2. CPT®
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3. • Word elements
• Diagnostic and procedural terms
• Anatomy
Objectives
3
4. • PRN
• pro re nata
• When necessary
Medical Terminology
4
5. Word Elements
Word Root Compound Words
5
• Derm/o – skin
• Splen/o – spleen
• Cardiovascular
• Cardi/o – heart
• Vascul/o – vessel
• Nephrolithiasis
• Nephr/o – kidney
• Lith – calculus or stone
6. Word Elements
Prefix-beginning of a word Suffix-end of a word
6
• Tri – three
• Cyan - blue
• ectomy – excision, surgical removal
• itis - inflammation
7. Anatomy & Physiology
Anatomy – structure of the body parts and their relationship to each other
Physiology – function of the body and how the body parts work to carry out their
life-sustaining activities
7
8. Anatomy
Organ – Multiple tissue types formed together to perform a specific function for
the body.
Organ System – A collection of body parts depending on one another to achieve
a mutual objective.
8
10. Anatomical Position
10
The tumor was photographed and then
using a standard 24 French cutting loop
the tumor was resected; the solid
portion was resected from the superior
portion down to the inferior portion.
Application to Documentation
Superior
Inferior
13. Integumentary System
11042 Debridement, subcutaneous tissue (includes epidermis and dermis,
if performed); first 20 sq. cm or less
(For debridement of skin [i.e., epidermis and/or dermis only], see 97597,
97598)
13
14. Nail Unit
• Root
• Nail bed
• Nail plate
• Eponychium
• Perionychium
• Hyponychium
14
16. Bones
Long (tubular) – longer than they are wide
Short (cuboidal) – shaped like a cube
Sesamoid – shaped like a sesame seed
Flat – cross-section is flat
Irregulabones that do not fit in other categoriesr –
16
17. Cartilage and Joints
Cartilage
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• Flexible connective tissue
• Matrix made of chondrocytes,
collagen, and cells
Joints (articulating surfaces)
• Provide connection between two or
more parts of the skeleton
21. Lymphatic System
Lymph vessels and nodes
Collects excess fluid and returns it to the heart
Valves ensure fluid travels in one direction
• Lymphoid organs:
• Spleen
• Thymus
• Tonsils
• Peyer’s Patches
21
23. Digestive System
Gastrointestinal tract, or GI tract, begins in the mouth, ends at the anus
Mechanically and chemically breaks down food into minuscule or molecular
size
23
24. Stomach
Cardiac orifice – opening to the stomach
Fundus – rounded upper portion
Body – main portion
Pyloric antrum – lower portion
24
27. Large Intestine
Endoscopy
27
• Proctosigmoidoscopy – rectum, sigmoid colon
• Sigmoidoscopy – rectum, sigmoid colon, a portion of the descending colon
• Colonoscopy – entire colon from rectum to the cecum
28. Urinary System
Urine Production
28
• Excrete metabolic waste
• Fluid and electrolyte balance
Structures
• Kidneys
• Ureters
• Urinary bladder
• Urethra
29. Reproductive Systems
Female Genitalia
29
• External
• Vulva
• Labia majora and minora
• Clitoris
• Introitus, opening of the urethra or urinary
meatus
• Skene’s glands
• Bartholin’s glands
• Internal
• Vagina
• Uterus
• Fallopian tubes
• Ovaries
Male Genitalia
• External
• Testes
• Epididymis
• Scrotum
• Penis
• Internal
• Prostate gland, seminal vesicles, and
Cowper’s glands
• Vas Deferens, ejaculatory duct, and
urethra
30. Nervous System
Central Nervous System (CNS)
30
• Brain
• Spinal Cord
Peripheral Nervous System (PNS)
• Cranial nerves
• Spinal nerves
31. Nervous System
Functions as central operator and central intelligence for the body
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• Regulates body function
• Provides for an internal method of communication
• Regulates subconscious body functions (respiratory rate, body temperature,
peristalsis of intestines)
• Sends signals when hot, cold, or sharp objects are encountered
32. Sensory Organs - Eye
Sense organ of sight
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• Layers
• Retina (nervous)
• Choroid (vascular)
• Sclera (fibrous)
33. Sensory Organs - Eye
Two segments divided by Crystalline Lens
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• Anterior segment
• Filled with aqueous humor
• Responsible for intraocular pressure
• Posterior segment
• Filled with vitreous humor
• Prevents the eyeball from collapsing
35. Sensory Organs - Ear
Eustachian tube – connects each middle ear to the throat.
Otology
• Audiometry Services
• Surgical Services
35
36. Endocrine System
Comprised of glands
36
• Glands
• Group of cells that secrete or excrete hormones
• Can be found in a variety of locations
• Each gland and its associated hormone has a cause and effect that is unique.
37. Hemic System
Red Cells (erythrocytes)
White Cells (leukocytes)
Platelets (thrombocytes)
37
38. Immune System
Classified as a separate system from the hematologic system - most
immune cells have their origin in the hematologic system
Human immune system - body’s defense against invading microorganisms,
harmful chemicals, and foreign bodies
38
39. Immune System
Two kinds of immune cells
(lymphocytes)
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• B-cells
• T-cells
Protection cells
• Neutrophils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
40. Immune System
Antigens
• Elicit an immune response in the body
• Types of antigens
• Inhaled macromolecules
• Ingested macromolecules
• Molecules introduced beneath the skin
Antibodies
• Immune system-related proteins called immunoglobins
40
In this chapter, we will review word elements such as combining forms, prefixes, and suffixes; look at some diagnostic and procedural terms and interpret their meaning; and understand anatomy as it relates to coding. This is a review of anatomy and medical terms you should already know. This is not meant to replace a comprehensive course in medical terminology or anatomy.
Every profession has its own language, and medicine is no exception. Medical terminology is an ancient language that has been in use for many years. For example, we often see PRN in medical documentation. PRN stands for the Latin phrase pro re nata which means when necessary. To code medical procedures and diagnoses accurately, you must first know the language of medicine.
The base of a word is considered the Root. These are terms that are the main portion of a medical term. A root word often defines the body area or system being discussed. Such as Derm for skin, or Splen for spleen. It is possible for a word to have multiple roots, which is referred to as a compound word.
An example of a compound word is Cardiovascular. Cardio means heart, vasculo means vessel. Cardiovascular is pertaining to the heart and blood vessels. Another example is nephrolithiasis. Nephro is the kidney and lith is a calculus or stone. Nephrolithiasis is a disorder characterized by stones in the kidney.
A prefix is attached at the beginning of a word. It typically indicates location, time, or number, although a prefix can also give other definitions to words such as color. An example of a prefix indicating a number is Tri meaning three. The Tricuspid valve has three points or cusps. An example of a prefix indicating color is cyan which means blue. Cyanosis is bluish color of the skin which indicates a lack of oxygen.
A suffix is attached to the end of a word. Suffixes frequently indicate the procedure, condition, disorder, or disease. An example of a suffix indicating a procedure is ectomy which means excision or surgical removal. Mastectomy is the surgical removal of a breast. An example of suffix indicating a disorder is –itis for inflammation. Pericarditis is inflammation of the pericardium which is a fluid sac surrounding the heart.
Knowledge of medical terminology is required to understand the documentation you will be interpreting into codes.
Often, you will hear the terms Anatomy and Physiology used together. Anatomy refers to the structure of the body parts and their relationship to one another. Physiology refers to the function of the body and how the body parts work to carry out their life-sustaining activities. In this chapter we will be discussing anatomy.
The human body contains multiple organ systems. An organ is multiple tissue types formed together to perform a specific function for the body. An example of an organ would be the heart. An organ system is a collection of body parts that depend on one another to achieve a mutual objective. An example of an organ system is the cardiovascular system where the heart and blood vessels work together to carry blood and oxygen to all body cells. The organ systems make up the human body.
In this chapter we will discuss a brief overview of the organ systems. Each organ system is also discussed in subsequent chapters as it pertains to the chapter.
Health care personnel use a standard form for body directions and orientations. The standard body position is considered the “anatomical position.” The anatomical position is an upright, face forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart. This position is used when talking about directional terms in medical documentation. In this medical documentation it states the resection was from the superior portion, which is toward the head, down to the inferior portion, which is toward the feet. Understanding directional terms will help when interpreting medical record documentation.
The Integumentary System consists of the skin, hair, and nails. There are only a few procedures pertaining to the hair, so we will focus on the skin and the nails. These structures work together to provide protection from injury, fluid loss and outside elements such as bacteria and viruses. They also provide body temperature regulation, fluid balance and sensation.
In the CPT book, the breasts are also included in the Integumentary System Chapter.
There are two layers that make up the human skin; the dermis and the epidermis. Below the dermis is the subcutaneous layer. The subcutaneous layer is just beneath the skin and is composed of fatty tissue.
Some codes are selected based on the depth of the procedure. An example is skin debridement. CPT code 11042 is for debridement of the subcutaneous tissue. There is a parenthetical instruction underneath 11042 directing the coder to look at codes 97597 and 97598 if debridement only involves the dermis and epidermis layers.
The nail is made up of six parts. The root is the part that extends into the skin. The nail bed is the area the nail lays on. It extends from the lunula to the hyponychium. This is the pink part of your nail which gets its color from blood vessels, nerves and melanocytes. The nail plate is the actual nail made of translucent keratin. The eponychium is the cuticle. The perionychium is the skin around the nail and is the site of hangnails, ingrown nails, and infection of the skin around the nails call paronychia. The hyponychium is the junction between the free edge of the nail and the skin. A term you’ll want to be familiar with for nails is subungual. Subungual means under the nail. Evacuation of a subungual hematoma is coded with CPT code 11740.
The musculoskeletal system is made up primarily of muscles and bones. It includes the joints, tendons and ligaments.
The bones form the skeleton which supports the body, provides a mechanism for motion, and protects vital organs. he bones also serve as a production factory for blood cells and store calcium, phosphorus, and magnesium salts. The muscles provide form and heat for the body.
Bones can be classified according to their shape. Long bones are longer than they are wide and are found in the limbs such as the femur and the humerus.
Short or cuboidal bones are shaped like a cube. Examples of short bones include the carpal bones of the wrist and the tarsal bones of the ankle.
Sesamoid bones are shaped like a sesame seed and can be found imbedded in tendons in joints. There are two sesamoid bones in the ball of the foot beneath the big toe joint. The patella in the knee is the largest sesamoid bone.
Flat bones have a layer of spongy bone between two thin layers of compact bone. The cross section is flat, not rounded. The skull and ribs are examples of flat bones.
Irregular bones are the bones that do not fit into the other categories of bones. Vertebrae have their own shape and are considered irregular bones.
Cartilage is a type of flexible connective tissue that is nonvascular (has no blood vessels). Cartilage is a matrix made of chondrocytes, collagen, and cells called proteoglycans, depending on the type of cartilage.
Joints and articulating surfaces are synonymous and provide a connection between two or more parts of
the skeleton. Joints are classified according to the type of connective tissue at the articulating surfaces.
The three types of joints are fibrous, cartilaginous, and synovial. Most joints are synovial.
The human skeleton is divided into two parts, the axial skeleton and the appendicular skeleton. The axial skeleton contains the skull, spine, ribs, sternum, and sacrum and protects your vital organs. The appendicular skeleton is your extremities and the girdles that connect them.
Muscles have the property of contractility. They also provide form and produce heat for the body.
There are three types of muscles. Skeletal, also called striated, muscles move the skeleton. They are attached to the skeleton by tendons. Cardiac muscle is the heart muscle. It is an involuntary muscle that pumps blood throughout the body. Smooth muscle is found in the walls of hollow organs of the body like the esophagus to move food through, bladder to control urine flow, and even in your eyes.
The cardiovascular system is made up of the heart and blood vessels. The heart pumps to move blood throughout the body through the pulmonary circulation and systemic circulation.
The heart is composed of three layers; the epicardium which is the outer lining, the myocardium, which is the main heart muscle, and the endocardium, which is the inner lining. The muscles of the heart sit in a fluid filled sac called the pericardial sac. A pericardial window described in CPT code 33025 is an incision made in the pericardium to drain fluid that has build up around the heart.
There are three types of blood vessels. The arteries take blood away from the heart. The veins take blood back to the heart. Capillaries are tiny, semi permeable vessels that facilitate the exchange of fluids, oxygen, nutrients, and waste between local tissues and the blood stream. Coronary Artery Bypass Grafts can be created using veins or arteries.
Like the Cardiovascular System, the lymphatic system includes a network of vessels that transports fluids. The lymphatic system is important to our body’s defense system and its resistance to disease. The lymph vessels and nodes collect excess fluid from interstitial spaces and return it to the heart using a series of valves. Lymphoid organs include the spleen, thymus, tonsils, and Peyer’s patches of the intestines.
The respiratory system is also known as the pulmonary system. It includes the nose and nasal cavity, pharynx, larynx, bronchi and their smaller bronchioles, lungs, and alveoli.
The respiratory system functions to swap carbon dioxide for oxygen. This gas exchange occurs through the permeable membranes of the alveoli.
The digestive system is a feeding tube that begins in the mouth and ends at the anus. This structure winds its way through several body cavities. It encompasses a multitude of structures and organs that mechanically and chemically break down food for absorption into the blood stream and use at the cellular level.
The esophagus joins the stomach at the cardiac orifice. The fundus of the stomach is the rounded upper portion of the stomach. The body is the main portion, and the pyloric antrum is the lower portion of the stomach.
The small intestine is divided into three sections. The first one-third of the small intestine is the duodenum, the second one-third is the jejunum, and the distal one-third is the ileum. There is also an ilium in the pelvis bone. To easily remember which ileum is in the small intestines, remember all three sections of the small intestines are spelled with an e.
The large intestine begins just after the ileocecal valve at the cecum, with the appendix attached at the bottom, then the colon, rectum, and anal canal. There are four portions to the colon. The ascending colon proceeds from the ileocecal valve upward to the hepatic flexure, becomes the transverse colon, and then turns downward to become the descending colon at the splenic flexure. The descending colon gives way to the sigmoid colon and ends at the rectum. The internal and external anal sphincters at the terminus of the rectum control the flow of fecal material leaving the body.
When coding for endoscopies of the large intestines, it is important to know the extent of the large intestine examined. The endoscopy begins at the rectum. For a proctosigmoidoscopy, the examination goes into the sigmoid colon. For a sigmoidoscopy, the examination goes through the sigmoid colon and possibly into a portion of the descending colon. For a colonoscopy, the entire colon is examined.
The urinary system is primarily responsible for the production of urine for the excretion of metabolic wastes, along with fluid and electrolyte balance. Structures of the urinary system include the kidneys, ureters, urinary bladder and the urethra.
A urinary calculi, or stone, can exist anywhere within the urinary system. The diagnostic and procedural coding are both dependent upon where in the urinary system the stone exists.
The organs of the reproductive system differ greatly between male and female; however, their functions are similar. The male and female reproductive organs include external and internal genitalia. Because of the make up of the male and female reproductive systems, the female is more likely to get a urinary tract infection.
The Nervous System provides three general functions; sensory, integrative, and motor. The nervous system helps us to feel, think, remember, move, and be aware of the world around us. It is divided into two groups; the central nervous system and the peripheral nervous system. The central nervous system is the brain and spinal cord. The peripheral nervous system are the nerves that attach the brain and spinal cord to the rest of the body. The cranial nerves stem from the brain and the spinal nerves stem from the spine.
The nervous system functions as a central operator and as the central intelligence for the body. It detects changes outside and within the body, makes decisions based on the information received, and stimulates muscles or glands to respond.
Organs of sense are classified as a subsection of the nervous system. The sensory organs receive and filter sensory input that is interpreted in the central nervous system. Organs of sense include the Eye and the Ear.
The Eye is the sense organ of sight. The eyeball is made up of three layers; the innermost layer is the retina, the middle layer is the choroid, and the outermost layer is the sclera.
The eyeball is separated into an anterior segment filled with aqueous humor and a posterior segment filled with vitreous humor. The crystalline lens separates the two segments. The aqueous humor is responsible for the intraocular pressure in your eye. The vitreous humor shares in the responsibility for the intraocular pressure, but also prevents the eyeball from collapsing.
One of the most common procedures on the eye is actually on the muscles that control the eye movement instead of the eyeball itself. That is, strabismus surgery which is performed by shortening or lengthening various muscles of the eye.
The ear plays a part in both the sense of hearing and the sense of equilibrium. The ear works in tandem with the auditory nerves to send auditory impulses to the temporal lobes of the cerebrum. These structures, working together, form the auditory apparatus.
The ear has three distinct and separate anatomical divisions: the outer, or external, ear, the middle ear or tympanic cavity, and the inner ear or labyrinth. The auditory apparatus uses the ear to capture sound waves and transmits or conducts them into the tiny hair cells in the organ of Corti. Dendrites (nerve endings) of the sensory neurons for hearing are found in the bottom of those tiny hair cells.
The auditory canal, or Eustachian tube, connects each middle ear to the throat. This allows easy transfer of infections in the throat to move into the ear causing a middle ear infection. Children who have repetitive ear infections at an early age will sometimes have tubes placed in their ears.
Otology is the study of the ear. This is a very specialized field of medicine. There are two types of services; audiometry and surgical. Surgical services are often performed by an ENT physician and the codes for procedures are typically found in the Surgery Section of the CPT code book. Audiometry services are studies to test and improve your hearing. The codes for these services are typically found in the Medicine section of the CPT code book.
Regulating the functions of the human body to maintain homeostasis is accomplished by the Nervous System and Endocrine system working together. They form a system of internal communication for the human body. The endocrine system includes cells, tissues, and organs called endocrine glands.
Endocrine glands are ductless glands secreting their hormones directly into the blood stream.
The Hemic, or hematologic, system involves the blood. Red cells, or erythrocytes contain hemoglobin that enables the cells to pick up and deliver oxygen to all parts of the body. White cells, or leukocytes, are the body’s primary defense against infection. Platelets, or thrombocytes, form clusters to plug small holes in blood vessels and assist in the clotting process.
The immune system is classified as a separate system from the hematologic system; however, most immune cells originate in the hematologic system. Often, the study of allergies will go hand in hand because an allergic response is actually an immune response.
The immune system is made up of two types of cells; B-cells and T-cells. B Cells are created and mature in the bone marrow. They get activated and produce antibodies that attach to the surface of the infectious agent. T-cells identify infectious agents and directly attack them. Both T-Cells and B-Cells are lymphocytes.
Other types of white blood cells used by the body for protection include neutrophils, lymphocytes, monocytes, eosinophils, and basophils.
Antigens elicit an immune response in the body. Antigens that enter the body from the environment include:
Inhaled macromolecules. For example, proteins on cat hairs that can trigger an asthma attack;
Ingested macromolecules such as shellfish proteins that trigger an allergic response or a peanut allergy; and
Molecules that are introduced beneath the skin such as on a splinter or in an injected vaccine.
Antibodies are immune system-related proteins called immunoglobulins. Some antibodies destroy antigens directly; others indirectly by making it easier for white blood cells to destroy the antigen.
As you have heard in this lecture, it is imperative for a coder to know and understand Medical Terminology in order to be able to read and understand what is written in medical documentation. It is also essential for a coder to know and understand anatomy as it relates to medical procedures and diagnoses.
