Bundled Services

Common Causes for 97

Denials with code 97 typically happen for the following specific reasons:

• Billing a service that is inherently included in a global surgical package (e.g., postoperative visits, wound care, or suture removal during the global period).
• Submitting separate claims for procedures that are automatically bundled by payer edits (e.g., anesthesia with surgery, or hot/cold packs with physical therapy).
• Failing to use appropriate modifiers (such as Modifier 59, XE, XS, XP, XU) when services are distinct and justifiably unbundled.
• Incorrectly coding a bundled service using individual component codes instead of the comprehensive CPT code.
• Billing E/M services on the same day as a procedure when the payer considers them part of the procedure payment.

How to Prevent 97 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Review payer-specific bundling guidelines and global period rules before submitting claims.
• Check the Medicare Physician Fee Schedule (MPFS) database for procedure codes with a 'b' status indicating bundled services.
• Use appropriate modifiers (e.g., Modifier 59 or X modifiers) when services are truly distinct and unbundling is justified.
• Conduct pre-claim audits to ensure bundled services are not billed separately unless clinically and policy-wise justified.
• Train billing staff regularly on current bundling/unbundling rules and payer updates.

Appeal Letter Template for 97

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 97 - Bundled Services

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 97: "Bundled Services".

The denied service should be considered separately payable because it was performed independently and is not an integral or included component of the primary procedure. Clinical documentation supports that the service was distinct in nature, required additional physician work, and was not part of the global surgical package or bundled code. According to CPT and payer-specific guidelines, when services are performed on a different anatomical site, on a different day, or require separate decision-making, they may be unbundled with appropriate modifier use. The submitted documentation demonstrates medical necessity and justifies separate billing, and therefore, the claim should be reconsidered for payment.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]