Medical billing denials are one of the biggest challenges for healthcare providers, directly impacting cash flow and operational efficiency. Among these, Denial Code 97 is a common but often misunderstood reason for claim rejection. If not handled properly, it can lead to significant revenue loss and delayed reimbursements.
In this guide, we will break down Denial Code 97, explain why it occurs, and share proven steps to prevent revenue loss while improving your revenue cycle performance in 2026.
What is Denial Code 97 in Medical Billing?
Denial Code 97 generally indicates:
“Payment is included in another service or procedure that has already been billed.”
In simple terms, it means the payer considers the billed service as bundled or already covered under another procedure, and therefore denies separate reimbursement.
This often occurs due to:
- Incorrect coding combinations
- Bundled services not billed correctly
- Missing or incorrect modifiers
- Lack of understanding of payer bundling rules
Understanding this denial code is essential for maintaining clean claims and avoiding unnecessary revenue loss.
Why Denial Code 97 Happens
Denial Code 97 is usually triggered by billing inconsistencies such as:
1. Bundling Issues
Insurance companies follow strict bundling rules where certain services are included in a primary procedure and cannot be billed separately.
2. Missing Modifiers
Improper or missing modifiers like -25 or -59 often result in claim rejection under Denial Code 97.
3. Duplicate Billing
Submitting the same service under multiple claims can lead to automatic denial.
4. Incorrect Coding Pairing
Improper CPT code combinations can cause payers to consider services as non-payable separately.
5. Lack of Documentation
Insufficient clinical documentation to justify separate services often leads to bundling denials.
Impact of Denial Code 97 on Revenue Cycle
If not managed properly, Denial Code 97 can lead to:
- Delayed reimbursements
- Increased accounts receivable (AR) days
- Revenue leakage
- Higher administrative workload
- Increased claim resubmissions and appeals
This is why healthcare providers must focus on strong denial management strategies or partner with expert billing professionals.
How to Prevent Denial Code 97: Proven Steps
1. Understand Payer Bundling Rules
Each insurance payer has specific bundling guidelines. Staying updated on these rules is essential to prevent unnecessary denials.
Healthcare organizations working with often rely on billing experts to stay compliant with payer-specific rules and reduce errors.
- Use Correct Modifiers Appropriately
Modifiers play a crucial role in separating services when appropriate.
Commonly used modifiers:
- Modifier 25 – Significant, separately identifiable E/M service
- Modifier 59 – Distinct procedural service
Incorrect use or omission of these modifiers is a major cause of Denial Code 97.
- Improve Medical Documentation
Strong documentation supports medical necessity and justifies separate billing.
Ensure:
- Clear provider notes
- Detailed procedure descriptions
- Justification for multiple services
Poor documentation often results in claim bundling and denied reimbursement.
- Conduct Regular Coding Audits
Routine audits help identify:
- Coding errors
- Modifier misuse
- Pattern-based denial trends
This proactive approach reduces repeated Denial Code 97 occurrences and improves overall claim accuracy.
- Train Billing and Coding Staff
Ongoing training is essential to keep staff updated on:
- CPT coding updates
- ICD-10 guidelines
- Payer policy changes
Well-trained teams significantly reduce denial rates and improve clean claim submission.
- Implement Strong Denial Management Systems
A structured denial management process includes:
- Categorizing denial reasons
- Tracking recurring issues
- Filing timely appeals
- Root cause analysis
This helps reduce revenue leakage and improves long-term billing performance.
Role of Medical Billing Companies in Reducing Denial Code 97
Many healthcare providers struggle with complex billing rules, especially bundling-related denials like Code 97. That’s why outsourcing to experts has become a smart financial decision.
A professional can help practices by:
- Ensuring correct CPT and modifier usage
- Managing payer-specific billing rules
- Reducing claim rejections
- Improving reimbursement rates
Similarly, experienced medical billing companies in Minnesota provide end-to-end revenue cycle management services that help healthcare organizations maintain financial stability.
How Providers Care Billing LLC Helps Reduce Denials
Providers Care Billing LLC is a trusted name in the medical billing industry, offering comprehensive billing and RCM solutions designed to reduce denials and maximize revenue.
Their services include:
- Medical billing services in Connecticut and nationwide
- Denial management and AR follow-up
- Coding and credentialing support
- End-to-end revenue cycle management (RCM)
- Transparent pricing starting at 2.49%
- 99% clean claims submission rate
- 98% first-pass acceptance rate
By leveraging advanced billing strategies and compliance-focused processes, Providers Care Billing LLC helps healthcare providers significantly reduce denials like Code 97 and improve cash flow efficiency.
Best Practices to Avoid Revenue Loss from Denial Code 97
To summarize, healthcare providers should focus on:
- Accurate coding and modifier usage
- Understanding payer-specific bundling rules
- Strengthening clinical documentation
- Regular denial tracking and analysis
- Partnering with expert billing professionals
These steps ensure a smoother revenue cycle and fewer claim rejections.
Conclusion
Denial Code 97 is a preventable but costly billing issue that often results from bundling errors, incorrect modifiers, or insufficient documentation. With the right strategies in place, healthcare providers can significantly reduce claim denials and protect their revenue.
By following these proven steps to prevent revenue loss from Denial Code 97, practices can improve billing accuracy, reduce AR delays, and enhance overall financial performance.
If you are looking to reduce claim denials, improve reimbursement rates, and optimize your revenue cycle, for expert medical billing support. Their experienced team provides end-to-end solutions designed to maximize revenue and ensure accurate, compliant billing for your practice.
