CARC 97 Active

OA-97: Bundled Service — Not Paid Separately

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

Action
Review & Decide
Who Pays
Depends
Appeal
No
Patient Impact
Indirect
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does OA-97 Mean?

When paired with Group Code OA, CARC 97 (Bundled Service — Not Paid Separately) is processed as an adjustment outside the standard CO/PR classifications. This typically occurs in secondary payer or coordination of benefits scenarios. Review the remittance details and the COB arrangement to determine financial responsibility and appropriate next steps.

CARC 97 indicates bundled service — not paid separately. The payer's adjudication logic determined that this service or procedure is included within another service that was billed on the same claim or a related claim.

Common scenarios that trigger this adjustment include: the billed procedure code is bundled with another code on the same claim per CMS National Correct Coding Initiative (NCCI) edits, and the bundled service cannot be billed separately; The billed service is part of the global surgical package for a procedure performed on the same date or within the global period, and separate payment is not allowed; A modifier (such as modifier 59, XE, XS, XP, or XU) was not appended to indicate that the service was distinct and separate from the bundled procedure. The group code paired with CARC 97 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

How to Resolve

  1. Review the coordination of benefits Examine the OA-97 adjustment to understand how it fits within the primary/secondary payer relationship or other multi-payer context.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine the responsible party Based on the COB review, identify whether the adjustment should be absorbed, billed to another payer, or if additional documentation is needed.
  4. Appeal or resubmit if needed If the OA adjustment appears incorrect based on the COB arrangement, submit an appeal or corrected claim with the appropriate documentation.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Do Not Appeal This Code

Bundled Service — Not Paid Separately reflects a bundling or NCCI edit — the service was paid as part of another procedure on the same claim. Bundling is governed by published coding edits, so a direct appeal usually doesn't apply. Verify the edit, and if a modifier (such as 59 or XS/XU) legitimately unbundles the services, submit a corrected claim instead.

How to Prevent OA-97

Also Filed As

The same CARC 97 may appear with different Group Codes:

CO-97 PR-97

Related Denial Codes

OA-59 — Multiple/Concurrent Procedure Rules Applied OA-60 — Outpatient Services Not Covered Near Inpatient Stay OA-231 — Mutually Exclusive Procedures OA-234 — Procedure Not Paid Separately OA-236 — Procedure/Modifier Not Compatible per NCCI

Sources

  1. https://www.cms.gov/medicare/payment/ncci-coding-edits
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/97
  4. Codes maintained by X12. Visit x12.org for official definitions.