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Claim adjustment reason code

CO-167: Diagnosis is not covered

CO-167 means: This (these) diagnosis(es) is (are) not covered. The payer does not cover the condition you billed, whatever the procedure was.

Read the group code before you act on this

167 is the claim adjustment reason code. The CO in front of it is the group code — a separate field the payer sets on the remittance. The same reason code arrives under different group codes depending on the payer and the situation, and the group code, not the reason code, decides who owes the money.

CO — contractual obligation. You write it off. You may not bill the patient.
PR — patient responsibility. Billable to the patient.
OA — other adjustment, and PI — payer initiated reduction. Neither is patient responsibility.

What causes it

A diagnosis excluded from the plan — cosmetic, experimental or a specific carve-out
The most specific supporting diagnosis not sequenced first
A screening diagnosis where the plan covers only diagnostic indications, or the reverse
Coverage governed by a local or national coverage determination the diagnosis does not meet

How to work it

Read the payer’s coverage policy for the procedure and find the diagnosis list it accepts.
Check the chart for a covered diagnosis that the provider addressed and that was not sequenced first — do not add a diagnosis the note does not support.
Where the note supports a covered indication, correct the sequencing and resubmit corrected.
Where the condition genuinely is not covered, an advance beneficiary notice or a financial conversation is the right route, not a resubmission.

How to stop it recurring

Where a procedure has a coverage policy with a diagnosis list, check it before the service. Afterwards the only options are appeal or write-off.

Who does this work

A medical coding seat at $2,500 per seat per month works this queue full time, during your business hours, inside your own system. Every call is logged with the payer reference number and the outcome, and every Friday you get it in writing.

What that seat does →

Codes worked the same way

CO-167 is appealed with clinical documentation. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

CO-50 — Not deemed medically necessary
CO-151 — Too many services billed
CO-96 — Non-covered charges
CO-170 — Provider type not paid
CO-234 — Not paid separately
CO-236 — Modifier combination not allowed

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

Pain Management
RFA denied because the chart does not carry percent relief and duration from both diagnostic blocks
Orthopedics
Implant and hardware charges denied for missing invoice documentation
Behavioral Health
Time-based psychotherapy codes not supported by documented duration
Cardiology
Stress tests denied for medical necessity documentation
Podiatry
At-risk foot care documentation not naming the treating physician for the systemic condition
Physical Therapy
Timed code units not supported by documented treatment minutes

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time. Source. At 100 denials a month — an illustration, not a measurement of your practice — that is $5,723 a month, or $68,676 a year, in labour alone.

The figure that makes it worth spending: about 90% of initially denied claims are eventually paid. Source. The reason a denial sits is almost never that nobody knows how to work it — it is that nobody has the hours.

Questions

What does denial code CO-167 mean?

This (these) diagnosis(es) is (are) not covered. In plain terms: The payer does not cover the condition you billed, whatever the procedure was.

What causes CO-167?

A diagnosis excluded from the plan — cosmetic, experimental or a specific carve-out. The most specific supporting diagnosis not sequenced first. A screening diagnosis where the plan covers only diagnostic indications, or the reverse. Coverage governed by a local or national coverage determination the diagnosis does not meet.

How do you fix a CO-167 denial?

Read the payer’s coverage policy for the procedure and find the diagnosis list it accepts.. Check the chart for a covered diagnosis that the provider addressed and that was not sequenced first — do not add a diagnosis the note does not support.. Where the note supports a covered indication, correct the sequencing and resubmit corrected.. Where the condition genuinely is not covered, an advance beneficiary notice or a financial conversation is the right route, not a resubmission..

Can CO-167 be prevented?

Where a procedure has a coverage policy with a diagnosis list, check it before the service. Afterwards the only options are appeal or write-off.

Is CO-167 the same as PR-167?

Same reason, different group code. The number 167 is the reason: The payer does not cover the condition you billed, whatever the procedure was. The prefix says who carries the amount. CO means contractual obligation — the payer says the amount is not billable to anybody, and it is written off unless the denial itself is overturned. PR-167 is the same reason assigned to patient responsibility — the payer says the amount is owed by the patient, and it is billed to them. Read the prefix before the number: it decides whether you appeal, write off, or bill the patient.

What about the codes next to CO-167?

CO-166 and CO-168 are separate codes and this site does not yet cover them. The authoritative list is the X12 Claim Adjustment Reason Codes at x12.org/codes/claim-adjustment-reason-codes; a code is only described here once its official text, causes and fix have been written and checked.

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.

Last updated 2026-09-12. This is operational guidance drawn from payer remittance practice, not legal, coding or reimbursement advice. Payer-specific rules vary and change; confirm against the payer’s own policy before acting on a specific claim.

Written by Ibtesam Asif · Last reviewed 2026-09-12

Code descriptions are the standard published text. Everything after them is operational guidance from our own work, and payer policy governs any individual claim.

Other denial codes

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