This lesson provides an overview of coding and reporting guidelines for diagnostic and screening services. It will cover documentation requirements and medical necessity criteria that help differentiate between screening and diagnostic services. The information in this lesson applies to facility-based outpatient coders, billers, and revenue cycle managers. This lesson will include outpatient coding information using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes and guidelines. ICD-10-CM codes establish medical necessity by communicating the reason for the screening or diagnostic exam. Learners should have a basic knowledge of facility-based outpatient coding and/or billing regulations before completing this lesson.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.50 contact hours.
This activity is approved for 0.50 contact hours.
Section 1: Introduction
About This Course
Section 2: Definitions
Differentiating Between Screening and Diagnostic Services
CMS Definition of Diagnostic Services
Section 3: Guidelines
ICD-10-CM Coding and Medical Necessity
Outpatient Coding Guidelines
Coding Guidelines for Screening Services
Coding Guidelines for Diagnostic Services
Coding Examples for Diagnostic Services
Section 4: Documentation
Other Sources of Documentation
How Documentation Supports Screening vs Diagnostic Reporting
Relationship of High-Risk Criteria to the Coverage of Screening Exams
Frequency of Screening Exams
Section 5: Conclusion
Expert Reviewer: Richard R. Cooley, BA, CCS
Rita Johnson is a Senior Consultant working as an independent contractor with over 10 years of experience in health information management, coding, and documentation improvement. Ms. Johnson contributes to the success of the healthcare practice by offering comprehensive coding, compliance and education services. Ms. Johnson’s particular area of expertise is outpatient coding and billing. She is knowledgeable in ICD-9-CM, CPT and HCPCS coding for a variety of outpatient services which include: Outpatient Surgery, Emergency Department, Interventional Radiology, Cardiology, Chemotherapy and short procedure services. She also possesses skills in Evaluation and Management (E/M) coding for facility and professional based clients. She has extensive outpatient auditing experience. Ms Johnson also has experience with Federal, state and local billing regulations , National Correct Coding Initiative and Outpatient Code Editor , Denials Management, Charge Description Master (CDM) Reviews, Data Collection and Analysis, and Charge Capture.
Ms. Johnson is a Registered Health Information Administrator certified by the American Health Information Management Association. She holds a Bachelor's of Science degree in Health Information Management and Systems from the Ohio State University School of Allied Medical Professions. Ms. Johnson currently resides in Bermuda and is employed by the Bermuda Hospitals Board as Consultant APC Coordinator.Disclosure: Rita Jeannine Johnson, RHIA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Jean C. Russell, MS, RHIT
Richard has more than eighteen years in healthcare consulting. He has developed an expertise in hospital outpatient and inpatient coding, including professional split billing and E/M coding, admission criteria, reimbursement and compliance, and charge master reviews. His areas of expertise include Medicare reimbursement for the Medicare Outpatient Prospective Payment System (OPPS), Medicaid Ambulatory Payment Groups (APGs), as well as commercial payers, and professional reimbursement. He is a certified coder with AHIMA (CCS). Richard earned his Bachelors from Hobart College.Disclosure: Richard R. Cooley, BA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Jean Russell has over thirty years of healthcare and information system experience. Her areas of expertise include the Medicare outpatient prospective payment systems (APCs, and APGs), as well as ICD-10-CM/PCS training, Charge Description Master (CDM), admission status reviews, and outpatient coding and compliance. She is a frequent speaker at the national, state and local levels for HFMA and AHIMA professional groups. Jean has her Masters from the University of Houston in Biomedical Engineering; her Bachelors from Colgate University in Biology; and her RHIT from the independent study program through the American Health Information Management Association.Disclosure: Jean C. Russell, MS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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