CARC 97 — Benefit included in another service (bundling)

CARC 97 — "The benefit for this service is included in the payment/allowance for another service/procedure"#

Official meaning: CARC 97 reads "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated." It is the standard bundling / inclusive-service denial.

What it means in practice: the payer considers the billed service part of another procedure that was already paid, so it will not pay separately for it. This is driven by bundling edits such as the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, where one code is a component of a more comprehensive code.

Note: CARC 97 must be reported with a Remittance Advice Remark Code (RARC) to explain the specifics, often:

• N20 — Service not payable with other service rendered on the same date.
• M15 — Separately billed services/tests have been bundled as they are considered components of the same procedure.

How to resolve and appeal CARC 97:

1. Determine whether the bundling edit is correct. Check NCCI PTP edits for the code pair and the date of service.
2. If the services were genuinely distinct and separately reportable, the fix is usually a modifier — most commonly modifier 59 (distinct procedural service) or the more specific X{EPSU} modifiers (XE, XP, XS, XU) — submitted on a corrected claim with documentation supporting the separate, medically necessary service.
3. If the edit allows a modifier override (modifier indicator "1"), append the modifier and resubmit; if the indicator is "0," the codes can never be unbundled and an appeal will not succeed.
4. Appeal with documentation (op note / encounter note) proving the second service was separate, not a component of the first, when you believe the bundling was applied in error.

CARC 97 denials are heavily preventable: coding edits and modifier logic applied pre-submission stop most bundling denials before they happen.