Medical Coding Terminology

· Redaction – Editing a document and removing some details before publishing

· Aliquot - A weighable quantity of drug is dissolved in a calculated volume of a suitable solvent, usually water or ethanol. Then, an aliquot of the solution containing the desired amount of drug is removed

· Arthrodesis – Fusion of a joint

· Carte Blanche – Unconditional authority

· Nomenclature - the body or system of names used in a particular specialist field.

· Standby - readiness for duty or immediate deployment.

· Moribund – at the point of death

· Physiological - Normal function of a living organism

· Therapeutic – healing of a disease

· Cephalic – Towards the head

· Caudad – towards the tail

· Percutaneous – Through the skin

· Pathology – Study of disease

· Benign – Harmless

· Malignant – Invasive, dangerous

· Viscera - the internal organs in the main cavities of the body, especially those in the abdomen, e.g. the intestines.

· Radical - Radical surgery, also called radical dissection, refers to the removal of blood supply, lymph nodes and sometimes adjacent structures of a diseased organ or tumor during surgery (Major surgery).

· Medial - situated near the median plane of the body or the midline of an organ

· Lateral – Towards the sides of the body

· Proximal – situated near the center of the body

· Distal – situated far away from the center of the body

· Peripheral – outlying, border

· Steinstrasse – German word describing a possible complication of ESWL

· Peau D orange – French word – skin looking like orange peel

· Adjacent – nearby

· Lesion – An abnormal area of skin like a lump

· Diagnosis – Process of determining the Disease condition

· Laterality - Laterality" (side of the body affected) is a new coding convention added to relevant ICD-10 codes to increase specificity. Designated codes for conditions such as fractures, burns, ulcers, and certain neoplasms will require documentation of the side/region of the body where the condition occurs.

· Convention - Rules to be followed when coding

· Guidelines: Rules

· Adverse reaction: An adverse effect means a substance is taken according to direction and a reaction occurs.

· Placeholder: This frequently occurs with poisonings and injuries. The letter "x” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The "x” also allows for future expansion of the codes.

· La carte: The definition of a la carte is a list of items on a menu which are priced separately.

· Morbidity: Disease condition

· Puerperium: the period of about six weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition.

· Postpartum: Following childbirth

· Perinatal: The period surrounding childbirth

· Subluxation: Partial dislocation

· Manipulation: The process of manipulating a body part by manual examination and treatment.

· Bundling: In medical billing, you can link some services together under one code, also known as bundling

· Dislocation: An injury in which the ends of two connected bones separate

· Myocardial Infarction: Heart Attack - Death of a tissue due to lack of blood supply

· Angina pectoris: Chest pain

· Sequela: a condition which is the consequence of a previous disease or injury

· Adnexa: The parts adjoining an organ

· Appendages : Extremities

· Sequencing: IN a particular order

· Neoplasm: A neoplasm is a type of abnormal and excessive growth of tissue

· Etiology: The cause of a disease

· Manifestation: symptoms

· Sepsis : Infection of blood

· Ischemia: Inadequate blood supply to a body part/organ

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Vascular Catheterization - Coding

Vascular system anatomy and terminology to make reporting these procedures less challenging. A thorough understanding of the anatomy and medical terminology of the vascular system is required to accurately code arterial vessel procedures. Here’s a quick run-through of clinical information and coding guidance to show you how order affects coding. Order Matters Please refer to Appendix L of the CPT® code book for the vascular families. The aorta is the major artery. Each main vessel branching off the aorta is a first order vessel (e.g., left common carotid). First order vessels have several vessels branching off them, designated as second order vessels (e.g., right subclavian and axillary). Second order vessels have several vessels branching off them, designated as third order vessels (e.g., right internal carotid). Third order vessels have several smaller vessels branching off them, designated as beyond the third order (e.g., left deep palmar arch). Catheterization Can Ei...

CPT Quiz - 40000 Series

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Injections & Infusions Coding

Here are the three basic coding rules that you must adhere to when billing for Injection/Infusion services: Rule #1: Pay Attention to the Administration Route When you’re looking at the treatment note, you can first look for hints to proper coding by identifying the Route of Administration. the Injection/Infusion CPT® codes fall into one of three major categories: 1. Intravenous Infusions (IV) 2. Intravenous Pushes (IP) 3. Injections (Sub-Q, IM) Don’t forget: The Centers for Medicare & Medicaid Services (CMS) regulations look at the way a drug is administered only as “the physical process by which the drug enters the patient’s body” – not whether a medical professional administers the drug or supervises the administration. But the administration route hierarchy isn’t the only one you need to understand for Injection/Infusion coding — there is another hierarchy for the type of agent that works in tandem with the administration one. Rule #2: Unde...

Systemic vs. Pulmonary Circulation

What Does the Heart Do? The heart is a pump, usually beating about 60 to 100 times per minute. With each heartbeat, the heart sends blood throughout our bodies, carrying oxygen to every cell. After delivering the oxygen, the blood returns to the heart. The heart then sends the blood to the lungs to pick up more oxygen. This cycle repeats over and over again. What Does the Circulatory System Do? The circulatory system is made up of blood vessels that carry blood away from and towards the heart. Arteries carry blood away from the heart and veins carry blood back to the heart. The circulatory system carries oxygen, nutrients, and hormones to cells, and removes waste products, like carbon dioxide. These roadways travel in one direction only, to keep things going where they should. What Are the Parts of the Heart? The heart has four chambers — two on top and two on bottom: · ...

Place Holder X

The letter " x ” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The " x ” also allows for future expansion of the codes. When reporting ICD - 10 - CM codes, coders must add a placeholder so the seventh character is in the correct position. Not every ICD-10-CM code with a seventh character has a sixth character—or even a fifth or fourth character for that matter. This frequently occurs with poisonings and injuries. The letter "x” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The "x” also allows for future expansion of the codes. When reporting ICD-10-CM codes, coders must add a placeholder so the seventh character is in the correct position. Without this placeholder to ensure characters appear in the correct positions, codes are invalid. For example, a patient presents with an accidental poisoning by an antiallergic drug. For the initial ...

Burns and Corrosions

Chemicals, such as lye or acid, can cause corrosion upon contact with a person's skin. As a professional coding specialist, you may need to code the diagnosis of a burn or corrosion. A chemical burn occurs when living tissue is exposed to a corrosive substance such as a strong acid or base. Chemical burns follow standard burn classification and may cause extensive tissue damage. Burns from a heat source are classified by depth (first, second, third, unspecified), extent, and agent. For multiple burns, sequence the highest degree burn first. Multiple burns of the same three-character category are coded to the highest degree. Non-healing burns are coded as acute burns. The extent of injury is best described using the percentage of the total body surface area (%TBSA) that is affected by a burn. The measurement of burn surface area is important during the initial management of people with burns for estimating fluid requirements and determining need for transfer to a burns service T...

Allograft vs Autograft vs Xenograft

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Combination Codes

It’s one of the most important questions coders must ask while using ICD-10: Is there a single combination code that fully identifies the patient’s relevant conditions, or is it necessary to report two separate codes? The volume of combination codes in ICD-10 has increased, making it imperative for coders to be alert and aware of instances in which combination codes are applicable. Defining Combination Codes The ICD-10-CM Official Guidelines for Coding and Reporting describe combination codes as those used to classify the following: • Two diagnoses • A diagnosis with an associated secondary process (manifestation) • A diagnosis with an associated complication Coders cannot — and should not — assign multiple diagnosis codes when a single combination code clearly identifies all aspects of the patient’s diagnosis. For example, say a pati...

Complete List of Modifiers

Modifier - as the name implies a modifier will modify a service / procedure or an item under certain circumstances for appropriate reimbursement. Modifiers may add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered. Appending of an appropriate modifier will effectively respond to reimbursement. Modifier are two digit codes and are categorized into two levels 1. Level I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA - American Medical Association. 2. Level II Modifiers: Normally known as HCPCS Modifiers and consists of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS - Centres for Medicare and Medicaid Services. Both the above levels of Modifiers are recognized nationally. List of Level I Modifiers: Modifier -21 Prolonged Evaluation and Man...

Spleen - Anatomy

The spleen is an organ located in the upper left abdomen, and is roughly the size of a clenched fist. In the adult, the spleen functions mainly as a blood filter, removing old red blood cells. It also plays a role in both cell-mediated and humoral immune responses. The spleen in located in the upper left quadrant of the abdomen, under cover of the diaphragm and the ribcage – and therefore cannot normally be palpated on clinical examination (except when enlarged). It is an intraperitoneal organ, entirely surrounded by peritoneum (except at the splenic hilum). The spleen is connected to the stomach and kidney by parts of the greater omentum – a double fold of peritoneum that originates from the stomach: The spleen has a slightly oval shape. It is covered by a weak capsule that protects the organ whilst allowing it to expand in size. The outer surface of the spleen can be anatomically divided into two: · ...