Examine the Differences Between Diagnostic Imaging and Radiology
Understand the roles, differences, and importance of diagnosis coding. In healthcare, terms like diagnostic imaging and radiology often get lumped together. While related, each one serves distinct roles. Diagnostic imaging refers to the actual capture of internal images of the body, while radiology refers to interpreting those images to diagnose and manage conditions. Read through this guide, which breaks down the differences, overlaps, and why diagnostic imaging and radiology are critical to effective patient care. Break Down Screening Radiology vs. Diagnostic Imaging vs. Radiology What is screening radiology? Screening radiology is imaging for preventive care. It is performed before symptoms appear to help identify the disease early, when treatment is typically more effective. Standard screening radiology exams include: What is diagnostic imaging? Diagnostic radiology is imaging performed when a patient presents with symptoms or there is an apparent clinical reason to investigate a suspected health issue. The aim is to uncover, confirm, or monitor a known or suspected condition. Common diagnostic radiology exams include: What is radiology? Radiology is the medical field devoted to interpreting diagnostic and screening images. Radiologists are physicians with specialized training in anatomy, pathology, and imaging technology. A radiologist is responsible for: Radiology also includes advanced subspecialties like neuroradiology, musculoskeletal radiology, and interventional radiology. Aspect Diagnostic/Screening Imaging Radiology Function Captures internal images Interprets and diagnoses from images Performed By Technologists, sonographers Radiologists (medical doctors) Decision-Making Not involved in diagnosis Central to patient diagnosis and treatment planning Specialization Image capture across modalities Includes highly trained subspecialists Know What Must Be Included in Radiology Documentation In imaging reports, clear documentation ensures accurate diagnoses, effective follow-up, and proper reimbursement. A comprehensive report should include: Dive Into Diagnosis Coding in Diagnostic Radiology Assigning accurate diagnosis codes for diagnostic imaging procedures, such as X-rays, CT scans, MRIs, ultrasounds, and mammograms, presents one of the more complex tasks for medical coders. Even seasoned professionals must apply precision, sound judgment, and have a thorough grasp of coding guidelines to guarantee accuracy. Unlike other forms of medical documentation, radiology reports stand out because the radiologist typically does not engage directly with the patient. Instead, the radiologist depends on information supplied by the ordering physician to ascertain the purpose or intent of the study. Despite these challenges, coders can achieve dependable and precise results by mastering the essential documentation elements required for coding radiology reports and adhering to the ICD-10-CM Official Guidelines for Coding and Reporting. Review the Key ICD-10-CM Guidelines for Radiology Diagnosis Coding To ensure accurate and complete diagnosis coding, coders must be familiar with several sections of the ICD-10-CM guidelines that are particularly relevant to radiology. Next, in Section I.C.21.c.5: Coding for Screening Exams, you’ll notice that this guideline is crucial for screening studies, such as screening mammograms. The guidelines state, “A screening code may be a first-listed code if the reason for the visit is specifically the screening exam … Should a condition be discovered during the screening, then the code for the condition may be assigned as an additional diagnosis.” Under Sections I.B.4-6 and I.B.18, you’ll find guidelines that provide directions on coding signs and symptoms versus definitive diagnoses. This helps coders interpret how to use information found in the radiology report, particularly when a clear diagnosis is not established. Choose Codes From Findings or Indications When coding a diagnostic radiology report, the ICD-10-CM code selected by the coder typically comes from the findings or the impression noted in the report. If the findings are normal, then you’ll code the signs and symptoms to justify the medical necessity for the study. However, if there are no indications or reasons given for the study or findings reported, a generic diagnosis code for a “routine radiology study” would be used. This method will likely result in denials from many payers. Your diagnosis code selection could also be based on the test order if the test comes back normal. A good example is if the patient came in for left knee pain and an X-ray was performed and found to be normal. You’d use M25.562 (Pain in left knee) to report left knee pain since it was the indication for the test and is also a symptom. Remember This Advice Diagnostic/screening imaging captures the internal picture. Radiology interprets it. Together, they form the foundation of accurate, timely medical care. Technologists focus on image acquisition. Radiologists bring medical expertise to interpret those images and guide clinical decisions. Understanding this partnership — and the difference between the two — enhances patient care, reduces unnecessary procedures, and ensures better health outcomes. Sharonn Johnson, CPC, Senior Manager, CCR Services, Pinnacle Enterprise Risk Consulting Services Alysia Delozier, CPC, CPMA, Senior Provider Auditor/Educator, Pinnacle Enterprise Risk Consulting Services
Identify the Key Differences Between Diagnostic/Screening and Radiology
Begin here: Starting with Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services, you’ll want to familiarize yourself with the following sections:
