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Coders’ Dictionary
00 TCD Prelim Intro 05b
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Page i
Introduction
Congratulations on your decision to purchase the
second 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 Coders’ Dictionary is not to provide
definitions for all conceivable medical terms, but to
provide definitions for those terms in the medical
record that may confound a coder or biller. Readers
should not expect to find a definition for “prostate” in
this book, as a certain basic level of medical
terminology knowledge is presumed of a coder. A
reader will, however, find in Coders’ Dictionary a
definition for “WIT,” an acronym for water-induced
thermotherapy, a minimally invasive treatment for
benign prostatic hyperplasia. WIT is not defined in
most medical dictionaries.
rather than:
To create Coders’ Dictionary, Ingenix coding experts
generated a list of ambiguous or vexing words found
in the medical record or in billing and reimbursement
communications. 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.
Terms and Definitions
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.
Compound nouns will appear in their natural
language order:
radiotherapy afterloading
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)
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, CPT, and HCPCS Level II coding, and
Appendixes of tables for metric conversions.
© 2005 Ingenix, Inc.
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.
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Introduction
Prefixes and suffixes are typically not seen in medical
documentation as stand-alone words.
Multiple Definitions
Some definitions in the main body of the book will
have multiple meanings. These are presented in two
ways in the Coders’ Dictionary. The first way in which
terms with multiple meanings are listed is as one term
followed by different numbered definitions:
trephine 1) Specialized round saw for cutting
circular holes in bone, especially the skull;
2) Instrument that removes small disc-shaped
buttons of corneal tissue for transplanting.
The second way in which terms with multiple
meanings are presented is with the main term
followed by additional concepts containing the main
term. The main term is not listed again; instead, only
the first letter of the main term appears in its place
within the sequence of words for the additional terms:
ganglion Fluid-filled, benign cyst appearing on a
tendon sheath or aponeurosis, frequently found
in the hand, wrist, or foot and connecting to an
underlying joint. gasserian g. Large group of
nerve cells at the root of the trigeminal nerve
(cranial nerve V). geniculate g. Group of nerve
cell bodies of the facial nerve where the fibers
turn sharply at the lateral end of the internal
acoustic meatus.
Cross References
Cross references are indicated with a “See.” It will
refer the user to the term where they can find the
definition:
conjugated estrogen See estrogen.
Coders’ Dictionary
the appropriate code set and sometimes the code for
claim reporting purposes. These codes are not to be
used directly out of the Coders’ Dictionary. Always
refer to the appropriate code book to identify the best
choice of code to be reported. Do not code directly
from this book. Some codes listed will not be
complete codes; this book is only a map to help the
user identify the definitions of medical terms found in
medical documentation, and possibly, the coding
usage for those terms.
Illustrations
The anatomical illustrations located among the main
terms consist of anatomical areas or body parts and
procedures commonly found in medical
documentation and operative reports. Not all of the
illustrations will be listed in the main body of the
book; some will be located in the Anatomical
Illustrations chapter at the front of the book.
Anatomical Illustrations
The front of the book contains detailed anatomical
illustrations to help the user in identifying anatomical
sites seen in medical documentation.
Appendixes
Metric Conversion Tables
These tables convert metric measurements into the
standard measuring system used in the United States.
Metric system measurements are used in many of the
code descriptions, such as:
In ICD-9-CM:
Other Conditions Originating in the Perinatal Period
(764–779)
estrogen Group of estrus-stimulating hormones
produced by the ovaries, possibly the adrenal
cortex and testes, that have different functions
in both sexes. They are the main female sex
hormones (estradiol, estrone, and estriol)
responsible for the maturation and development
of female secondary characteristics and act on
the reproductive organs to prepare for
fertilization, implantation, and nourishment of
the embryo. Estrogens also have
nonreproductive actions such as minimizing
calcium loss from bones by antagonizing the
effects of parathyroid hormone and promoting
blood clotting.
The following fifth-digit subclassification is for
use with category 764 and codes 765.0 and 765.1
to denote birthweight:
0
1
2
3
4
5
6
7
8
9
unspecified [weight]
less than 500 grams
500-749 grams
750-999 grams
1,000-1,249 grams
1,250-1,499 grams
1,500-1,749 grams
1,750-1,999 grams
2,000-2,499 grams
2,500 grams and over
In CPT:
Coding Information
Many definitions include the ICD-9-CM diagnosis
and/or procedural, CPT procedural, and/or HCPCS
Level II supply and service codes associated with the
term being defined. These codes will guide the user to
58260
The notes in the medical documentation may indicate
the weight in ounces and/or pounds. These charts will
CPT only © 2005 American Medical Association. All Rights Reserved.
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Vaginal hysterectomy, for uterus 250
grams or less
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Coders’ Dictionary
Introduction
assist the user in converting the weight to match the
documentation.
How to Use Coders’ Dictionary
In the main body of the Coders’ Dictionary, terms are
listed alphabetically and numerically. They will
include a term and definition and may have coding
information for ICD-9-CM, CPT, and/or HCPCS Level
II. Not all terms will include coding, billing, and
reimbursement information, especially the anatomical
sites. Coding, billing, and/or reimbursement
information, if listed, will help direct the user to the
most appropriate code or have billing or
reimbursement information that may be useful when
submitting claims.
This book is not to be used as a coding book but as a
resource to help direct the user to the appropriate
code set. From there, the user should reference the
CPT, ICD-9-CM, and/or HCPCS Level II book or
electronic product for further direction on the use of
the code(s).
© 2005 Ingenix, Inc.
Entries will provide definitions to diseases,
conditions, procedures, medical or surgical devices,
eponyms, anatomical sites, acronyms, modifiers,
reimbursement terms, medical terminology, prefixes,
suffixes, and drug names (both brand names and
generic names). These terms are defined in the
Coders’ Dictionary mainly because they can be found
in medical documentation and operative reports.
Unable to Locate a Term
Coders’ Dictionary is an ambitious project and already
represents thousands of hours of clinical coding
research and documentation. In subsequent editions,
users will find an expansion of terms as our database
of difficult terms and concepts from the medical
record continue to grow. If you seek information on a
term not found in Coders’ Dictionary, forward that
information to Ingenix for inclusion in the next
edition. Please email your term to
[email protected] or mail to Customer
Service, Coders’ Dictionary, Ingenix; 2525 Lake Park
Boulevard; Salt Lake City, Utah, 84120.
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Bandl’s ring
newborn, report 763.7. Synonym(s): pathologic
retraction ring.
A-C
Banflex Muscle relaxant used for stiff and sore
muscles secondary to injury or trauma.
Bang’s disease Infectious disease caused by a
species of Brucella bacteria—gram-negative,
aerobic coccobacilli, transmitted from cattle to
humans by direct or indirect contact. Seldom fatal,
symptoms include fever, weakness, sweating, and
aching. Treatment consists of antibiotics. Bang’s
disease is reported with ICD-9-CM code 023.1.
Synonym(s): Brucella abortus.
Bankart 1) Deformity osteochondral fracture or
detachment of the inferior glenoid labrum, the ring
of fibrocartilage attached to the rim of the glenoid
cavity of the scapula, occurring with anterior
shoulder dislocation. 2) Procedure done to repair
the labrum with capsulorrhaphy, reported with
CPT code 23455. Synonym(s): Bankart lesion.
Bantam-Albright-Martin disease Rare genetic
disease in which there is sufficient amount of
parathyroid hormone produced, but the body is
unable to respond to it due to a defective type of
protein required for the hormone’s signal
transduction. This results in low blood calcium
levels and high phosphate levels. Physical
characteristics include a short physique, round
face, obesity, and short hand bones. Report this
disorder with ICD-9-CM code 275.49. Synonym(s):
Albright’s hereditary osteodystrophy, Martin-AlbrightBantam disease, pseudohypoparathyroidism.
Coders’ Dictionary
baritosis Type of pneumoconiosis. Chronic
nonmalignant respiratory disease caused by the
inhalation of barium dust. Report this condition
with ICD-9-CM code 503.
barium enema Radiology exam for viewing the
intestine that utilizes a suspension of barium
sulfate, a chalk-like substance that appears white
on x-ray, to delineate the lining of the colon and
rectum. The barium is administered via the rectum
and held inside the colon while x-rays are taken.
Barium enema may also be performed
therapeutically in order to relieve intussusception
or intestinal obstructions. Report barium enema
with ICD-9-CM procedure codes 87.64, 96.29, and
96.38-96.39 and CPT codes 74270-74283
according to therapeutic or diagnostic purpose.
barium sulfate Contrast agent used for enhancing xrays of the digestive tract. It is ingested as a chalky
liquid. Synonym(s): blanc fixe, synthetic baryta.
Barlow’s syndrome “Mid-late” systolic click of the
heart due to massive protrusion of the mitral
valvular leaflet in the left atrial cavity. Report this
disorder with ICD-9-CM code 424.0.
baro- Relating to weight or heaviness.
Baron Munchausen’s syndrome Chronic,
factitious illness with physical, but psychosomatic
symptoms. Report this disorder with ICD-9-CM
code 301.51. Synonym(s): hospital addiction
syndrome, Munchausen’s syndrome.
baragnosis Loss of the ability to sense or
consciously perceive weight, such as the weight of
hand-held objects, reported with ICD-9-CM code
781.99. Synonym(s): abarognosis.
barotrauma Pain or damage caused to tissue by
changes in pressure that constrict or expand the
gas contained in various parts of the body such as
lungs, sinuses, or middle ear. Report this condition
with ICD-9-CM codes 993.0-993.2.
Bard-Pic syndrome Signs and symptoms associated
with cancer of the head of the pancreas, including
jaundice, a palpable gallbladder with common bile
duct blockage, and cachexia. This syndrome is
reported with ICD-9-CM code 157.0.
Barraquer (-Simon) syndrome Progressive
lipodystrophy, a progressive atrophy of the
subcutaneous fat of the face. Report this disorder
with ICD-9-CM code 272.6. Synonym(s):
Barraquer’s disease.
bariatric Describing supplies, services, or diagnoses
assigned to the treatment of obesity. Bariatric
surgery seeks to reduce the patient’s weight by
restricting the amount of food that can be held in
the stomach and/or by reducing the body’s ability
to absorb nutrients. There are specific CPT and
ICD-9-CM procedure codes to describe these
surgeries, and also specific HCPCS Level II codes
to describe supplies required to accommodate
bariatric patients. The most common diagnosis
associated with these supplies and procedures is
morbid obesity, reported with ICD-9-CM code
278.01.
Barré-Guillain syndrome Disorder of the immune
system with paraplegia of limbs, flaccid paralysis,
ophthalmoplegia, ataxia, and areflexia. Report this
disorder with ICD-9-CM code 357.0. Synonym(s):
Fisher’s syndrome, Guillain-Barre syndrome, Landry
syndrome, Miller-Fisher’s syndrome, Strohl syndrome.
Barré-Liéou syndrome Irritation of the nerve roots
emanating from the posterior cervical spinal cord.
Report this disorder with ICD-9-CM code 723.2.
barrel chest Acquired deformity of the chest in
which it appears rounded or bulging, resembling a
barrel shape with little movement noticed upon
respiration. Underlying causative conditions may
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Orthospec ECSW
Coders’ Dictionary
Its use for plantar fasciitis is reported with CPT
code 28890.
Orthospec ECSW/OssaTron
orthostatic hypotension Low blood pressure that
occurs when standing from a sitting or lying
position, reported with ICD-9-CM code 458.0.
Point of
maximum
tenderness
orthostatic hypotensive-dysautonomic
dyskinetic syndrome Nerves between the
striatum and pallidum are completely demyelated.
Report this disorder with ICD-9-CM code 333.0.
Synonym(s): Déjérine-Thomas syndrome,
Hallervorden-Spatz syndrome.
calcaneus
plantar
fascia
(inflamed)
orthotic Use of a mechanical orthopedic device that
compensates for, supports, corrects, or prevents
deformities.
ESWT
device
orthotopic transplant Movement or replacement of
an organ or tissue in which the patient’s
nonfunctioning organ is removed.
OSA Obstructive sleep apnea. Most common form of
sleep apnea, in which the patient repeatedly stops
breathing during sleep due to complete or partial
obstruction of the airway. OSA is reported with a
code from ICD-9-CM category 780.
shock waves
The clinician treats the patient's plantar fasciitis
with extracorporeal shock waves
oscheo- Relating to the scrotum.
oscilloscope Instrument in which a varying
electrical signal (y) vertically deflects an electron
beam impinging on a fluorescent screen, while
some other function (x or time) deflects the beam
horizontally. The result is a visual graph of y
plotted against x or time with negligible distortion
by inertia.
-oscopy To examine.
-osis Condition, process.
O-R
Osler-Weber-Rendu syndrome A post-pubescent
disorder with small telangiectasia and dilated
venules developing slowly on the skin and mucus
membranes of the lips, nasopharynx, and tongue.
Report this disorder with ICD-9-CM code 448.0.
OssaTron Brand name shock wave generator for
plantar fasciitis therapy. The shock waves are
created by a spark plug enclosed in a soft plastic
dome filled with water. During treatment, the
dome is placed closely against the heel so that the
shock waves pass through the dome to the heel.
The procedure is reported with 28890.
ossicular chain Anatomic structure formed by the
three small bones of the middle ear - incus,
malleus, and stapes - functioning together to
conduct sound vibrations through the ear.
ossification Formation of bony growth or hardening
into bone-like substance.
osteo- Having to do with bone.
osteoarthritis deformans endemica Endemic,
chronic, and slowly progressing degenerative
disease of the spine and peripheral joints believed
to be caused by eating cereal grains infected with
the fungus Fusarium sporotrichiella. This disease
occurs mainly in children in Siberia, China, and
Korea. Report this condition with a code from
ICD-9-CM subcategory 716.0. Synonym(s):
Kaschin-Beck disease, Kashin-Bek.
osteodermopathic hyperostosis syndrome
Irregular linear streaks of skin atrophy, skeletal
malformations, and papillomas of lips. Report this
disorder with ICD-9-CM code 757.39.
osteogenesis imperfecta A hereditary collagen
disorder that produces brittle, osteoporotic bones
that are easily fractured, with hypermobility of
points, blue sclerae and a tendency to hemorrhage.
This disease varies in its manifestations and
severity as well as in its molecular and genetic
heterogeneity. Type 1 is the most common and
mildest form, appearing with blue sclera and the
affected person’s stature being normal or near
normal. Type II is a perinatal lethal type, causing
death at or soon after birth. Type III is the
progressive deforming type, and type IV is
autosomal dominant as is type I, manifesting with
normal sclerae. All types of osteogenesis
imperfecta are reported with ICD-9-CM code
756.51.
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Septra IV
Level II code S0039. Synonym(s): Bactrim IV, SMZTMP, sulfamethoxazole-trimethoprim, Sulfutrim.
sequela Abnormality, dysfunction, or other residual
condition produced after the acute phase of an
illness, injury, or disease is over. There is no time
limit on when sequelae can appear. It may be
apparent early, as with a stroke, or it can occur
years later, as in arthritis following an injury. The
code for the condition is sequenced first, and then
the sequelae or late effect code, unless the late
effect code is combined with the manifestation in
one code or the late effect is followed by the
manifestation. Synonym(s): late effect.
sequencing codes Codes reported according to
ranking guidelines defining severity, time, and skill
required to treat the diagnosed condition and cost
of the service for procedures.
SERM Selective estrogen receptor modulator.
seroma Tumor-like swelling caused by the collection
of serum, or clear fluid, in the tissues. For incision
and drainage of a seroma, see CPT code 10140.
serous meningitis syndrome Meningitis with
serious inflammation in subarachnoid and
ventricle spaces and little change in cerebrospinal
fluid. Report this disorder with ICD-9-CM code
348.2.
SERPACWA Skin exposure reduction paste against
chemical warfare agents, seen in military use.
sertoli cell syndrome Congenital germinal
epithelium absence of the testes. Report this
disorder with ICD-9-CM code 606.0.
SETTLE Spindle epithelial tumor with thymus-like
element. Rare, malignant thyroid gland tumor
found most often in children, adolescents, and
young adults. Report this disease with ICD-9-CM
code 193.
sever Separate completely.
Sever’s disease Inflammation of the calcaneus at
the point of Achilles tendon insertion usually
occurring in boys ages 8 to 14. Pain, tenderness,
and localized swelling are present. Report this
condition with ICD-9-CM code 732.5. Synonym(s):
calcaneal apophysitis, epiphysitis of the calcaneus.
severity of illness Relative levels of loss of function
and mortality that may be experienced by patients
with a particular disease.
S-U
sextant One sixth of the dental arch.
SF HCPCS Level II modifier, for use with CPT or
HCPCS Level II codes, that identifies a second
opinion ordered by a QIO, eligible for
Coders’ Dictionary
reimbursement at 100 percent. The usual
deductible and/or coinsurance amounts are not
applied.
SFMS Smith-Fineman-Myers syndrome. Rare, Xlinked dystrophy featuring short stature,
psychomotor retardation, narrow face, and
strabismus, reported with ICD-9-CM code 759.89.
SG HCPCS Level II modifier, for use with CPT or
HCPCS Level II codes, that identifies an
ambulatory surgery center (ASC) facility service.
Physicians who provide services at ASC facilities
do not need to append this modifier to their
claims. Reimbursement is based on the appropriate
APC.
SGA Substantial gainful activity.
SGC Swan-Ganz catheter. Flexible, flow-directed
catheter inserted through the inferior or superior
vena cava through the right side of the heart to the
pulmonary artery, where it measures blood
pressure in pulmonary circulation and estimate
cardiac output. Report its insertion with
ICD-9-CM procedure code 89.64 or CPT code
93503.
SH HCPCS Level II modifier, for use with CPT or
HCPCS Level II codes, that identifies a second
concurrently administered infusion therapy.
shadow pricing Setting rates just below a
competitor’s rates. Maximizes profits but raises
medical costs.
shared risk Cost-control incentive whereby both the
provider and the payer share risk for excessive
utilization and/or excessive costs associated with
the care of plan members.
Shaver’s syndrome Condition resulting from the
ingestion of bauxite fumes and fine particles of
alumina and silica in the aluminum mining and
manufacturing process. Symptoms include
pulmonary emphysema and pneumothorax. Report
this disorder with ICD-9-CM code 503.
sheath Covering enclosing an organ or part.
Sheehan’s syndrome Secretion of all anterior
pituitary hormones is inadequate or absent;
presenting after childbirth. Report this disorder
with ICD-9-CM code 253.2. Synonym(s): ReyeSheehan syndrome.
shields Devices that protect specific areas of healthy
tissue from radiation.
shigellosis Infection by the rod-shaped, nonmotile,
gram-negative bacteria of the genus Shigella, from
the family Enterobacteriaceae. Known to cause an
acute dysenteric infection of the bowel with fever,
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