97: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated

On Call Scenario:

                                                     Claim denied as Bundle/Inclusive
                                                                              ↓
                                                            May I get the denial date?
                                                                              ↓
                                                      To which CPT is it bundled with?
                                                                              ↓
                                            What is the time limit to send corrected claim?
                                                                              ↓
                                      What is the fax# or mailing address to send an appeal?
                                                                              ↓
                                                    May I have the claim# and Call ref#?

Important Note:

• This denial should be sent to the coding team to check if the claim can be resubmitted by updating the modifier or not.
• If you have access to the encoder, findacode, etc. tools then you can also check the NCCI edit between procedures. These tools will help you to identify whether NCCI edit exists between CPTs billed on the same DOS or not. If yes then whether it can be overridden using the appropriate modifier or not. It also provides the most suitable modifier to override the CPT. If CPT cannot be overridden then it should be written off. 
• If the coding team response is received with a correct modifier or you identify the correct modifier through any tools then update it and send the corrected claim to insurance. Medicare does not accept the corrected claim, so send a fresh claim to medicare.
• If the coding team response is received as coding is correct or you identify that there is no NCCI edit existing through any tools then call the insurance and ask them to reprocess the claim. if they deny then send an appeal to insurance.
• Tools to Identify Bundle CPT Codes

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Has rep provided CPT to bundle with?/Bundled CPT available?:

* Yes No

CPT to bundle with?:

*

What Information is Available?:

* Corrected Claim Time Frame Appeal Information Corrected Claim Time Frame and Appeal Information None

Corrected Claim Time Frame:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Mailing Address:

*

Appeal Limit:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need coding assistance Updated correct modifier and resubmitted the claim Updated correct procedure and resubmitted the claim Updated correct DX and resubmitted the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



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