Claim denied as Bundle (or) Inclusive

Denial Code 97: Claim Denied as Bundled/Inclusive – Simple Explanation + What to Do

Denial Code 97 is one of the most common denial reasons in medical billing. Many billing teams get stuck because they don’t know whether the claim should be corrected, appealed, or written off.

In this guide, you’ll learn:

• What Denial Code 97 means
• Why claims get denied as bundled/inclusive
• What questions to ask the payer on call
• How to fix it using modifiers and NCCI edits

What is Denial Code 97?

Denial Code 97 means:

“The benefit for this service is included in the payment/allowance for another service or procedure that has already been adjudicated.”

In simple words:

The insurance says this procedure is already included in another CPT code paid on the same date of service, so they will not pay separately.

That’s why this denial is also called:

• Bundled Denial
• Inclusive Denial
• Package Payment Denial

Why Does Denial Code 97 Happen?

Denial 97 happens when:

1. Two CPT codes are billed together
2. Payer rules say the smaller procedure is bundled into the main procedure
3. The claim was billed without the correct modifier
4. An NCCI edit exists between those CPTs

Example:

• Major procedure CPT is paid
• Minor procedure CPT is denied as inclusive/bundled

On-Call Scenario: What to Ask the Insurance?

If a claim is denied with Denial Code 97, your call flow should be like this:

1. Claim denied as Bundle/Inclusive

Confirm the denial reason clearly.

2. Ask: “May I get the denial date?”

This helps you track payer processing date and timelines.

3. Ask: “To which CPT is it bundled with?”

This is the most important question.

The payer will confirm the paid CPT and the bundled CPT.

4. Ask: “What is the time limit to send a corrected claim?”

Corrected claim filing limit varies by payer (30/60/90/180 days etc.)

5. Ask: “What is the fax number or mailing address for appeal?”

Keep payer appeal address for documentation.

6. Ask: “May I have the claim number and call reference number?”

This is critical for follow-up and proof.

Important Note: Send This Denial to Coding Team

Denial 97 is not just a billing issue — it is also a coding review issue.

You must send it to coding and ask:

Can this CPT be paid separately using a modifier?
Or is it truly bundled and must be written off?

How to Fix Denial 97 (Bundled/Inclusive)

Step 1: Check NCCI Edits Between the CPT Codes

Use tools like:

• Encoder
• Find-A-Code
• NCCI edit tools
• CPT Assistant / Coding resources

These tools help identify:

• Whether an NCCI edit exists
• If the edit can be overridden
• Which modifier is appropriate

Step 2: If NCCI Edit Exists – Add Correct Modifier

If NCCI edit exists and is override-able, you may need modifiers like:

• Modifier 59 (Distinct Procedural Service)
• Modifier X{EPSU}

XE (Separate Encounter)
XS (Separate Structure)
XP (Separate Practitioner)
XU (Unusual Non-Overlapping Service)

• Modifier 25 (Significant, separately identifiable E/M)
• Modifier 51 (Multiple procedures) – payer dependent

Once the correct modifier is identified:

Update the claim and submit as corrected claim.

Medicare Special Note (Very Important)

Commercial plans: You can submit corrected claims

Medicare: Usually does not accept corrected claims

So for Medicare:

Submit a fresh claim (new claim submission) with the correct modifier.

Step 3: If Coding Is Correct & No NCCI Edit – Request Reprocessing

If coding team confirms:

• Coding is correct
• No NCCI edit exists

Then:

Call the payer and request reprocessing of the claim.

If payer still denies:

Submit an appeal with supporting documentation.

When to Write Off Denial Code 97

If:

• CPT is truly bundled
• No modifier is allowed
• NCCI edit cannot be overridden
• Coding team confirms it is inclusive

Then:

The claim should be written off as contractual/non-payable.

Quick Summary (Easy Workflow)

Here’s the simplest workflow:

1. Claim denied as 97 Bundle/Inclusive
2. Call payer → ask bundled CPT + denial date + ref number
3. Send to coding team
4. Check NCCI edit
5. If modifier possible → send corrected claim (or fresh claim for Medicare)
6. If no edit → request reprocessing
7. Still denied → appeal
8. Not override-able → write off

Final Tips for Billing Teams

• Always capture call reference number
• Always verify filing time limit
• NCCI edit checking is mandatory before appeal
• Don’t appeal without coding review