Скачать или смотреть Ch# 6 - What is CO167 denial | Diagnosis is not covered under the patient's plan

In this video, you will learn about CO167 Denial Code in Medical Billing

*CO167* — “This (these) diagnosis(es) is (are) not covered.”
This means the *insurance payer denied the claim because the diagnosis code(s)* submitted *do not support coverage* of the procedure performed, based on their medical necessity policies.

Example 1: Routine Foot Care Not Covered**

Claim Details
Procedure:** 11721 – Debridement of nails
Diagnosis:** Z41.1 – Encounter for cosmetic surgery

Denial Received:** CO167

Reason:** Routine foot care is not covered** under diagnosis *Z41.1* because it's considered **cosmetic**, not medically necessary.

Fix:** If patient had a qualifying condition (e.g., diabetes with foot complications), correct the diagnosis to something like *E11.42* (Type 2 diabetes with peripheral angiopathy) and resubmit the claim with documentation.

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*Example 2: Screening Service Without Appropriate Diagnosis*

*Claim Details:*
*Procedure:* 45378 – Colonoscopy
*Diagnosis:* R10.9 – Unspecified abdominal pain

Denial Received:** CO167

*Reason:* Colonoscopy billed under a *screening code* requires a *screening diagnosis* (e.g., Z12.11 – Encounter for screening for malignant neoplasm of colon). R10.9 implies a diagnostic procedure.

*Fix:* If the intent was a screening colonoscopy, correct the diagnosis to *Z12.11* and add modifier *33* (preventive service), then resubmit.
Here are *15 hashtags* related to the *CO167 denial code* in medical billing:

1. #CO167
2. #MedicalBilling
3. #DenialCodeCO167
4. #ClaimDenial
5. #DiagnosisNotCovered
6. #BillingErrors
7. #MedicalNecessity
8. #ICD10Denial
9. #InsuranceDenial
10. #HealthcareBilling
11. #RevenueCycle
12. #ClaimRejection
13. #DenialManagement
14. #BillingCompliance
15. #MedicalCodingTips