Introduction to Medical Terminology (Chapter 1) From the Medical Terminology and Anatomy for Coding by Betsy J. Shilled 5th Edition

Healthcare terminology is what?

Predominantly derived from ancient Greek and Latin word parts, and is used to precisely name the anatomy involved, the diagnosis treated, the procedures performed, and the medical equipment (including medicines) used.

Coding is what?

The process of of assigning a series of numbers and/or letters to the diagnoses, procedures, and equipment used to in the treatment of a patient encounter

Continual updates and additions to the coding manuals reflect what?

The inevitable increase of newly emerging/discovered diseases and the triumph of medical science in finding new diagnosing testing and treatments to combat sickness and injury

Medical coding involves detailed knowledge of what?

four primary code systems

Inpatient and outpatient diagnoses are coded with which coding manual?

ICD-10-CM (International Classification of Diseases, 10th edition, Clinical Modification

Inpatient procedures are coded with which coding manual?

The International Classification of Diseases, 10th edition, Procedure Coding System (ICD-10-PCS)

Outpatient procedures are coded using which coding manual?

The Current Procedural Terminology, 4th edition (CPT-4)

What is The Healthcare Common Procedural Coding System (HCPS) used to code?

products, supplies, and services not covered in CPT

What is non-translatable term?

Words used in medicine whose definitions must be memorized without the benefit of Greek and Latin word parts.

Ex: Asthma

Asthma

From the greek term meaning “painting.” Although this word origin is understandable, the definition is “a respiratory disorder characterized by recurring episodes of proximal dyspnea (difficulty breathing).

Cataract

From the Greek term meaning “waterfall”. In healthcare language, this means “progressive loss of transparency of the lens”.

Translatable Terms

Are those terms that can broken down into their Greek and Latin word parts and given a working definition based on the meanings of those word parts.

Ex: Glossitis

Combining Form

Word root with its respective combining vowel

Word Root

word origin

Combining Vowel

a letter sometimes used to join word parts, Usually and “o”, but occasionally and “e” of “I”

Suffix

a word part that appears at the end of a term. Suffixes are used to indicate whether the term is an anatomic, pathologic, or procedural term

Prefix

A word part that sometimes appears at the beginning of a term. Prefixes are used to further define that absence, location, number, quantity, or state of the term.

Simple Abreviation

A combination of letters (often, but not always, the first letters of significant word parts)and sometimes numbers.

Ex: C2

C2:

Second cervical vertebra (Second bone in the neck)

IM:

Intramuscular (pertaining to within the muscles

Symbol or symbols

Graphic representation of terms

Ex:

Stands for female

Stands for male

• up arrow stands for increased

• down arrow stands for decreased

+

Stands for present

-

Stands for absent

Acronym

Abbreviations that are are also pronounceable.

Ex: CABG

CABG:

coronary artery bypass graft (a detour around a blockage in an artery of the heart)

TURP:

transurethral resection of prostate (a surgical procedure that removes the prostate through the urethra

Eponym

terms that are named after a person or place associated with the term.

Ex: Alzheimer’s Disease

Alzheimer’s Disease

which is named after Alois Alzheimer a German neurologist. The disease is a progressive mental deterioration

Achilles Tendon

a body part named after a figure in greek mythology whose one week spot was this area of his anatomy. Tendons are bands of tissue that attach muscles to bone. The achilles tendon is the particular tendon that attaches the calf muscle to the heel bone (calcaneous). Unlike smoother eponyms, this one does not have a medical equivalent, the calcaneal tendon.

Cesarean Delivery

The delivery of an infant through a surgical abdominal incision. Note that in CPT it is included under the heading “cesarean delivery” with code for delivery only, antepartum care, delivery and postpartum care, with hysterectomy, and with tubal ligation, and delivery

Diagnosis

A disease or condition that is determined by evaluation

Prognosis

Prediction of the probable outcome of a disease

Sequela

A condition that results from an injury or disease

Acute

Abrupt, severe onset to a disease

Chronic

Developing Slowly and lasting a long time

Sign

Objective finding of a disease

Symptom

A subjective report of a disease

Syndrome

A group of signs/symptoms that constantly appear together

Etiology

Cause of a disease

Manifestation

Outward demonstration or prescription

Portmanteau

A combination of words not built from traditional word parts

Ophthalmologist

The study of the eye

Otoplasty

Surgical forming of the ear

Gastralgia

Stomach pain

Arthroscope

Instrument used to view the joints

Rhinotomy

Cutting of the nose

Spelling Rules

1. If the suffix starts with a vowel, a combining vowel is not needed to join the the two word parts.

2. If the suffix starts with a consonant, a combining vowel is needed to join the two word parts.

3. If a combining form ends with the same vowel that begins a suffix, one of the vowels is dropped

4. If 2 or more combining forms are used in a term, the combining vowel is retained between the the two, regardless if the second combining form begins with a vowel or consonant.

What coding system is used for outpatient procedures

CPT-4

How do you build a term when suffix begins with a vowel?

Do not use a combining vowel between the root and suffix

What is the CARD method for translating terms?

1. check word parts

2. assign meanings

3. reverse suffix meaning to the front

4. define the term

What coding system is used for inpatient procedures?

ICD-10-PCS

What is a “Clinical Documentation Improvement”(CDI)’?

A discipline that checks the accuracy and completeness of medical records

What is the purpose of medical coding?

Assigning numbers and/or letters to diagnoses, procedures, and equipment used in treatment for building and record- keeping

What are the four primary coding systems used in medical coding?

ICD-10-CM (diagnoses), ICD-10-PCS (inpatient procedures), CPT-4 (outpatient procedures), and HCPCS (products, supplies, and services not covered by CPT).

What is meant by ‘‘combining form” in medical terms?

A word root with its respective combining vowel

What does “‘suffix” indicate in medical terminology?

The part of a term at the end that indicates whether the term is anatomic, pathological, or procedural

What is the ‘‘Check, Assign, Reverse, Define (CARD)” method?

A four step process for deciphering medical terms: Check for word parts, assign meanings, reverse the suffix meaning to the front, and then define the term

What is the distinction between signs and symptoms?

Signs are objective findings observed by others; symptoms are subjective experiences reported by the patient