What Is CARC 97?

What CARC 97 Means

CARC code 97 indicates that the benefit for the billed service is included in the payment or allowance for another service or procedure that has already been adjudicated. In practical terms, the payer applied a bundling edit — typically from the NCCI Policy Manual — and determined that two CPT codes billed on the same date of service should be paid as a single combined service. The primary code receives payment; the secondary code is denied with CARC 97 and a CO group code, meaning you cannot bill the patient for the denied amount.

Why CARC 97 Matters

CARC 97 is the most common bundling denial in medical billing, representing an estimated 12% of all commercial claim denials. It hits surgical practices, radiology groups, and any specialty that bills multiple procedure codes on one date of service. Each denied line can represent $150 to $800 or more in lost revenue. Because the CO group code prohibits patient billing, the only recovery path is an appeal with clinical documentation or a corrected claim with a valid modifier — making quick identification essential.

How CARC 97 Affects Your Claim

When CARC 97 appears on a line item, that line shows $0 allowed amount regardless of what you billed. The payer has linked it to a specific primary code on the same claim. Your remittance may include a RARC code naming the exact NCCI edit pair. If you submitted modifier 59 or XU and still received CARC 97, the payer rejected your modifier — either because documentation did not support distinct services or because the edit does not permit modifier override. Multiple lines on one claim can each carry CARC 97 tied to different primary codes, requiring separate appeal arguments for each pair.

What to Do About CARC 97

Identify the NCCI edit pair from your remittance or the CMS edit table. Pull the operative report or procedure note and highlight documentation showing each service was clinically distinct. Write an appeal letter citing the specific NCCI policy, explaining why the edit should not apply, and attach the supporting records. If the services were truly bundled, consider whether rebilling with corrected coding is more appropriate than appealing. Submit within the payer's appeal window — typically 60 days for Medicare and 30 to 180 days for commercial plans. Denial Appeal Pro generates CARC 97-specific appeal letters with NCCI language in under 60 seconds.

Frequently Asked Questions

What does CARC code 97 mean on a denial?

CARC 97 means the payer considers the billed service included in the payment for another procedure on the same claim or date of service. The secondary code receives zero payment because of a bundling or NCCI edit.

Which modifier fixes a CARC 97 denial?

Modifier 59 or its XE, XP, XS, or XU replacements indicates a distinct procedural service. The modifier alone is not enough — your appeal must document why the procedures were clinically separate.

How common are CARC 97 denials?

CARC 97 is the single most frequent bundling denial code, accounting for an estimated 12% of all commercial claim denials. Surgical and radiology practices see it most often.

Can I successfully appeal a CARC 97 denial?

Yes, when operative notes or progress records prove the bundled procedures were performed at different anatomic sites, during separate sessions, or for distinct clinical reasons. Appeals with strong documentation overturn roughly 55% of CARC 97 denials.