Does this template tell me which modifier to use?

No. Undeny gives no CPT, ICD, or modifier advice — that is your coder's determination against the record and the payer's policy. This letter argues that the documentation shows separate work, which is the part an appeal can actually carry.

What makes these appeals succeed?

Contemporaneous documentation showing the services as genuinely separate: a different session, a different site, or a distinct clinical indication, each recorded at the time rather than reconstructed for the appeal.

CO-97

Appeal letter template: service included in another payment (CO-97)

For denials treating a distinct service as already paid. Argues from documentation of separate work, without straying into coding advice.

Free, no signup required to read or copy it. Replace every bracketed field before sending, and refer to the patient by initials and account reference only — never a full name.

Use this when

The remittance shows CO-97 or states the benefit is included in another service's payment.
The services were performed at separate sessions, sites, or for distinct indications.
The service fell outside the global period of an earlier procedure.
The payer's own policy does not bundle these services.

The letter

[PRACTICE NAME]
[PRACTICE ADDRESS]
[PHONE] · [FAX]

[DATE]

[PAYER NAME] — Appeals Department
[APPEALS ADDRESS FROM YOUR REMITTANCE]

RE: Appeal of claim denial
Claim number: [CLAIM NUMBER]
Patient reference: [PATIENT INITIALS] / [ACCOUNT REFERENCE]
Date of service: [DATE OF SERVICE]
Billed amount: [AMOUNT]
Denial code: CO-97 — benefit included in the payment for another service

To the Appeals Department:

We are appealing the denial of the claim identified above, which was denied as included in the payment for another adjudicated service.

The services in question were distinct and are separately documented in the record.

[DESCRIBE THE SEPARATION AS THE RECORD SHOWS IT — for example: separate sessions on the same date at [TIMES]; a distinct anatomic site; a clinical indication unrelated to the other service; a separate encounter documented in its own note]

Documentation of each service is attached, including [DESCRIBE THE NOTES OR REPORTS], which record the work performed independently of the service the payer considered inclusive.

[IF A GLOBAL PERIOD IS THE BASIS] The service was furnished outside the global period of the procedure performed on [PRIOR PROCEDURE DATE], and is unrelated to that procedure.

[IF THE PAYER'S POLICY DOES NOT SUPPORT THE EDIT] We have reviewed the plan's published policy for these services and it does not indicate that they are inclusive of one another.

So that we can respond to the specific basis for this determination, we request the policy or edit relied upon in bundling these services.

Attached in support of this appeal:
[LIST ATTACHMENTS — operative or encounter notes for each service, remittance advice, relevant policy]

We ask that you conduct a line-item review, reprocess this claim, and remit payment in the amount of [AMOUNT].

Please provide a written determination within your stated appeal-response window. If any additional documentation would assist the review, contact me directly at [PHONE] or [EMAIL].

Sincerely,

[NAME]
[TITLE]
[PRACTICE NAME]
[NPI / TAX ID]

How to adapt it

Everything rests on the documentation showing separate work. If the note reads as one continuous service, this appeal will not change the outcome.
Describe the separation in the record's own terms — times, sites, indications — rather than asserting the services were distinct.
Your coder decides what the record supports before you send this. This letter argues from documentation, not from code selection.

Understand the denial first

CO-97CO-97 denial: service already included in another paymentThe payer treated this service as already paid for as part of another service on the claim.

Common questions

Does this template tell me which modifier to use?: No. Undeny gives no CPT, ICD, or modifier advice — that is your coder's determination against the record and the payer's policy. This letter argues that the documentation shows separate work, which is the part an appeal can actually carry.
What makes these appeals succeed?: Contemporaneous documentation showing the services as genuinely separate: a different session, a different site, or a distinct clinical indication, each recorded at the time rather than reconstructed for the appeal.

Or skip the blanks entirely

Undeny reads the denial document, fills every one of these fields from it, and tracks the appeal deadline. About three minutes instead of thirty.

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