DENIAL CODE · CO-167

CO-167: Diagnosis Not Covered

CO-167 means the payer says the diagnosis billed isn't covered for this service under its coverage policy — usually an LCD/NCD or medical-policy diagnosis-list issue, not a problem with the care.

Official (X12/WPC): "This (these) diagnosis(es) is (are) not covered."

Why payers issue CO-167

  • The diagnosis isn't on the payer's covered-dx list for that code
  • A more specific, covered diagnosis wasn't coded from the chart
  • Diagnosis pointers linked the wrong dx to the line
  • The policy's covered-dx list is narrower than the clinical reality

Is it recoverable? Recoverable as a coding fix — recode to the most specific diagnosis the chart supports and cite the payer's own covered-diagnosis list.

How to appeal a Medical Necessity denial →

Common questions

What does CO-167 mean?

CO-167 means the payer says the diagnosis billed isn't covered for this service under its coverage policy — usually an LCD/NCD or medical-policy diagnosis-list issue, not a problem with the care. This (these) diagnosis(es) is (are) not covered.

How do I appeal or fix a CO-167 denial?

Recoverable as a coding fix — recode to the most specific diagnosis the chart supports and cite the payer's own covered-diagnosis list. Common causes: the diagnosis isn't on the payer's covered-dx list for that code; a more specific, covered diagnosis wasn't coded from the chart; diagnosis pointers linked the wrong dx to the line; the policy's covered-dx list is narrower than the clinical reality.

Is a CO-167 denial worth appealing?

Recoverable as a coding fix — recode to the most specific diagnosis the chart supports and cite the payer's own covered-diagnosis list. You only pay on what's actually recovered, so there's no cost to working the ones that are winnable.

Other denial codes
CO-197 · Precertification / Authorization Absent →CO-50 · Not Medically Necessary →CO-16 · Missing or Invalid Information →CO-45 · Charge Exceeds Fee Schedule →CO-97 · Bundled into Another Service →CO-29 · Timely Filing Expired →CO-96 · Non-Covered Charge →OA-18 · Duplicate Claim →OA-22 · Coordination of Benefits →CO-11 · Diagnosis Inconsistent with Procedure →CO-151 · Too Many Services (Frequency/MUE) →CO-B7 · Provider Not Eligible →CO-27 · Coverage Terminated →CO-204 · Not Covered Under Current Plan →CO-109 · Not Covered by This Payer →CO-119 · Benefit Maximum Reached →CO-4 · Modifier Inconsistent or Missing →CO-15 · Authorization Number Missing or Invalid →OA-23 · Prior Payer Adjudication Impact →CO-24 · Charges Covered Under Capitation →CO-26 · Expenses Incurred Prior to Coverage →CO-54 · Assistant Surgeon Not Covered →CO-55 · Experimental / Investigational →CO-58 · Inappropriate Place of Service →CO-59 · Multiple/Concurrent Procedure Reduction →CO-107 · Related/Qualifying Claim Not Identified →CO-170 · Denied for This Provider Type →CO-181 · Procedure Code Invalid on Date of Service →CO-182 · Procedure Modifier Invalid on Date of Service →CO-183 · Referring Provider Not Eligible to Refer →CO-185 · Rendering Provider Not Eligible →CO-198 · Precertification / Authorization Exceeded →CO-226 · Requested Provider Information Not Provided →CO-231 · Mutually Exclusive Procedures →CO-234 · Procedure Not Paid Separately →CO-236 · Procedure/Modifier Combination Not Compatible →CO-242 · Out-of-Network / Non-Network Provider →CO-252 · Documentation Required to Adjudicate →CO-253 · Sequestration Reduction →CO-256 · Not Payable Per Managed-Care Contract →CO-288 · Referral Absent →CO-B15 · Qualifying Service Not Received →CO-B16 · New Patient Qualifications Not Met →CO-A1 · Claim/Service Denied (Remark Required) →

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