How do I fix or resolve code 167?

Obtain the payer's coverage policy or benefit plan document to identify the list of non-covered diagnoses and confirm whether the billed diagnosis is excluded. Review the medical record to confirm the actual diagnosis documented for the date of service and determine whether a different, covered diagnosis code accurately represents the patient's condition. If a different covered diagnosis accurately reflects the documented condition, correct the diagnosis code and resubmit the claim. If the diagnosis is correctly coded but the plan excludes it from coverage, determine whether the patient signed an ABN or financial responsibility form; if so, bill the patient for the non-covered service. If the diagnosis should be covered based on the plan documents or the payer's own coverage policy, file an appeal with the benefit plan citation and the medical record supporting the diagnosis.

167Denial CodeGeneral Adjustment

Code 167

Problem Description

This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Root Cause

The diagnosis code(s) reported on the claim is not covered under the patient's benefit plan. Unlike CO-11 (where the diagnosis is inconsistent with the procedure), CO-167 means the diagnosis itself is excluded from coverage — for example, a plan that excludes coverage for certain mental health diagnoses, cosmetic-related conditions, or fertility-related diagnoses. The payer's coverage policy cross-references the ICD-10-CM diagnosis against a list of non-covered diagnoses for the plan and denies the claim when the diagnosis appears on the exclusion list. This is a plan benefit limitation, not a coding error.

Resolution Steps

1Obtain the payer's coverage policy or benefit plan document to identify the list of non-covered diagnoses and confirm whether the billed diagnosis is excluded.
2Review the medical record to confirm the actual diagnosis documented for the date of service and determine whether a different, covered diagnosis code accurately represents the patient's condition.
3If a different covered diagnosis accurately reflects the documented condition, correct the diagnosis code and resubmit the claim.
4If the diagnosis is correctly coded but the plan excludes it from coverage, determine whether the patient signed an ABN or financial responsibility form; if so, bill the patient for the non-covered service.
5If the diagnosis should be covered based on the plan documents or the payer's own coverage policy, file an appeal with the benefit plan citation and the medical record supporting the diagnosis.

EHR Documentation Note

Claim denied 167 — diagnosis not covered under plan; verified plan exclusion list, corrected diagnosis if applicable, or billed patient with ABN for non-covered diagnosis.

Preventative Action

Maintain a list of commonly excluded diagnoses by payer and verify diagnosis coverage during pre-visit eligibility checks for services likely to involve excluded conditions.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.