CO-167 Denial Code: Diagnosis Not Covered

Coverage policies often list the diagnoses that justify a service. CARC 167 means the diagnosis on the claim is not among them, or is specifically excluded. It is closely related to CO-11 and CO-50 and is often fixed by coding to the specificity the record already supports.

Also appears as PR-167. The group code changes who is responsible, not the reason.

CO-167 means the payer does not cover the diagnosis billed for this service. Check the coverage policy for covered diagnoses, then review whether the documentation supports a more specific covered code. Correct the claim if it does, or determine patient liability if it does not.

Common causes of CO-167.

• Nonspecific diagnosis code where the policy requires a more specific one
• Diagnosis is excluded from coverage for that service
• Screening service billed with a diagnosis the payer does not recognize for screening
• Wrong diagnosis linked to the line

How to work a CO-167 denial.

The order matters: confirm the facts before deciding between a corrected claim, a reconsideration, or an adjustment.

1. 1Check the payer's coverage policy or the Medicare LCD for covered diagnoses.
2. 2Review the record for a more specific or additional documented diagnosis.
3. 3If documentation supports a covered diagnosis, submit a corrected claim.
4. 4If not, determine whether the patient can be billed under your contract and any waiver or ABN on file.

How to keep CO-167 from coming back.

• Scrubber edits that check diagnosis coverage against policy
• Provider education on documentation specificity

Fixing this at the source usually sits with medical coders →

Questions about CO-167.

Denials that often travel with this one.

Browse all denial codes →

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