Denial codes · Denial code
CO-167 on a nutrition claim: the diagnosis isn't covered
By Javier Alvarez · Updated · 4 min read
| Official description | This (these) diagnosis(es) is (are) not covered. |
|---|---|
| Group code | Usually CO; PR-167 means the patient is liable |
| Medicare MNT covers | Diabetes, non-dialysis kidney disease, 36 months after a kidney transplant |
| Fix route | Corrected claim only if a covered diagnosis is documented |
| Common remark codes | N386 (NCD), N115 (LCD), N130 (plan documents) |
| Never | Add a diagnosis the record does not support |
CO-167 is the payer telling you the problem is the diagnosis itself, not how you coded the line. Before you do anything, answer one question honestly: does the record contain a covered diagnosis that you left off the claim? If yes, this is fixable in a day. If no, no amount of resubmitting will change it, and the conversation moves to who pays.
What CO-167 means
The X12 CARC list defines code 167 as:
"This (these) diagnosis(es) is (are) not covered."
Compare it with its neighbors:
- CO-11: the diagnosis does not fit the procedure (a pairing or pointer problem).
- CO-50: the payer judged the service not medically necessary.
- CO-167: the plan does not cover this diagnosis for this service, full stop.
Payers are not perfectly consistent, so read the remark code too. N386 or N115 point to a Medicare national or local coverage determination; N130 ("Consult plan benefit documents/guidelines for information about restrictions for this service.") points to the plan's own documents.
Coverage exclusion vs coding error
When it is a coverage exclusion
Medicare MNT outside its three conditions. Medicare's MNT benefit covers beneficiaries with diabetes or renal disease, on a treating physician's referral (NCD 180.1). The regulation defines renal disease as chronic renal insufficiency, end-stage renal disease when dialysis is not received, or the 36 months after a kidney transplant (42 CFR 410.130). A 97802 for obesity, hyperlipidemia, IBS, PCOS or prediabetes alone is outside the benefit. Medicare has other benefits for some of these (intensive behavioral therapy for obesity in primary care, the Diabetes Prevention Program), but they have their own rules and billing providers.
Commercial plans with a condition list. Many commercial nutrition policies cover 97802/97803 only for listed conditions, or only under the preventive benefit with specific diagnoses. A claim for a condition outside the list will deny no matter how well it is coded.
Medicaid and managed care rules. Medicaid programs and their managed care plans set their own nutrition coverage, and it varies by state and by plan. Always read the specific plan's provider manual; do not generalize one plan's rule to all of them.
When it is a coding error
- The referral says type 2 diabetes with CKD stage 3, but the claim listed only obesity and a BMI code. The covered condition was documented; it just was not billed.
- The covered diagnosis was on the claim but not first, and the line pointed only at the uncovered code.
- The code was right but the payer's file shows a different diagnosis because a previous claim for the same visit was never voided.
In each of these the record already supports a covered diagnosis. That is a legitimate correction.
Recode legitimately, never upcode
The line is simple: you may bill any diagnosis that is documented in the record or the referral and that you addressed at the visit, in the order the guidelines and the payer's policy require. You may not add a diagnosis the patient does not have, pick a more severe code than the documentation supports, or list a condition you did not treat because it is on the payer's list. Those are false claims, and a CO-167 is not worth that.
How to fix a CO-167
- Read the plan's nutrition policy (or the NCD for Medicare) and list the covered diagnoses.
- Compare with the record and the referral. Is a covered diagnosis documented and addressed?
- If yes: send a corrected claim (frequency code 7 with the original claim number) with the covered diagnosis first and each line pointed at it. For Medicare, use your contractor's reopening or redetermination process.
- If yes, but the referral is vague: ask the referring provider for an updated referral naming the diagnosis. Do not backdate anything.
- If no: stop resubmitting. Decide who is liable (below) and fix the intake process so the next patient is screened before the first visit.
- Appeal only if the diagnosis is on the payer's own covered list and the payer denied anyway. Quote the policy.
Who pays after CO-167
- CO-167, in network: generally you. Some commercial contracts let you bill a non-covered service to the patient if they signed a waiver before the visit; read yours.
- PR-167: the plan assigned liability to the patient. Bill per your financial policy.
- Medicare: the patient can be billed for services outside the benefit only within Medicare's rules; for services that may be denied as not reasonable and necessary, that means a valid ABN signed before the visit. When in doubt, ask your Medicare contractor.
- Cash alternative: for patients whose condition is not covered, offering a clear self-pay rate up front is kinder than a surprise bill. See preventive vs medical benefits for when the preventive benefit may apply instead.
How to prevent CO-167
- Screen at booking. For Medicare, confirm the referral names diabetes or kidney disease. For commercial plans, ask which diagnoses are covered for MNT using our verification call script.
- Keep the referral with the chart so the covered diagnosis is always visible when the claim is built.
- Code everything you address, in the right order. See ICD-10 codes for dietitians.
More codes and fixes in the nutrition claim denial lookup. Medicare specifics are in our Medicare MNT billing guide.