CARC Code 97 Appeal Letter

Why Payers Issue CARC 97 Denials

When you bill two CPT codes on the same date of service, the payer checks NCCI edits to determine if one code is bundled into the other. If no valid modifier is present — or if the payer rejects your modifier — you receive a CARC 97 denial and $0 payment on the secondary code. This happens frequently in surgical billing, radiology add-on codes, and E/M visits billed with procedures.

Building Your CARC 97 Appeal Argument

Your appeal letter must do more than restate that you billed modifier 59. You need to demonstrate clinical distinctness: different anatomic sites, separate encounters, or independent clinical decisions. Pull the operative report or progress note and highlight the specific documentation that shows each procedure served a separate medical purpose. Reference the NCCI Policy Manual section for the edit pair in question.

Documentation to Attach

• Operative report or procedure note describing each service separately
• Original claim showing both CPT codes and modifiers submitted
• NCCI edit table excerpt showing the edit pair and modifier indicator
• Remittance advice with CARC 97 and any associated RARC code

Submit and Track Your Appeal

Submit your CARC 97 appeal through the payer portal with all attachments labeled by document type. Note the appeal reference number and expected response timeframe — typically 30 days for commercial payers. If overturned, verify the remittance shows payment on both line items, not just the primary code.