2/29/2012
Medical Terminology
Getting Ready for ICD-10-CM
Kim Huey
MJ, CPC, CCS-P, CHCC, PCS, CHAP
[email protected]
Never code what you do not understand.
Do not simply look up a word in the
ICD9/ICD-10 or CPT index without
knowing what it means –
also know the synonyms, or other
interchangeable terms.
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2/29/2012
IT’S GREEK TO ME!
• Actually, mostly Latin with a smattering of other
languages thrown in.
• Medical terms are made up of:
– Prefixes
– Suffixes
– Roots – mostly anatomical terms or otherwise related
to a specific organ system
PREFIXES
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a(n)antiautobidiplodyseuheteromacro-
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malmegametamicromonomultioligopoly-
SUFFIXES
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-algia
-itis
-lysis
-oma
-osis
-plasia
-plegia
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-pnea
-poiesis
-praxia
-rrhea
-taxis
-trophy
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2/29/2012
DYSPNEA IS BETTER THAN NO
PNEA AT ALL!
Do you agree?
DIRECTIONAL TERMS
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ab- – away from
ad- – toward
ante- before, forward
apo- – away from
juxta- – near
endoexoperiretrohyper-
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infraintraparasubsupersupraproximal
distal
ventral
dorsal
PROCEDURAL TERMS
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-desis
-ectomy
-otomy
-ostomy
-oscopy
-plasty
-tripsy
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2/29/2012
POSITIONAL TERMS
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Fowler
lateral recumbent
lithotomy
supine
prone
Trendelenburg
reverse Trendelenburg
EPONYMS
• There is no trick to learning these – you just have
to look them up. If you can’t find the term in the
ICD-9/
ICD-10 index, then research the disease (google,
bing, wikipedia, etc.)
• CPT is “cleaning up” eponyms from its index.
EXAMPLE
• You have an op note in which the physician has
titled the surgery “Ivor-Lewis procedure”
• You can’t find this in the CPT index
• Google “Ivor-Lewis” and find that it is a particular
type of esophagectomy – and that leads you to
43117-43118
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2/29/2012
43117 - Partial esophagectomy, distal 2/3, with
thoracotomy and separate abdominal incision,
with or without proximal gastrectomy; with
thoracic esophagogastrostomy, with or without
pyloroplasty (Ivor Lewis)
EXAMPLE
Patient has juvenile rheumatoid arthritis in her
ankles and wrists
714.3* - rheumatoid arthritis
*0 – polyarticular, chronic or unspecified
*1 – polyarticular, acute
*2 – pauciarticular
*3 – monoarticular
• You probably know what poly means and what
mono means, but can you accurately code this
without knowing what pauci- means?
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2/29/2012
ABBREVIATIONS
• Hospitals are required to have an approved list for
abbreviations.
• There is no such requirement for physician’s office
documentation, but remember that other
clinicians, as well as auditors, must be able to
understand the record.
ABBREVIATION EXAMPLES
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BBFX
CA
Ca
DOA
PROM
SPECIALTY-SPECIFIC
• TMN staging – Oncology – describes tumor: Ttumor size, M-metastatic progress, N-nodal
involvement
• PGA – Para, Gravida, Aborta –
– # of pregnancies that produced living offspring
– # of pregnancies
– # of abortions/miscarriages
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2/29/2012
• D- dexter – right side
• S – sinister – left side
• U – universal – both sides
• AD?
• OS?
BEWARE OF HOMONYMS
• ante – anti
• ilium – ileum
• dysphagia - dysphasia
ORDERS
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q – every
qd –
qh –
qod
qs
• prn?
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2/29/2012
EXAMINATION TERMS
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auscultation
Tinel’s sign
cyanosis
turgor
clubbing
Murphy’s sign
rebound
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Rovsing’s sign
Thornton’s sign
bradylalia
exophthalmos
angioedema
lymphadenopathy
anisopia
osmodysphoria
WHICH SYSTEM?
• No C/C/E – (clubbing, cyanosis, edema)
• EOMI
• Butterfly rash
IN CONTEXT?
Imperative to read the word in context – also helps
when deciphering handwriting –
• suture
• cervical
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2/29/2012
Question: How many medical terminology
questions are on the CPC exam?
Answer: All of them!
Only 10 questions involve definitions, but anatomy
and terminology are key to the other 140 – as well
as to working in this field every day!
RESOURCES
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Medical Terminology Made Incredibly Easy
Steadman’s
Netter
Online resources
Kim Huey, MJ, CPC, CCS-P, CHCC, PCS, CHAP
877/893-5583
[email protected]
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