Denial Code PI-97
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.
What PI-97 means
A bundling adjustment — like CO-97 but under the Payer Initiated group: the payer says this service is already paid for as part of another code that was adjudicated, so it isn't paid separately. Under the PI group code the patient is not liable.
Why PI-97 happens
- An NCCI procedure-to-procedure edit pair billed without the required modifier
- A component/incidental service billed alongside the comprehensive procedure that includes it
- A code that is always bundled into the primary service reported separately
- Two overlapping services billed without documentation of a distinct service
What to do when you get PI-97
- 1Look up the NCCI edit for the code pair and check the modifier indicator
- 2If the indicator is 1 and the services were truly distinct, append the most specific X{EPSU} modifier (59 only when none is more specific) and resubmit
- 3If the indicator is 0, the component code isn't separately payable
- 4Confirm documentation supports a separate site, session, or encounter before unbundling
Got this denial right now?
Ask D3 whether to appeal or correct PI-97
PI-97 can go either way depending on the claim. Ask D3 tells you whether to appeal, correct, or just confirm status — free.
PI group code: who absorbs the charge
Payer Initiated Reductions — Payer believes the patient is not liable, but no contractual obligation supports a CO.
A PI adjustment is used when the payer reduces payment, considers the patient not responsible, yet there is no contractual obligation to classify it as CO. It is comparatively uncommon on routine remittances.
Appeal, correct, or write off PI-97?
PI-97 turns on the NCCI modifier indicator, exactly like CO-97. Indicator 1 plus documentation of a distinct service means a corrected claim with the most specific X{EPSU}/59 modifier. Indicator 0 is an absolute bundle — the component is not separately payable. Because it carries the PI group code, the patient isn't billed regardless; resolution is provider-side coding.
Timing & deadlines
Submit the corrected claim within the timely-filing limit (Medicare 12 months from date of service; commercial ~90-180 days). Appeals follow the standard windows (Medicare 120 days; commercial ~180 days from the remittance).
Example
A component service is billed alongside the comprehensive procedure that includes it, and the payer returns PI-97. If the component was genuinely distinct (separate site/session) and documented, the right X{EPSU} modifier and a corrected claim allow separate payment.
Prevent PI-97 going forward
- Run NCCI edits in your claim scrubber before submission
- Reserve modifier 59 / X{EPSU} for genuinely distinct services and document them
- Know which incidental codes are always bundled into your common procedures
- Audit modifier-59 usage to avoid both bundling denials and overuse flags
Code families most affected
- Surgery code pairs subject to NCCI edits
- Lab panels vs. component tests
- Procedures with bundled incidental/add-on services
Related codes
Payer notes
PI-97 shares CARC 97 with CO-97 — the bundling logic is identical, but the PI (Payer Initiated) group code means the payer considers the patient not liable. Resolution is the same NCCI modifier-indicator analysis.
Not sure how to work PI-97?
Ask D3 whether PI-97 should be appealed, corrected, or simply confirmed — free, backed by CMS, Medicare, and major-payer data.
Medical billing disclaimer
CARC/RARC definitions are the standardized X12 set; group-code semantics follow the X12 Claim Adjustment Group Code standard. Filing and appeal windows vary by payer — the standard anchors shown (Medicare redetermination 120 days from the remittance; Medicare timely filing 12 months from date of service; most commercial payers ~90-180 days) are general references, not a guarantee for any specific plan. Always confirm the rule in the payer's provider manual before acting. D3rx is not responsible for claim outcomes.