What does CO 167 mean?

The diagnosis billed is not covered for this service. Contractual obligation. The provider absorbs it and cannot bill the patient.

Why does CO 167 happen?

The diagnosis billed is not on the payer's covered list for this service.

What documentation wins a CO 167 appeal?

A covered diagnosis that is already documented in the note, if one exists. Otherwise, an appeal on the merits citing the policy.

CO 167 denial code description — what it means and how to appeal it

Q: Can you appeal CO 167?

Winnable with a clinician. Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.

What CO 167 means

CO: Contractual obligation. The provider absorbs it and cannot bill the patient.

So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.

The same code, a different prefix. 167 also arrives as PR 167. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says PR 167, read that page instead.

Is it worth appealing?

Winnable with a clinician. Recoverable on the merits, but somebody clinical has to attest.

Why it fires

In the order we see it.

The diagnosis billed is not on the payer's covered list for this service.

What to do

Check whether a covered diagnosis is documented. If it is, correct the coding. If not, appeal on the merits.

What actually wins it

The documentation, not the argument.

A covered diagnosis that is already documented in the note, if one exists.
Otherwise, an appeal on the merits citing the policy.

The common mistake. Do not change the diagnosis to one that pays. Code what the record supports, and appeal if the record supports coverage.

Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.

CO 167 description

The diagnosis billed is not covered for this service. So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.

This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.

CO 167 denial code