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CO-160 Denial Code: Injury From Excluded Activity

CO-160 means the payer denied the claim because the injury or illness resulted from an activity the benefit plan excludes, such as certain hazardous activities or other excluded causes written into the plan. The exclusion is plan-specific.

Quick facts

Code
CO-160 (CARC 160)
Status
Active In use since September 30, 2003; last modified September 30, 2007.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): The payer holds the provider responsible for this plan's adjustment. It may apply where a contract limits patient billing.
  • PR (Patient Responsibility): More common for this code. The plan excludes the activity, so the patient is responsible for the charges.
Official description
Injury/illness was the result of an activity that is a benefit exclusion.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-160 means

CARC 160 reads “Injury/illness was the result of an activity that is a benefit exclusion.” Health plans list activities or causes of injury they do not cover. When the payer determines an injury came from one of those, it applies CARC 160.

Unlike CO-157 (war) or CO-159 (terrorism), this code is a general bucket: the specific excluded activity depends on the plan. The payer typically learns about the cause from accident questionnaires, external cause codes, or records.

Note that federal law restricts certain exclusions in many group health plans. For example, HIPAA nondiscrimination rules generally prevent plans from denying benefits for an injury solely because it resulted from domestic violence or a medical condition. Whether an exclusion is valid is a plan and legal question, not something to assume.

Example: a patient injured during an activity the plan lists as excluded returns an accident questionnaire describing the event. The payer then denies the related claims with CARC 160.

Common causes

  • Plan exclusion language covering the activity that caused the injury.
  • External cause and activity codes in box 21 that identify the activity.
  • Accident questionnaire answers from the patient.
  • Misread records, where the excluded activity was mentioned but not the cause.

How to fix it

  1. Get the exclusion language from the payer or plan documents and compare it to the documented cause of injury.
  2. Check your coding. If an activity or external cause code was wrong, submit a corrected claim with resubmission code 7.
  3. Appeal when the record shows a different cause, or when you or the patient believe the exclusion doesn’t apply. The patient can often appeal directly as the plan member.
  4. Check other coverage: auto, liability, or workers’ compensation may apply depending on where and how the injury happened (box 10a to 10c).
  5. Bill the patient only if the payer reports patient responsibility and no other source applies.

How to prevent it

  • Ask how the injury happened and document it clearly and consistently.
  • Report accident indicators in box 10 and include box 14’s date of injury.
  • Code activity and external causes only when documented, and double-check them on injury claims.
  • Track exclusion denials by payer so front-desk staff can warn patients about likely non-coverage. See preventable claim denials.

Remark codes that may appear with CO-160

  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points to the plan documents where the excluded activities are listed.
  • M127 (Missing patient medical record for this service.): The payer wants records describing how the injury occurred.
  • CO-157 (Service/procedure was provided as a result of an act of war.): An exclusion tied specifically to acts of war.
  • CO-159 (Service/procedure was provided as a result of terrorism.): An exclusion tied specifically to terrorism.
  • PR-204 (This service/equipment/drug is not covered under the patient's current benefit plan): The service itself is not covered, regardless of how the injury happened.
  • CO-21 (This injury/illness is the liability of the no-fault carrier.): The injury or illness is the liability of the no-fault carrier.

CO-160 FAQ

What activities do plans exclude?

It depends entirely on the plan. Some exclude injuries from certain hazardous sports, commission of a crime, or other listed activities. Federal rules limit some exclusions, so always read the plan's actual language.

Can CO-160 be appealed?

Yes, if the injury did not arise from the excluded activity, if the records were misread, or if the exclusion is not permitted for that plan type. Include a clear account of how the injury occurred.

Should the patient be billed for CO-160?

Not when the group code is CO. If the payer reports it as PR-160, the patient is generally responsible under the plan terms.