What CO-167 means
The diagnosis code submitted is not covered under the patient's plan or is not a covered indication for the service. Often a specificity or selection issue — a more specific or correct ICD-10 code resolves the denial.
Common causes
- ICD-10 code too vague or not the most specific available
- Diagnosis genuinely excluded from coverage
- Diagnosis doesn't meet the payer's covered indication for the procedure
How to appeal CO-167
Review the record for a more specific ICD-10 code that is a covered indication for the procedure. If the correct diagnosis is covered, correct and resubmit. If the diagnosis is truly not covered, appeal with clinical documentation establishing medical necessity under the payer's policy or a related covered indication.
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