Skip to main content

N97 Remark Code: Excluded Incontinence Conditions

N97 means the service was denied because the patient has a condition the payer excludes from coverage for this treatment: stress incontinence, urinary obstruction, or certain neurologic diseases (for example, diabetes with peripheral nerve involvement) linked to the covered indications.

Quick facts

Code
N97 (RARC N97)
Status
Active In use since August 24, 2001.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • CO (Contractual Obligation): A non-covered condition. The provider absorbs the amount unless a valid advance notice shifts liability to the patient.
  • PR (Patient Responsibility): The patient may owe the amount if they were informed in writing before the service that it was likely not covered and agreed to pay.
Official description
Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N97 means

Coverage for implanted stimulation therapy for urinary control is limited to particular problems, typically urge incontinence, urgency-frequency, and non-obstructive retention. N97 is the flip side: it names the conditions that take a patient outside that coverage. They are stress incontinence, urinary obstruction, and specific neurologic diseases whose effects produce the same symptoms, with diabetes involving the peripheral nerves given as an example.

On the remittance, N97 typically explains a diagnosis-based denial such as CARC 167, or a medical necessity denial such as CARC 50.

Where the denial comes from

The payer’s decision is driven mainly by the diagnosis codes on the claim (CMS-1500 box 21 and the pointers in 24E) and, if records were reviewed, the physician’s assessment. Common triggers:

  • A stress incontinence diagnosis appears anywhere on the claim, even as a secondary code.
  • An obstruction diagnosis was listed from a prior history but is no longer active.
  • A neuropathy code linked to diabetes was coded without documentation clarifying its relationship to the bladder symptoms.
  • Mixed incontinence was coded in a way the payer read as stress-type.

How to respond

  1. Review the diagnosis list against the chart. Remove codes that are not supported or not current, and confirm the primary indication is coded specifically.
  2. If a coding error caused the denial, send a corrected claim with resubmission code 7 in box 22 and the original claim number.
  3. If coding was accurate but the payer misread the case, appeal with the urologic evaluation showing the treated condition and why an excluded condition is not the cause.
  4. If the exclusion applies, the service is not covered. Check for a signed advance notice to decide whether the patient can be billed.

How to prevent it

Screen candidates for excluded conditions during the work-up and document the differential clearly. Having the coder and physician review the diagnosis list before the trial or implant is billed prevents most N97 surprises.

Codes that may appear with N97

  • CO-167 (This (these) diagnosis(es) is (are) not covered.): The diagnosis is not covered; N97 names the excluded conditions.
  • CO-50 (These are non-covered services because this is not deemed a 'medical necessity' by the payer.): Not medically necessary under the payer's policy for this patient.
  • CO-11 (The diagnosis is inconsistent with the procedure.): The diagnosis is inconsistent with the procedure billed.
  • N96 (Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate…): Addresses refractory status and surgical candidacy for the same implant.
  • N98 (Patient must have had a successful test stimulation in order to support subsequent implantation.): Concerns test stimulation results before permanent placement.
  • N115 (This decision was based on a Local Coverage Determination (LCD).): Shows that a Local Coverage Determination drove the decision.

N97 FAQ

The patient has diabetes. Does that automatically trigger N97?

Not by itself. The exclusion targets neurologic disease, such as diabetes with peripheral nerve involvement, when it is associated with the urinary symptoms. How the diagnoses are coded and documented matters.

Can the patient have both a covered and an excluded condition?

Yes. If records show the covered indication is the one being treated, and the excluded condition is not its cause, an appeal with that documentation may succeed. Payer interpretation varies.

Should I change the diagnosis codes to avoid N97?

Only if the original codes were inaccurate. Diagnosis codes must reflect the documented condition; recoding solely to obtain payment is not appropriate.