CO-167 denial code
This diagnosis is not covered
How to fix it
Confirm the diagnosis accurately reflects documentation. If another supported diagnosis better represents the encounter, correct and resubmit.
How to prevent it
Review payer coverage policies for diagnosis restrictions before performing elective services.
In practice
A claim returns CO-167 — this diagnosis is not covered. The plan excludes the condition itself, rather than questioning whether the service was appropriate for it.
Diagnosis-level exclusions apply to a narrow set of situations: some cosmetic indications, certain work-related conditions that belong to workers compensation, and conditions specifically excluded by the plan document.
The first check is whether the diagnosis is correct and complete. A claim carrying only an excluded diagnosis, where the record also supports a covered one that better reflects the encounter, is a coding problem rather than a coverage problem.
What sits behind it
CO-167 sits between CO-11 and CO-50 and is distinct from both. CO-11 says the diagnosis does not support this procedure. CO-50 says the service was not medically necessary. CO-167 says the diagnosis itself is outside the plan's coverage entirely.
Work-related conditions are the most common practical cause. A condition attributable to employment belongs to workers compensation, and a group health plan that identifies it as work-related will exclude it — sometimes before the workers compensation claim has been accepted, leaving the patient temporarily between two payers.
Where the exclusion is correct, the route to payment is the correct payer rather than an appeal. Identifying that payer and its filing deadline early is what preserves the claim, because the deadline usually runs from the date of service regardless of how long the coverage question took to resolve.
Related codes
Terms used here — ICD-10-CM · Medical Necessity · Coordination of Benefits
How we handle it — Denial Management · Medical Coding · Eligibility Verification
Primary sources
The rules behind CO-167, at the bodies that publish them.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
- ICD-10-CM official guidelines and files (opens in a new tab)
CDC / National Center for Health Statistics — The official ICD-10-CM code files and coding guidelines, updated annually. Specificity requirements here drive a large share of medical necessity denials.
Every denial code with a guide
Authorization
Bundling
Contractual
Coverage
Data quality
Documentation
Eligibility
Liability and workers comp
Patient responsibility
Provider eligibility
Timely filing
Looking for a different code? Search all 190 CARC and RARC codes
Questions about CO-167
The diagnosis itself is not covered under the plan. It differs from CO-11, which says the diagnosis does not support the procedure, and from CO-50, which says the service was not medically necessary. Here the condition is outside coverage entirely.
Work-related conditions that belong to workers compensation rather than group health, some cosmetic indications, and conditions specifically excluded by the plan document.
Only where the diagnosis submitted was incorrect or incomplete and the record supports a covered diagnosis that better reflects the encounter. Where the exclusion is correctly applied, the route to payment is the correct payer rather than an appeal.
They belong to workers compensation, and a group health plan identifying them as work-related will exclude them — sometimes before the compensation claim is accepted, leaving the patient temporarily between payers. Identify the correct payer and its filing deadline early, since the deadline usually runs from the date of service.
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