When can I appeal a CARC 97 bundling denial?

You can appeal when the services were genuinely distinct (different sites, sessions, or organ systems) and the NCCI edit indicator is 1. Attach documentation that supports the distinct-service claim.

Should I use modifier 59 or an X-modifier?

X-modifiers (XE, XP, XS, XU) are more specific than 59 and are preferred by CMS and most commercial payers. Use 59 only when no X-modifier applies.

CARC 97: Service Bundled into Another Payment

Q: What does CARC 97 mean?

CARC 97 means 'The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.' The payer is saying this service is bundled.

Official CMS Definition

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

Group Code: CO, PI, or PR Category: Bundling Risk Level: Low Appealable: Rarely, but possible

What CARC 97 Actually Means

Claim Adjustment Reason Code (CARC) 97 is a bundling denial. The payer is telling you that one of the procedures on your claim is considered part of another procedure that was already paid, either on the same claim or on a prior claim. The payment for the comprehensive procedure is considered to include the payment for the component procedure.

This is one of the most misunderstood denial codes in billing, because sometimes the payer is correct and sometimes they're not. Knowing the difference is what determines whether you write it off or fight it.

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