CO-97 Denials for Same-Day E/M With Minor Procedures

The clinic should triage the denials claim by claim rather than choosing one disposition for all 23. The decision turns on whether the documentation supports a significant, separately identifiable E/M service above and beyond the procedure's usual pre-, intra-, and post-service work.

• If the note supports a separate E/M: submit a corrected claim with modifier 25 appended, if the payer accepts corrected claims for this denial reason and the 180-day filing window is open. Attach the procedure note and the E/M note. For claims where the payer's policy treats CO-97 as appeal-only, file a written appeal within the 90-day window instead.
• If the documentation is ambiguous or the E/M is routine pre-procedure work: do not append modifier 25 defensively. Write off the E/M line or adjust it, because a modifier 25 without supporting documentation is a compliance exposure.
• If the denial window is close: prioritize the oldest claims and any high-dollar claims; a corrected claim and an appeal can be prepared in parallel only if the payer permits it.

The manager should not write off all 23 simply because the dollar amount is modest. The pattern will continue, and the denial data may affect the clinic's contracts and quality metrics. A claim-level review also reveals whether the issue is isolated to a few physicians or is systemic.

The root cause is not simply "coders forgot modifier 25." The workflow allows a same-day E/M and procedure to be captured without a forcing function. Physicians add the E/M after the procedure note is signed, the charge master has no edit, and coders are making a judgment late in the process without a structured prompt.

A stronger control set includes:

1. A pre-bill edit that flags any claim containing an E/M and a same-day minor procedure from the same provider and requires either modifier 25 with supporting documentation or a documented reason for removing the E/M.
2. A charge-capture prompt in the EHR or charge worksheet that asks whether a separately identifiable E/M occurred and, if yes, requires the physician to link the medical reason.
3. Physician education using de-identified examples showing what counts as separate E/M work versus routine procedure work.
4. Coder review of a sample before claims drop, with feedback to the charging physician.
5. A weekly denial report by CARC and physician, not just by department, so outliers are visible.

The control should not encourage automatic modifier 25 use. It should force a documented decision. That distinction protects revenue and compliance.

The manager should track both process and outcome measures:

• Modifier 25 denial rate by CARC 97, expressed as a percentage of same-day E/M-plus-procedure claims, not just a raw count.
• Clean claim rate for the affected clinic and physicians.
• Initial denial rate overall and for procedure claims, so improvement is not masked by other denial types.
• Days to resolve denials and appeal overturn rate, which show whether the disposition strategy is effective.
• Pre-bill edit override rate and the reasons for overrides, which reveal whether the edit is being bypassed.
• Documentation query rate for same-day E/M and procedure encounters, as an early indicator of unclear documentation.

A useful comparison is the denial rate before and after the edit, segmented by physician and procedure type. If modifier 25 denials fall but a new denial reason such as CO-11 or CO-16 rises, the edit may be creating a different problem. The manager should report a balanced set, not a single declining denial count.