Wiki co 97 denial

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parentj

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Hello! I am coding for an ASC and I often get a CO 97 denial for either the facility or the professional charge for surgery on the same DOS. I'm thinking the denied charge needs a modifier. Any advice on what is the best modifier to add in this scenario? Thanks!
 
There may be some payers that still require the SG modifier on the facility claim to distinguish it from the professional claim. Aside from this, though, facility and professional charges represent completely separate services by separate providers, and there should never be a need to add a modifier to distinguish them. If you're getting a CO-97, then it's either one code bundling against another code that was submitted by the same entity (facility or professional), or else it's a payer error.
 
I think they are bundling it against another claim with the same code by the same entity. It's frustrating b/c it's obvious these are separate charges billed under two different NPI's. Thank you for your advice!
 
parentj said:
I think they are bundling it against another claim with the same code by the same entity. It's frustrating b/c it's obvious these are separate charges billed under two different NPI's. Thank you for your advice!
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I would call the payer and ask them to explain it to you clearly. Professional services shouldn't bundle with facility services, and vice versa, if you are coding them correctly. The only exceptions I can think of would be 1) if you're using an incorrect place of service code on the professional claim or 2) if you are billing a technical service code on the professional claim. As long as that's not happening, there shouldn't be any issues between the two claims.
 
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