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

Видео Ch# 6 - What is CO167 denial | Diagnosis is not covered under the patient's plan канала Medical Billing Training in Urdu