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Coder`s Dictionary
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2018
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SCoders' Dictionary
Defining medical terms from a coding
and reimbursement perspective
POWER UP YOUR CODING with Optum360, your trusted
coding partner for 32 years. Visit optum360coding.com.
1/12/17 3:42 AM
Contents
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Introduction ........................................... 1
Cardiovascular System ........................20
Contents .............................................. 1
Lymphatic System ...............................22
Organization ........................................ 1
Digestive System .................................25
Anatomical Illustrations ....................... 2
Genitourinary System .........................27
Abbreviations, Prefixes, Suffixe{is, and
Acronyms ...................................... 2
Endocrine System ...............................31
Appendixes .......................................... 2
Eye .....................................................37
How to Use Coders’ Dictionary ............. 3
Ear and Lacrimal System ....................38
Unable to Locate a Term ...................... 4
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Anatomical Illustrations ......................... 5
Abbreviations, Prefixes, Suffixes, and
Acronyms Table ................................... 39
Body Planes and Movements ................ 5
Integumentary System ......................... 6
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Nervous System ..................................33
Metric Conversion Tables ....................613
Musculoskeletal System ....................... 7
Respiratory System .............................13
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Arterial System ...................................15
Venous System ...................................18
An Illustration of Weight ...................613
An Illustration of Lesion Size .............613
Measures of Length ...........................614
Measures of Weight ..........................614
Conversions to Celsius .....................614
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CPT only © 2016 American Medical Association. All Rights Reserved.
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Introduction
Introduction
Congratulations on your decision to purchase the
ninth edition of Coders’ Dictionary, the only medical
dictionary designed exclusively for medical coders,
billers, and reimbursement professionals. It was
created when our own clinical editors discovered
traditional medical dictionaries often did not provide
answers to their coding questions. Unlike more
traditional medical dictionaries, Coders’ Dictionary
lays the groundwork for understanding medical
terminology from a coding perspective, enhancing the
ability to interpret a medical record and more
accurately code a claim.
Organization
The intention of the Coders’ Dictionary is not to
provide definitions for all conceivable medical terms,
but instead to focus on definitions that may
confound a coder or biller. Subsequently, while a
certain basic level of medical terminology knowledge
is presumed of a coder, the Coders’ Dictionary is
continuing to include common medical abbreviations
and anatomical definitions particularly with the
implementation of ICD-10. The additional specificity
inherent with ICD-10 places a greater emphasis on
anatomy and physiology and including these terms
can help ease a coder’s transition by allowing for
quick and easy reference of key anatomic terms and
common abbreviations frequently seen in medical
documentation.
rather than:
The entries in the main body of the book are
organized in numeric and alphabetic order, with
numeric entries preceding the alphabetic entries. The
term being defined will appear in bold, at the
beginning of the entry.
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Contents
Coders’ Dictionary is comprised of different
segments, including anatomical illustrations, the
main body of alphabetically ordered terms with
coding information for ICD-9-CM, ICD-10-CM, CPT®,
and HCPCS Level II coding, and Appendixes of tables
for metric conversions.
© 2017 Optum360, LLC
CPT © 2016 American Medical Association. All Rights Reserved.
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Compound nouns will appear in their natural
language order:
radiotherapy afterloading
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To create Coders’ Dictionary, Optum360 coding
experts generated a list of ambiguous or vexing
words found in the medical record or in billing and
reimbursement communications, in addition to
standard anatomy and physiology terminology and
common medical abbreviations. The words may be
acronyms, eponyms, or abbreviations, or they may
represent generic or brand name medical devices or
pharmaceuticals. Unusual procedural, anatomical,
or epidemiological terminology from the medical
record is also included. The goal of Coders’ Dictionary
is to provide specific definitions and sometimes
instructions that accommodate the narrow focus of
the medical coder or biller. In some cases, the
definition may direct the reader to a single, specific
code. In other cases, only a general clinical definition
is necessary to provide a road map to appropriate
code selection.
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Terms and Definitions
afterloading, radiotherapy
Following the bolded term will be a definition
appropriate to coding and reimbursement and
sometimes coding instructions. If the term being
defined is an acronym, the first words of the
definition will provide the acronym’s actual meaning:
TCD Transcranial Doppler. Noninvasive
ultrasound technology used to evaluate blood
flow in the major intracranial arteries. TCD done
with contrast is performed by intravenous
microbubble injection, in which the bubbles
serve to enhance ultrasound signals, thereby
producing better visualization. TCD procedures
are reported with a CPT code from range
93886–93893.
Prefixes and Suffixes
Prefixes and suffixes used in medical terminology are
incorporated alphabetically into the main body of the
book. These are not complete words; only the
beginning (prefix) or end (suffix) of a word appears
with its meaning. Each partial word has a meaning:
cyst- Relating to the urinary bladder or a cyst.
(prefix)
-ectomy Excision, removal. (suffix)
These partial words can be put together to define a
complete word:
cystectomy 1) Excision or removal of the urinary
bladder. 2) Excision or removal of a cyst on any
anatomical site.
Prefixes and suffixes are typically not seen in medical
documentation as stand-alone words.
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02 TCD Abbreviations Table.fm Page 42 Wednesday, January 18, 2017 3:14 PM
Abbreviations
Table
Abbreviations, Prefixes, Suffixes, and Acronyms Table
Coders’ Dictionary
Term
Definition
Term
FP
1) Family planning. 2) Family
practitioner.
hor. decub. At bedtime.
FTT
Failure to thrive.
FUO
Fever of unknown origin.
G
Gram.
gastro-
Relating to the stomach and
abdominal region.
GB
Gallbladder.
GDM
Gestational diabetes mellitus.
GERD
Gastroesophageal reflux disease.
GFR
Glomerular filtration rate.
GI
Gastrointestinal.
GID
Gender identity disorder.
GLC
Gas liquid chromatography.
gm
GnRH
Gonadotropin-releasing hormone.
GP
General practitioner.
grad
Gradually; by degrees.
Glucose tolerance test.
GU
Genitourinary.
H
Hertel measurement.
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h (hora)
Hour.
H&H
Hemoglobin and hematocrit.
H&P
History and physical.
h.d.
At bedtime.
h.s.
At bedtime.
h/o
H2
H2O
H2O2
HAA
HAV
HBV
HDL
History of present illness.
HPV
Human papilloma virus.
HR
Heartrate.
HRT
Hormone replacement therapy.
HSV
Herpes simplex virus.
HTN
Hypertension.
Hx
History.
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hydro-
Relating to fluid, water, or hydrogen.
I&D
Incision and drainage.
I&O
Intake and output.
IBS
Irritable bowel syndrome.
IBW
Ideal body weight.
ICD
Implantable cardioverter defibrillator.
ICU
Intensive care unit.
IM
1) Infectious mononucleosis.
2) Internal medicine.
3) Intramuscular.
INF
1) Inferior. 2) Infusion.
infra-
Inferior to, beneath, under.
INJ
Injection.
Int.
Internal.
IOP
Intra-ocular pressure. High IOP is
glaucoma.
IPD
Intermittent peritoneal dialysis.
ISG
Immune serum globulin.
IU
International units.
IUD
Intrauterine device.
IV
1) Cranial nerve on the brainstem
responsible for motor control of the
superior oblique muscle (trochlear).
2) Intravenous.
Hepatitis A virus.
IVC
1) Inferior vena cava. 2) Intravenous
cholangiogram.
1) Hepatitis B vaccine. 2) Hepatitis B
virus.
IVF
In vitro fertilization.
jejuno-
Relating to the jejunum (part of the
small intestine).
JODM
Juvenile onset diabetes mellitus.
History of.
Histamine.
Water.
Hydrogen peroxide.
Hepatitis antigen.
High-density lipoproteins.
HDV
Hepatitis D virus.
HEENT
Head, eyes, ears, nose, and throat.
HEV
Hepatitis E virus.
HF
Heart failure.
HIV
Human immunodeficiency virus.
HOB
Head of bed.
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HPI
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Gram.
GTT
Definition
Jt.
Joint.
JVD
Jugular venous distention.
JVP
Jugular venous pressure.
K
Potassium.
KCL
Potassium chloride.
© 2017 Optum360, LLC
CPT © 2016 American Medical Association. All Rights Reserved.
Coders' Dictionary
NUBC
to a disease but has not yet contracted it. NPEP is
reported with codes from ICD-9-CM category V01.
Associated ICD-9-CM Code(s): V01, V01.0-V01.9
NPF National provider file.
NPI National provider identifier. Standard nine-digit
numeric provider identifier implemented under the
Health Insurance Portability and Accountability Act of
1996 (HIPAA) requirements. Providers are required to
report their NPI number for electronic and paper billing.
The NPE is also used to identify the eligible professionals
(EP) billing under the tax identification number (TIN)
reported on a claim containing PQRS quality data.
Nplate Brand name for romiplostim, an injectable
thrombopoietin receptor agonist used to treat low platelet
counts (thrombocytopenia) in patients with idiopathic
thrombocytopenic purpura (ITP) who have not responded
well to immunoglobulins, steroids, or removal of the
spleen.
Associated HCPCS Code(s): J2796
NPPES National Plan and Provider Enumeration
System. System that uniquely identifies a health care
provider and assigns it an NPI.
NPQ Not physically qualified.
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NPWT Negative pressure wound therapy. NPWT is
used to promote healing of acute or chronic wounds.
Associated CPT Code(s): 97605, 97606
Associated ICD-9-CM Code(s): 707.00, 707.01,
707.02, 707.03, 707.04, 707.05, 707.06, 707.07,
707.09, 707.10, 707.11, 707.12, 707.13, 707.14,
707.15, 707.19, 998.32
Associated HCPCS Code(s): A6550, E2402
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NQF National Quality Forum. Private, non-profit
voluntary consensus building organization with the goal
of improving the quality of health care by establishing
national priorities and goals for performance
improvement, endorsing consensus standards for
measuring health care performance, and reporting on
that performance and promoting reaching the goals via
education and outreach programs. Endorsement by the
NQF has become the "gold standard" for health care
performance measures and is relied on by major health
care companies, as well as CMS, to certify that measures
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NSC Non-service connected, as noted on a veteran's
chart regarding his ailment.
NSD Nominal standard dose.
NSF National standard format.
NST Nonstress test.
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NSU Nonspecific urethritis. Infection and inflammation
of the urethra, most commonly seen in males. Though
commonly considered a sexually transmitted disease,
NSU can occur as a result of a urethral stricture, trauma,
or spreading of another urinary track infection. A
discussion with clinicians regarding NSU is advised to
ensure coding reflects intent of documentation.
Associated ICD-9-CM Code(s): 099.40-099.49,
597.80, 646.60-646.64, 647.20-647.24
NSV Nonspecific vaginitis. If complicating pregnancy,
childbirth, or the puerperium.
Associated ICD-9-CM Code(s): 616.10,
646.60-646.64
NSVB Normal spontaneous vaginal bleeding.
NSVD Normal spontaneous vaginal delivery.
NT 1) Nasotracheal. 2) Nontender.
NTD Nitroblue tetrazolium dye test. Primarily used to
diagnose chronic granulomatous diseases. A slide is
made and the cells are stained using the nitroblue
tetrazolium dye. Normally, the white blood cells turn
blue when dye is added. This means that the cells should
be able to kill bacteria and protect the person from
infections. The specimen is blood.
Associated CPT Code(s): 86384
NTE Neutral thermal environment.
NTL Near total laryngectomy.
Associated CPT Code(s): 31367, 31368
NTP Normal temperature and pressure.
NTT Near total thyroidectomy.
Associated CPT Code(s): 60252, 60271
Nubain Synthetic injectable opiate analgesic used to
relieve moderate to severe pain caused by acute or
chronic medical conditions including cancer, colic,
certain forms of headaches, and postoperative pain. It
may also be used for labor and delivery analgesia. Nubain
contains nalbuphine HCl.
Associated HCPCS Code(s): J2300
NUBC National Uniform Billing Committee.
Organization, chaired and hosted by the American
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417
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NPRM Notice of proposed rule making. Document that
describes and explains regulations the federal
government proposes to adopt at some future date, and
invites interested parties to submit comments related to
them. These comments can then be used in developing
a final regulation.
npt Normal pressure and temperature.
NSAID Non-steroidal antiinflammatory drug. Analgesic
and antiinflammatory drug commonly used to mitigate
inflammatory conditions. NSAIDs include aspirin,
ibuprofen, naproxen, and nabumetone.
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NPN 1) Non-par not approved. 2) Nonprotein nitrogen.
NPS National provider system.
are scientifically sound and consequential, and to assist
in standardizing performance measures.