} · Member ID: {member_id} Date(s) of Service: {dos} On {remittance_date} this claim was adjusted with CARC 97: "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated." We respectfully request reconsideration. The X12 External Code List definition of CARC 97 does not apply to this claim for the following reasons: 1. [Cite the clinical / coding / policy fact that rebuts the adjustment] 2. [Cite the supporting documentation attached — op note, EOB, LCD/NCD citation, NCCI edit indicator, modifier rationale] 3. [Cite the payer's own policy where applicable] Attached: {list supporting documents} Please process payment under the member's benefits. If additional information is required, contact the billing office at {provider_phone} or {provider_email}. Sincerely, {billing_manager_name}, {credentials}

Edit the bracketed fields before sending. This template is a starting point; a payer-specific appeal form may still be required — check the provider portal first.

Payer-specific notes

Payer-specific behavior for CARC 97 publishes here as the QuickIntell anonymized denial ETL ingests sufficient volume. In the meantime, consult the payer directory for the relevant provider manual and appeal form.

How common is CARC 97?

Search demand rank
#4

Out of 306 seeded CARCs, ranked by combined US monthly search volume for "CARC 97", "CO-97 denial", and "denial code 97".

Platform frequency
Pending ETL

Platform frequency ranks publish once the anonymized denial-rate pipeline reaches the publication threshold (strategy §12 Phase 2).

How QuickRCM prevents CARC 97

QuickRCM catches the root causes above before the 837 leaves the clearinghouse:

  • Claim-scrub rules fire on every root cause listed above — the scrub references the same X12 CAS segment logic that drives the denial, so what the payer checks, QuickRCM checks first.
  • When a denial lands, QuickRCM routes it to the correct worker with the documentation bundle already attached (op note, LCD citation, modifier rationale, EOB, primary 835).
  • Appeal templates tuned to each CARC (including this one) pull the supporting facts from the claim and fill the bracketed fields automatically.
Prevent denials before submission →Work and appeal denialsBook a demo

CAQH CORE code combinations for CARC 97

Under the CAQH CORE Payment and Remittance Uniform Use rule, health plans may pair CARC 97 only with the remark codes and group codes below for the defined business scenario 4 (Benefit for billed service not separately payable). A combination outside this list on an 835 is itself a payer compliance issue worth raising.

CORE-required CARC/RARC/CAGC combinations for CARC 97
RARCRemark descriptionGroup codeScenario
(no RARC)CARC used without a remark codeCO, PI or PR4
M2Not paid separately when the patient is an inpatient.CO, PI or PR4
M14No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.CO, PI or PR4
M15Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.CO, PI or PR4
M80Not covered when performed during the same session/date as a previously processed service for the patient.CO, PI or PR4
M86Service denied because payment already made for same/similar procedure within set time frame.CO, PI or PR4
M97Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.CO, PI or PR4
M109We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.CO, PI or PR4
M112Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.CO, PI or PR4
M144Pre-/post-operative care payment is included in the allowance for the surgery/procedure.CO, PI or PR4
MA109Claim processed in accordance with ambulatory surgical guidelines.CO, PI or PR4
N19Procedure code incidental to primary procedure.CO, PI or PR4
N20Service not payable with other service rendered on the same date.CO, PI or PR4
N67Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient’s admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.CO, PI or PR4
N111No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.CO, PI or PR4
N122Add-on code cannot be billed by itself.CO, PI or PR4
N130Consult plan benefit documents/guidelines for information about restrictions for this service.CO, PI or PR4
N357Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.CO, PI or PR4
N390This service/report cannot be billed separately.CO, PI or PR4
N472Payment for this service has been issued to another provider.CO, PI or PR4
N525These services are not covered when performed within the global period of another service.CO, PI or PR4
N626New or established patient E/M codes are not payable with chiropractic care codes.CO, PI or PR4
N628Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.CO, PI or PR4
N637Consultations are not allowed once treatment has been rendered by the same provider.CO, PI or PR4
N646Reimbursement has been adjusted based on the guidelines for an assistant.CO, PI or PR4
N666Only one evaluation and management code at this service level is covered during the course of care.CO, PI or PR4
N806Payment is included in the Global transplant allowance.CO, PI or PR4
Source: CAQH CORE-required Code Combinations v3.10.0 (2026-02).

The rule behind CARC 97

CARC 97 is the remittance signature of an NCCI procedure-to-procedure edit: the column-2 code was reported with its column-1 code on the same date without an allowed modifier. Check the pair and its modifier indicator, then see how many pairs each HCPCS drug code sits in.

Frequently asked questions — CARC 97

What does CARC 97 mean?

CARC 97 is an X12 Claim Adjustment Reason Code. The official definition is: "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated." In plain English, the payer is telling you cARC 97 is a bundling denial — the payer is saying the service you billed is considered part of another service it already paid. The most common drivers are NCCI Procedure-to-Procedure (PTP) edits, the global surgical package, E/M-bundled-with-a-procedure rules, and payer-specific bundling policies. When two services are genuinely distinct, a distinct-procedural-service modifier (59, XE, XS, XP, XU) or modifier 25 on an E/M solves the problem — provided documentation supports the distinction.

How do I resolve a CARC 97 (CO-97) denial?

Start with the most common root cause: NCCI PTP edit between two codes billed on the same date without the override modifier. First step: If services were genuinely distinct, submit a corrected claim with the appropriate modifier (25 for E/M, 59 or X{EPSU} for distinct procedure) and the documentation supporting the distinctness. See the full remediation and appeal checklist on this page before filing a formal appeal.

Is CARC 97 patient responsibility?

No — CARC 97 is typically carried under CO (Contractual Obligation) or OA (Other Adjustment), which means it is the provider's responsibility, not the patient's. Do not bill the patient unless the 835 CAS group code is PR.

What does CARC 97 look like on an EOB or 835 remittance?

On the 835 ERA, CARC 97 appears in Loop 2110 CAS segment as "CAS*CO*97*{amount}". On a paper EOB the same code prints in the Adjustment/Denial Reason column with the X12 description: "The benefit for this service is included in the payment/allowance for another service/procedure that has already been a…" — usually paired with one or more RARC remark codes in the same remittance line for additional context.

Which RARC is paired with CARC 97?

CARC 97 is commonly observed with RARC M15, M25, N20. The RARC narrows the reason — for example, pointing at a missing modifier, an LCD citation, or a specific policy. Fix the underlying CARC first; the RARC usually clears with the corrected claim.

Disclaimer

This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. X12 code descriptors are maintained by the X12 External Code Lists; always verify against the current X12 release and the payer's own published policy before submitting or appealing a claim.