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 benefit for this service is included in the payment/allowance for another service/procedure that has already been 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 benefit for this service is included in the payment/allowance for another service/procedure that has already been 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.
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 code-pair edits and per-day unit limits that prevent improper payment when incorrect code combinations are submitted; it includes Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUE).
Read definition arrow_forwardModifier 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 definition arrow_forwardModifiers XE, XS, XP, XU
The X-modifiers (XE, XS, XP, XU) are HCPCS Level II 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 Site, separate Practitioner, or Unusual non-overlapping service.
Read definition arrow_forwardCARC 50
CARC 50 indicates the payer denied a claim because it determined the services were not medically necessary based on its medical-necessity policy, LCD, NCD, or commercial medical-policy criteria.
Read definition arrow_forwardCARC 197
CARC 197 indicates a denial because precertification, authorization, or notification required by the payer was not obtained before the service was rendered, often paired with RARCs identifying the specific authorization missing.
Read definition arrow_forwardWhere This Applies on MedPrecision
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