What Is CARC 97?
CARC 97 indicates the payer denied or reduced payment because the service is bundled with another service on the same claim under NCCI Procedure-to-Procedure edits (the payer treats the service as already paid for within another service it adjudicated).
- Cardiology and orthopedic billing teams should run NCCI Procedure-to-Procedure edit checks before claim submission.
- Practices that systematically apply modifier 59/XU when documentation supports it recover material payment per same-session diagnostic-to-PCI case.
- Track CARC 97 by CPT pair to identify systemic charge-entry issues.
CARC 97
Also known as: Denial Code 97; Payment Adjusted Because Procedure Is Bundled
CARC 97 indicates the payer denied or reduced payment because the service is bundled with another service on the same claim under NCCI Procedure-to-Procedure edits (the payer treats the service as already paid for within another service it adjudicated).
Definition
CARC 97 is a Claim Adjustment Reason Code defined by the X12 standard meaning that the service was packaged into another procedure's payment. Most often this reflects an NCCI PTP edit that flagged the procedure as a component of a more comprehensive procedure on the same date of service. With NCCI Modifier Indicator 1, an unbundle modifier (59 or X-modifiers) plus supporting documentation can permit separate payment. With Modifier Indicator 0, no modifier can bypass the edit. Common examples: cardiology diagnostic catheterization (CPT 93458) bundled into same-session PCI (CPT 92928); orthopedic simple closure (12001) bundled into the parent excision; dermatology lesion components bundled into excision codes; PT therapeutic activities bundled with manual therapy.
Common Causes of CARC 97
- An NCCI Procedure-to-Procedure (PTP) edit flagged the service as a component of a more comprehensive procedure on the same date of service.
- Common bundled pairs: diagnostic catheterization (93458) into same-session PCI (92928); simple closure (12001) into the parent excision; dermatology lesion components into excision codes; PT therapeutic activities with manual therapy.
How to Resolve CARC 97
- Verify the NCCI PTP edit applies to the code pair and read the Modifier Indicator.
- With Modifier Indicator 1, append an unbundle modifier (59 or the appropriate X-modifier) plus supporting documentation, and resubmit.
- With Modifier Indicator 0, no modifier bypasses the edit and the line is not separately payable.
- Ensure documentation (for example, the cath report) clearly identifies the separately identifiable component.
How to Prevent CARC 97 Denials
- Run NCCI Procedure-to-Procedure edit checks before claim submission, especially in cardiology and orthopedics.
- Apply modifier 59/XU systematically when documentation supports it, and track CARC 97 by CPT pair to catch systemic charge-entry issues.
Example
A claim for CPT 93458 (diagnostic left heart cath) submitted on the same date as 92928 (PCI) returns CARC 97 unless modifier 59 or XU is appended to 93458 to document the diagnostic component as separately identifiable. Documentation in the cath report should clearly identify the diagnostic findings as separate from the planned interventional procedure.
Common Misconceptions
CARC 97 is sometimes treated as a 'final denial' but it is a bundling adjustment — the service was performed and documented; the payer's edit just refused to pay it separately. The correct response is to verify NCCI edit applicability and resubmit with the appropriate unbundle modifier when supported by documentation.
Practical Application
Cardiology and orthopedic billing teams should run NCCI Procedure-to-Procedure edit checks before claim submission. Practices that systematically apply modifier 59/XU when documentation supports it recover material payment per same-session diagnostic-to-PCI case. Track CARC 97 by CPT pair to identify systemic charge-entry issues.
Related Terms
NCCI (National Correct Coding Initiative)
NCCI is a CMS-published set of edits that prevent improper payment when incorrect code combinations or unit counts are submitted. The program contains three edit types: Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE) limiting units of service, and Add-on Code edits.
Read definitionModifier 59
Modifier 59 is appended to a procedure code to indicate that a service was distinct or independent from other non-E/M services performed on the same day, used to bypass NCCI Procedure-to-Procedure (PTP) edits when documentation supports a separately identifiable service.
Read definitionModifiers XE, XS, XP, XU
The X-modifiers (XE, XS, XP, XU) are HCPCS modifiers introduced by CMS in 2015 as more specific subsets of Modifier 59, identifying the specific reason a procedure is distinct from another service: separate Encounter, separate Structure, separate Practitioner, or Unusual non-overlapping service.
Read definitionCARC 50
CARC 50 is the X12 claim adjustment reason code a payer returns when it has determined that a service does not meet its coverage criteria for medical necessity — a Medicare local or national coverage determination, or a commercial plan’s own medical policy.
Read definitionCARC 197
CARC 197 is the X12 claim adjustment reason code a payer returns when the plan’s own prior-approval step for a service was not completed before the claim was adjudicated; the remark codes alongside it usually indicate which approval the payer was looking for.
Read definitionWhere This Applies on MedPrecision
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