Introduction
Insurance denials are a common problem for radiology practices and can lead to serious issues with billing and cash flow. Radiology involves expensive equipment, regular upkeep, and highly trained staff so getting paid accurately and on time is important to keep things running smoothly.Compared to other medical specialties, radiology often sees higher denial rates, usually between 15% and 20%. This happens because imaging services often require specific approvals before they can be done, and the claims process can be more technical and complex. When claims are denied, it can delay payments, increase paperwork, and sometimes result in lost revenue.
This article looks at the 10 most frequent denial codes that affect radiology billing. It also explains why these denials happen and offers practical tips to help reduce them. With a better approach to handling claims and preventing errors, radiology practices can improve their payment success and keep their operations running more efficiently.
Common Denial Codes in Radiology
| Denial Code | Description |
|---|---|
CARC 50 | Non-Covered Services |
CARC 197 | Precertification/authorization Required |
CARC 16 | Claim/service lacks information |
CARC 96 | Non-covered charge(s) |
CARC 18 | Duplicate claim/service |
CARC 97 | The benefit for this service is included in the payment/allowance for another service. |
CARC 109 | Claim Not Covered by Payer/Contracted Provider |
CARC 29 | The time limit for filing has expired |
CARC 125 | Submission/billing error(s) |
CARC 22 | This care may be covered by another payer per coordination of benefits |
Detailed Analysis of Top 10 Denials
1. Denial Code: CARC 50
Description: Medical Necessity Not Established
Claims are often denied when insurers decide that a radiology exam wasn’t needed based on their medical guidelines. This issue comes up frequently with high-cost imaging procedures like MRIs, CT scans, and PET scans. To get these approved, insurance companies want clear evidence showing why the test was important for diagnosing a condition or guiding treatment. These denials usually happen when the doctor’s notes don’t clearly explain why that specific test was ordered or if more basic, lower-cost options weren’t considered first.
Prevention:
- Implement clinical decision support (CDS) systems that align with appropriate use criteria
- Create and distribute imaging guidelines to referring physicians
- Develop standardized order forms that prompt for relevant clinical information
- Train scheduling staff to identify potentially problematic orders early
- Educate referring providers on payer-specific documentation requirements
2. Denial Code: CARC 197
Description: Missing or Invalid Authorization
Some imaging claims are denied because prior approval wasn’t obtained, or the approval didn’t match the service that was ultimately performed. This can be especially difficult for radiology practices that depend on referring providers to handle the authorization step. Most insurance plans require pre-authorization for advanced imaging exams, including MRIs, CT scans with contrast, PET scans, and nuclear medicine procedures. Denials often occur when there’s a mismatch—like performing a scan with contrast when only a non-contrast study was approved, or imaging a different part of the body than what was authorized.
Prevention:
- Implement a robust authorization verification process before service delivery
- Create a centralized authorization tracking system
- Verify authorization details against the specific CPT code to be billed
- Train scheduling staff to confirm authorization specifics (with/without contrast, body area)
- Develop clear protocols for handling add-on procedures or changes to ordered studies
- Create processes for emergency/urgent situations when prior authorization isn’t possible
3. Denial Code: CARC 16
Description: Missing Information or Billing Errors
This denials happen when a claim includes errors or lacks essential information. In radiology, this often involves things like missing patient details, incorrect or incomplete information about the referring doctor, wrong modifiers, or missing documents that support the service. Sometimes, even the way the claim is formatted can trigger a denial. Because radiology billing involves detailed codes and specific rules for different types of scans, these kinds of errors are fairly common and can easily lead to delays or rejections if not carefully checked.
Prevention:
- Implement claim scrubbing software with radiology-specific edits
- Create comprehensive checklists for radiology billing requirements
- Train staff on proper use of modifiers for radiology services
- Implement quality control reviews before claim submission
- Verify patient demographics and insurance information at scheduling
- Create standardized documentation templates for technologists and radiologists
4. Denial Code: CARC 96
Description: Non-covered Charges
These denials occur when an imaging service isn’t included in a patient’s insurance coverage, no matter how medically reasonable it may seem. Unlike medical necessity denials, the issue here isn’t about justification it’s that the plan simply doesn’t pay for the service. In radiology, this can include scans done for routine screening outside of the approved age range, experimental imaging methods, or certain preventive tests not required by law. These situations can be tough to manage, as the full cost often falls to the patient.
Prevention:
- Verify specific coverage for planned studies during scheduling
- Create a database of commonly non-covered services by payer
- Implement advance beneficiary notice (ABN) protocols for Medicare patients
- Develop similar notice processes for commercial payers
- Train scheduling staff to identify potentially non-covered services
5. Denial Code: CARC 18
Description: Duplicate Claim/Service
These denials happen when an insurance provider believes the same service has been billed more than once. This can occur if a claim is sent again due to a delay in payment but isn’t clearly marked as a corrected or follow-up submission. Another common cause is when both the imaging center and the interpreting physician submit separate charges for different parts of the same procedure, such as the technical and professional components. For radiology practices handling a high volume of cases each day, it can be difficult to monitor claim statuses closely, which increases the risk of duplicate submissions.
Prevention:
- Implement a claim tracking system to monitor submission status
- Create clear protocols for resubmitting denied claims versus submitting corrected claims
- Train staff on proper use of corrected claim indicators
- Coordinate billing between facility and professional components
- Check claim status before resubmitting
- Utilize claim scrubbing software with duplicate detection capabilities
6. Denial Code: CARC 97
Description: Bundled Services
These denials happen when an insurance payer considers a radiology service to be part of a larger procedure, meaning it shouldn’t be billed on its own. For instance, imaging guidance used during a procedure may be treated as part of the main service, or multiple views might be included under a single, complete exam code. These situations can be tricky because they often involve detailed billing guidelines, such as those outlined in the National Correct Coding Initiative (NCCI), which defines what services can or cannot be reported together.
Prevention:
- Stay current on NCCI edits affecting radiology services
- Implement coding software that flags potential bundling issues before submission
- Train coders on proper use of modifiers to indicate separately billable services
- Create radiology-specific coding guides for common bundling scenarios
- Review denied claims to identify bundling patterns by payer
- Consider specialized radiology coding education for billing staff
7. Denial Code: CARC 109
Description: Provider Not Recognized or Authorized
These denials occur when imaging services are performed by a radiologist or facility that isn’t part of the patient’s insurance network. For radiology groups, this can be a tough issue to manage especially when working across multiple locations with different insurance contracts, or when using teleradiology services that involve providers licensed in other states. What makes this even more challenging is that patients usually don’t choose who reads their scans, which can lead to confusion and frustration when a claim is denied for being out of network.
Prevention:
- Verify provider network status during scheduling
- Maintain updated contracts with major payers in your region
- Create clear financial policies for out-of-network patients
- Train scheduling staff on insurance network verification
- Implement provider enrollment tracking systems
8. Denial Code: CARC 29
Description: Timely Filing Limits Exceeded
These denials happen when a claim is sent in after the insurance company’s deadline for submission. Each payer has its own timeline, some may allow up to a year from the date of service, while others require claims within just 30 days. For radiology practices handling large numbers of exams across various sites, meeting these deadlines can be difficult. Delays often occur when waiting on missing details from referring providers or when fixing issues with the claim itself, making timely filing a constant challenge.
Prevention:
- Create a complete filing deadline calendar organized by payer
- Establish a standard claim submission schedule (daily or weekly)
- Implement electronic claims submission for faster processing
- Develop a tracking system for claims approaching filing deadlines
- Prioritize high-dollar imaging studies for timely submission
- Train staff on varied timely filing requirements by payer type
9. Denial Code: CARC 125
Description: Submission/Billing Errors
Denial code 125 points to problems with how a claim was billed, rather than missing data. In radiology, this often includes things like using the wrong procedure code, incorrect modifier placement, mismatched diagnosis links, or errors in the place of service. Because radiology coding involves detailed distinctions between different imaging methods, even small mistakes can lead to a denial. The level of precision required in selecting the correct codes makes these types of errors fairly common in the field.
Prevention:
- Implement complete claim scrubbing before submission
- Create specialty-specific coding guidelines for radiology services
- Train billing staff on common radiology coding pitfalls
- Regularly update charge masters to reflect current coding requirements
- Implement quality control processes focused on technical claim elements
- Consider specialized radiology coding education for billing staff
10. Denial Code: CARC 22
Description: Coordination of Benefits Issues
COB denials happen when there’s uncertainty about which insurance plan should be billed first for a patient who has more than one type of coverage. For radiology practices especially outpatient centers that don’t always interact directly with patients it can be difficult to gather complete insurance details upfront. These denials are often seen in cases involving both Medicare and a secondary private plan, workers’ compensation claims, or imaging related to auto accidents where other types of coverage may apply.
Prevention:
- Implement thorough insurance verification processes that identify all potential coverage sources
- Train registration staff to ask specific questions about secondary insurance
- Verify primary vs. secondary insurance status during scheduling
- Capture images of all insurance cards (front and back)
- Create a dedicated process for handling patients with dual coverage
- Train staff on COB rules for specific scenarios (Medicare Secondary Payer, etc.)
Conclusion
Managing claim denials effectively is essential for the financial health of any radiology practice. With the complexity of imaging services and billing requirements, a thoughtful approach that begins before the patient is even scanned can make a significant difference. Focusing on accurate information collection, consistent coding practices, and timely follow-up helps reduce errors and avoid delays in payment. Regularly reviewing denial trends and staying updated on payer policies allows practices to adapt quickly. By making denial prevention a regular part of operations, radiology groups can reduce financial strain and stay focused on delivering high-quality imaging care.