A remittance advice posts contractual adjustment remark CO-97, indicating the benefit for a service is included in another service already adjudicated. What should the billing team do next?
Select an answer to reveal the explanation.
Short Explanation
CO-97 is the payer’s way of saying “that piece was already inside the other payment.” Do not chase the patient for the bundled bite. Check whether the inclusion is fair; if the service truly stood alone, appeal with proof—otherwise post the adjustment and move on.
Full Explanation
Remark CO-97 signals that the benefit for a service is included in payment for another service already adjudicated. The billing team in a civic clinic should evaluate whether that inclusive denial is legitimate under bundling/payment rules; accept the contractual adjustment when appropriate, or appeal only with documentation that a separately payable service was furnished. Treating CO-97 as an automatic patient bill or an invitation to game claim history undermines compliant professional-fee posting.
Balance-billing the full billed amount to the Medicare patient despite the inclusive contractual remark fails by concept because bundled inclusive adjustments are generally not the patient’s responsibility in that way. Deleting the paid primary service from history and rebilling both lines as new fails because it manipulates remittance history to evade an edit. Changing diagnosis pointers only to force payment of the inclusive line fails because pointer tweaks do not override a correctly applied inclusion edit.
Exam caveat: distinguish true bundling from incorrect payer adjudication; appeals need clinical and coding evidence of separateness. Operational check: post CO-97 adjustments when validated, suppress improper patient balance transfer for inclusive contractual remarks, and escalate borderline cases to coding for modifier/appeal review.