What does denial code CARC 97 mean?

CARC 97 means the benefit for this service is included in the payment or allowance for another service that was already paid. The payer sees the line as bundled into a primary code, usually because of a National Correct Coding Initiative (NCCI) edit. It is not a coverage decision, it is a bundling decision.

Should I use modifier 59 or an X-modifier on a CARC 97 denial?

Use an X-modifier (XE, XS, XP, XU) when one applies, because it is more specific and preferred by most payers, including Medicare. Fall back to modifier 59 only when no X-modifier fits. The modifier must be supported by the medical record, whether a separate encounter, separate structure, separate practitioner, or an unusual non-overlapping service.

Do I appeal or submit a corrected claim for CARC 97?

If the modifier was missing or wrong on the original claim, submit a corrected claim with the right modifier and the supporting documentation. If the modifier was correct and the payer bundled the service anyway, or if the NCCI edit indicator allows unbundling and the payer ignored it, appeal with the operative report or progress note that proves the services were distinct.

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CARC 97 Bundling: what it means, and how to appeal it.

CARC 97 is the classic bundling denial. The payer is saying: this service is already paid for as part of another line. Sometimes that is correct and the claim should be adjusted. Sometimes it is wrong because the services were genuinely distinct, and the fix is a modifier plus documentation. Working every CARC 97 the same way is how practices write off dollars they could recover.

Last verified July 9, 2026 against the current ASC X12 CARC master list and the CMS NCCI PTP edit tables. Source: ASC X12, CMS NCCI

From the EDI Code Intelligence Lab

CARC 97

CLAIM ADJUSTMENT REASON CODE

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Medium Risk

What This Means

Reimbursement for this service is already included in the payment for another adjudicated service on the claim; it is not separately payable.

Common drivers: NCCI bundling edit includes the denied code inside the primary procedure's payment; missing modifier 59 or X modifier for a genuinely separate service; or an add-on code submitted without its required primary code.

Root Causes

NCCI bundling edit includes the denied code inside the primary procedure's payment; missing modifier 59 or X modifier for a genuinely separate service; or an add-on code submitted without its required primary code.

Action Plan

Look up the denied code pair in the NCCI (National Correct Coding Initiative) edit table.
Check the modifier indicator: a '0' means the codes can never be billed together - post the adjustment.
A '1' means modifier 59 (or X modifiers XS, XE, XP, XU) can separate them - only if documentation supports a distinct site, session, or procedure.
If a valid modifier applies, resubmit.

Appeal Tips

Verify the NCCI modifier indicator: '0' means unbundling is never allowed; '1' means a modifier works if the service was separate.
If the indicator is '1' and modifier was omitted, file a corrected claim over a narrative appeal.
If a modifier was appended and still denied, appeal with documentation of the distinct site, session, or location.
For payer-specific edits more restrictive than NCCI, request the rationale.

Prevention Strategy

Load the current-quarter CMS NCCI edit table into your claim scrubber and update it quarterly when CMS publishes a new release.
Train coders to apply modifier 59 or X modifiers only when the record genuinely documents a distinct service; reflexive use to bypass edits creates compliance risk.
Run a monthly report of CARC 97 denials by code pair; for recurring distinct-service pairs, create a modifier-use protocol.

✅ Verified 2026-06-16 · Source: ASC X12 · Rendered live from the EDI Code Intelligence Lab data set.

CARC 97 is a bundling determination. The RARC narrows what needs to be different.

The payer already paid something on a related line and considers this service part of that payment. The RARC on your remittance is what tells you whether you need a modifier (usually 59 or an X-modifier), a corrected claim, or an appeal against the NCCI edit itself.

Common RARC pairings with CARC 97

These pairings and definitions can also be found in the EDI Code Intelligence Lab. ASC X12 Definitions are sourced from x12.org/codes/remittance-advice-remark-codes. Business Scenarios are sourced from CAQH CORE required code combinations (v3100, February 2026).

RARC	Official definition (ASC X12)	Business scenario (CAQH CORE)
M2	Not paid separately when the patient is an inpatient.	Benefit for Billed Service Not Separately Payable
M15	Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.	Benefit for Billed Service Not Separately Payable
M80	Not covered when performed during the same session/date as a previously processed service for the patient.	Benefit for Billed Service Not Separately Payable
M86	Service denied because payment already made for same/similar procedure within set time frame.	Benefit for Billed Service Not Separately Payable
M97	Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.	Benefit for Billed Service Not Separately Payable
M109	We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.	Benefit for Billed Service Not Separately Payable
M112	Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.	Benefit for Billed Service Not Separately Payable
M144	Pre-/post-operative care payment is included in the allowance for the surgery/procedure.	Benefit for Billed Service Not Separately Payable
MA109	Claim processed in accordance with ambulatory surgical guidelines.	Benefit for Billed Service Not Separately Payable
N19	Procedure code incidental to primary procedure.	Benefit for Billed Service Not Separately Payable
N20	Service not payable with other service rendered on the same date.	Benefit for Billed Service Not Separately Payable
N67	Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.	Benefit for Billed Service Not Separately Payable

This is one page. The Lab has every CARC and RARC in use today.

Root causes, action plans, appeal guidance, and prevention strategy for every code, plus the CARC and RARC pairing tool that completes the picture. Verified against the current ASC X12 master lists. Not a glossary. A playbook.

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This page helps you understand denial codes and build a starting point for resolution. Every denial has context that only the payer and the claim can provide. Before submitting an appeal or corrected claim, verify the payer's published policies and contact them directly with questions about your specific situation.