RemitBench/Denial codes/CO-167

CO-167 denial code

Code 167 denies the diagnosis rather than the treatment. That distinction is the whole page: the service you performed may be perfectly covered, for a different reason than the one you put on the claim.

The code list's own wording: This (these) diagnosis(es) is (are) not covered.

What it means: The plan excludes the condition you billed. The treatment itself was never assessed. Swap the diagnosis for one the chart supports and the same claim can pay.
Who owes the money: The practice, usually CO is common, making it a write-off. But treat this as provisional, because a 167 that turns out to be a coding problem should not be written off at all. It should be corrected.
Is appealing worth it: Usually the wrong tool. If the chart supports a covered diagnosis, send a corrected claim. Appeal only when the diagnosis is right and you believe the plan does cover it.

Never change a diagnosis to make a claim pay. Correcting a coding error is right. Choosing a different condition because it is covered is not, and it is the kind of thing that turns a billing question into a much larger problem. The rule is simple: the claim has to match the chart, and if the chart supports a covered diagnosis you may correct the claim to it.

Why the payer sent it

The plan genuinely excludes the condition.
The diagnosis code was wrong, or was the least specific version of a code family.
The diagnosis was valid but not on the date of service, which is really CO-146.
A more specific diagnosis exists in the chart and a general one was billed.
The payer pairs this procedure only with a listed set of diagnoses, and yours is not on the list.

Remark codes you will see with it

Remark code	What it adds
N115	The decision came from a Local Coverage Determination. That document lists the diagnoses the payer accepts.
N130	Read the plan document. Its own page.
M76	Missing, incomplete or invalid diagnosis. Points at a coding fix rather than an exclusion.

Remark code

What it adds

N115

The decision came from a Local Coverage Determination. That document lists the diagnoses the payer accepts.

N130

Read the plan document. Its own page.

M76

Missing, incomplete or invalid diagnosis. Points at a coding fix rather than an exclusion.

Read the letters in front of the 167

CO-167: Contractual obligation. Your write-off.
PR-167: Patient responsibility. Check the contract, because charging a patient for your coding choice is hard to defend.
PI-167: Payer initiated. The patient owes nothing.

What to do next

Read the chart before you read the plan

The most common cause is that the chart supports a better diagnosis than the one that reached the claim. Start there, because it is the fastest fix and it costs nothing.
If the chart supports a covered diagnosis: corrected claim. Do not appeal.
Find the list of diagnoses the payer accepts

For many procedures the payer publishes the pairings it will pay. On Medicare that is usually a coverage determination. Knowing the list turns guesswork into a decision.
Check the date

A diagnosis code that was retired or not yet valid on the date of service produces this denial even when the condition is covered. That is CO-146.
Only appeal if the diagnosis is right and covered

Then the argument is that the payer applied its own list wrongly, and you should quote the list back to them.

Codes that get mixed up with 167

Code	How it differs from 167
11	The diagnosis does not support the procedure. A mismatch rather than an exclusion. See CO-11.
146	The diagnosis was invalid on that date. A validity problem. See CO-146.
96	Not covered, with the reason in the remark. The general one. See CO-96.
50	Not medically necessary. A judgment about the patient. See CO-50.

Code 167 in dental

Straight dental claims usually carry no diagnosis at all, so 167 is a signal that you are on the medical side. It appears when a dental practice bills medical for surgical extractions, sleep appliances, trauma or biopsies, and the medical payer did not accept the condition you listed.

This is the medical-dental crossover code

Cross coding to medical is where dental offices meet diagnosis rules for the first time, and 167 is the usual welcome. The fix is almost never an appeal. It is finding out which diagnosis codes that payer pairs with the procedure, which is published for most of the common crossover procedures.

Questions people ask about CO-167

What is the difference between CO-167 and CO-11?

Code 11 says the diagnosis and the procedure do not go together, which is a mismatch. Code 167 says the plan does not cover that diagnosis at all, which is an exclusion. A mismatch is usually fixed by correcting one of the two codes. An exclusion is not.

Should I change the diagnosis so the claim pays?

Only if the chart supports the change. Correcting a coding error is normal and right. Picking a covered condition because it pays is not a billing decision, and it creates a far bigger problem than the denial did.

Related codes

Back to all denial codes

RemitBench reads dental EOB PDFs and turns them into posting-ready lines, in your browser, with no upload. It does not read medical remittances today.

Open the app

Opens your mail app with the message written. Nothing is sent from this page.