Glossary · Denial and adjustment codes
What is denial code CO-167?
CO-167 means the payer doesn't cover the service for the diagnosis billed. It's a coverage decision about the diagnosis, often driven by a coverage policy.
Example · fictional data
A vitamin D test billed with a diagnosis the coverage policy doesn't list.
Remittance advice, claim line
- Diagnosis billed
- R53.83 Other fatigue
| Service | Billed | Paid | Adjustment | Remark |
|---|---|---|---|---|
| 82306 Vitamin D, 25 hydroxy | $58.00 | $0.00 | CO-167 $58.00 | N115 |
- Many vitamin D policies don't cover screening for fatigue alone. If the record documents a covered condition, such as osteoporosis, it belongs on the claim.
Reason code 167 reads: This (these) diagnosis(es) is (are) not covered. Where CO-11 says the diagnosis and procedure don’t fit together, CO-167 says the diagnosis fits but the payer won’t pay for it.
How to resolve it
- Check the record for a more specific or additional diagnosis that the policy covers. Coding changes go through a coder.
- Check the policy. Lab tests and imaging often have LCDs listing covered diagnoses.
- Appeal when the patient’s situation meets the policy’s intent and the record proves it.
- Check the advance notice. For Medicare patients, a valid ABN signed before the service lets the provider bill the patient.
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