CARC 97 Active

PR-97: Bundled Service — Not Paid Separately

TL;DR

Patient responsibility — review the adjustment and determine if the patient truly owes this amount.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
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 PR-97 Mean?

With PR (Patient Responsibility), the CARC 97 adjustment for bundled service — not paid separately shifts the financial impact to the patient. Before billing the patient, verify that the denial reason is valid. if the underlying issue can be corrected, resubmit the claim first to potentially eliminate the patient's liability.

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 adjustment Examine the PR-97 adjustment and any RARC codes to understand the basis for the patient responsibility.
  2. Verify the adjustment is correct Confirm the PR designation and amount are appropriate based on the patient's plan benefits.
  3. Appeal if incorrect If the adjustment appears incorrect, file an appeal with supporting documentation.
  4. Collect from the patient if valid If the adjustment is confirmed correct, generate a patient statement and follow standard collection procedures.
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 PR-97

Also Filed As

The same CARC 97 may appear with different Group Codes:

CO-97 OA-97

Related Denial Codes

PR-234 — Procedure Not Paid Separately

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.