CO-167 Denial Code: Diagnosis Not Covered
CO-167 means the diagnosis code submitted is not covered or valid for the billed service. Learn how to identify covered diagnoses and prevent CO-167.
What CO-167 Means and How to Resolve It
This (these) diagnosis(es) is (are) not covered. The ICD-10-CM diagnosis code submitted is excluded from coverage under this payer's plan. Common for cosmetic, experimental, or plan-specific exclusion diagnoses.
- Review the patient's benefit document for diagnosis exclusions.
- Check if an alternate diagnosis code better reflects the clinical picture and is covered.
- Appeal with documentation if appropriate.
- Screen diagnosis codes against payer exclusion lists before submitting.
- Educate patients about plan exclusions during the scheduling or consent process.
Source: X12.org Official CARC Registry
CO-167 in Detail
What does CO-167 cover in detail?
CO-167 means the diagnosis code submitted is not covered or valid for the billed service under payer policy, a specificity or coverage issue requiring review of your ICD-10 codes assignment.
Correct the diagnosis to a covered, specific code and resubmit through denial management. See the full denial codes reference for related CARC codes.
How to Handle CO-167 Denials
How to Handle CO-167 Denials?
Identify the Root Cause
Review the claim submission to find the specific reason. Check the modifier-procedure combination and payer-specific coding requirements.
Gather Documentation
Collect the clinical documentation, EOB, and any payer communication needed to support a corrected claim or appeal.
Correct and Resubmit
Make the appropriate corrections: update codes, modifiers, or attach documentation, then resubmit within the payer's timely filing window.
Track and Prevent
Log this denial type in your denial tracking system and implement a front-end check to prevent the same issue on future claims.
Appealing a CO-167 Denial
How do I appeal a CO-167 Denial?
Corrected Claim or Appeal
These are different routes and choosing wrong costs time. If the denial was caused by something fixable on your side, a wrong modifier, a missing authorization number, or a transposed code, submit a corrected claim. It is faster and does not consume an appeal level. File a formal appeal when the original claim was correct and you believe the payer applied its policy incorrectly.
What to Submit
Include the remittance advice showing the denial, the claim as originally submitted, the clinical documentation that supports medical necessity, and a short cover letter that cites the payer's own coverage policy. Take the filing deadline from the remittance advice or determination letter for that specific claim rather than a general rule, since it differs by payer and by appeal level.
Medicare Appeal Levels
Original Medicare fee-for-service appeals move through five levels, and each one must be exhausted before the next:
- 1Redetermination by the Medicare Administrative Contractor (MAC)
- 2Reconsideration by a Qualified Independent Contractor (QIC)
- 3Decision by the Office of Medicare Hearings and Appeals (OMHA)
- 4Review by the Medicare Appeals Council
- 5Judicial review in federal district court
Source: CMS, Medicare Fee-for-Service Appeals
CO-167, PR-167, PI-167: Why the Group Code Matters
The number 167 always carries the same reason for the adjustment. The two-letter group code in front of it decides who is left owing the balance, which is why the same denial reason can arrive as CO-167 on one remittance and PR-167 on another.
Contractual Obligation. The provider absorbs the amount under the payer contract and cannot bill the patient for it.
Patient Responsibility. The balance moves to the patient and may be billed, subject to the payer agreement.
Payer Initiated Reduction. The payer reduced payment on its own initiative, not under a contractual term.
Other Adjustment. Used when neither contractual obligation nor patient responsibility applies.
Group code definitions follow the X12 claim adjustment structure.
CO-167 Denial Code Reference
| Field | Details |
|---|---|
| CARC Code | CO-167 |
| Code Group | Contractual Obligation (CO) |
| Official Description | This (these) diagnosis(es) is (are) not covered. |
| Common Cause | The ICD-10-CM diagnosis code submitted is excluded from coverage under this payer's plan. Common for cosmetic, experimental, or plan-specific exclusion diagnoses. |
| Resolution | Review the patient's benefit document for diagnosis exclusions. Check if an alternate diagnosis code better reflects the clinical picture and is covered. Appeal with documentation if appropriate. |
| Prevention | Screen diagnosis codes against payer exclusion lists before submitting. Educate patients about plan exclusions during the scheduling or consent process. |
Source: X12.org Official CARC Registry
Related Billing Resources
CO-167, Frequently Asked Questions
This (these) diagnosis(es) is (are) not covered.
The ICD-10-CM diagnosis code submitted is excluded from coverage under this payer's plan. Common for cosmetic, experimental, or plan-specific exclusion diagnoses.
Review the patient's benefit document for diagnosis exclusions. Check if an alternate diagnosis code better reflects the clinical picture and is covered. Appeal with documentation if appropriate.
Screen diagnosis codes against payer exclusion lists before submitting. Educate patients about plan exclusions during the scheduling or consent process.
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