Chapter One INTRODUCTION TO HEALTHCARE TERMINOLOGY Copyright 2015

Chapter One INTRODUCTION TO HEALTHCARE TERMINOLOGY Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc.

Introduction to ICD-10 History of ICD WHO ICD-10 -CM ICD-10 -PCS October 2014 Medical terminology matters! I 10 Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 2

What Is Medical Terminology? Specialized vocabulary composed of Greek and Latin word components used for communication among healthcare professionals. Essentially, a NEW language. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 3

Examples of Greek and Latin Derivations Latin lingu/o = tongue bilingual sublingual Greek gloss/o = tongue glossary glossitis Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 4

Word Parts lingu/o = tongue gloss/o = tongue -al = pertaining to -ary = pertaining to -itis = inflammation Decodable Terms Word Parts Word roots (ex. ling/) Combining vowels (ex. o, i, a, e) Word root + combining vowel = combining form (CF) (ex. lingu/o) Suffixes (ex. –al, -ary, -itis) Prefixes (ex. bi- and sub-) bi-= two sub- = under, below Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 5

Nondecodable Terms Most healthcare terms can be built from word parts. Examples include: Cataract Asthma Cataract From Zitelli and Davis: Atlas of pediatric physical diagnosis, ed 5, Mosby Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 6

Present and Future Conditions Diagnosis—present condition Prognosis—future condition Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 7

Sequela A condition that results from an injury or disease Referred to in coding as a “late effect” Guideline Alert! “A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used…The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. ” Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 8

Time/Severity of a Disease Acute—short term and sharp Chronic—long term and returns Guideline Alert! “If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. ” Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 9

Signs and Symptoms Sign Objective Observable signs Symptom Subjective Patient’s explanation Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 10

Guideline Alert! “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. ” Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 11

Etiology and Manifestation Etiology is the cause of a disease/disorder. Manifestation is the outward demonstration of the disease. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 12

CM Guideline Alert! ETIOLOGY/MANIFESTATION CONVENTION (“CODE FIRST, ” “USE ADDITIONAL CODE ” AND “IN DISEASES CLASSIFIED ELSEWHERE ” NOTES)* Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10 -CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes: etiology followed by manifestation. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 13

CM Guideline Alert! In most cases the manifestation codes will have “in diseases classified elsewhere” in the code title. Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. “in diseases classified elsewhere” codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. *For more of this guideline, see ICD-10 -CM Official Guidelines for Coding and Reporting. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 14

Syndrome: a group of signs and symptoms that consistently appear together Examples: Down’s syndrome, irritable bowel syndrome Guideline Alert! “Follow the alphabetic Index guidance when coding syndromes. In the absence of Index guidance, assign codes for the documented manifestations of the syndrome. ” Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 15

Review Question Which of the following would be a sign? A. B. C. D. pain blisters nausea dizziness Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 16

Eponyms ICD-10 -CM: Alzheimer’s disease & Achilles tendon ICD-10 -PCS Alzheimer’s disease Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 17

Abbreviations and Symbols Abbreviations Simple IM, IV, C 2 Acronyms CABG, TURP, AIDS Symbols (↑, ♀) Dangerous and DO NOT USE abbreviations OU, QID Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 18

Review Question Terms that are named after people or places are called: A. B. C. D. acronyms homonyms eponyms pseudonyms Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 19

Decodable Terms The code Combining form (in red) + suffix (in green) = decodable term gloss/o + -itis = glossitis Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 20

Decoding 101 (The CARD Method) Check the word parts in a term. Assign meanings to the word parts. Reverse the suffix to the front of the term. Define the term. C=Check A=Assign R=Reverse D=Define Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 21

Decoding Glossitis: Check for word parts in the term. glossitis Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 22

Decoding Glossitis: Assign meanings to the word parts. glossitis tongue / inflammation of Glossitis From Feldman: Sleisenger and Fordtran's Gastrointestinal and liver disease, ed 8, Saunders Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 23

Decoding Glossitis: Reverse the meaning of the suffix to the front of your translation. glossitis inflammation of / tongue Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 24

Decoding Glossitis: Define the term. Glossitis: inflammation of the tongue Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 25

Review Question So which activity comes first? A. B. C. D. Assign meanings to the word components. Define the term. Check for word components. Reverse the meanings. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 26

Using Combining Forms and Suffixes Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 27

New Word Parts Combining Forms arthr/o = joint gastr/o = stomach ophthalm/o = eye ot/o = ear rhin/o = nose hepat/o = liver Suffixes -algia = pain -scope = instrument to view -logy = study of -tomy = cutting -plasty = surgically forming -itis = inflammation Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 28

The CARD Method The patient complained of chronic gastralgia. Check the word parts in a term. gastralgia Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 29

The CARD Method Assign meanings to the word parts. gastralgia stomach / pain Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 30

The CARD Method Reverse the meaning of the suffix to the front of the definition. gastralgia pain / stomach Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 31

The CARD Method Define the term gastralgia pain (of ) the stomach Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 32

The CARD Method in Action The patient complained of chronic gastralgia (pain of the stomach). Is this complaint a sign or a symptom? What does the term “chronic” mean? Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 33

Building Terms Most terms are built according to five simple rules. You must know the difference between a consonant and a vowel. What are the vowels? Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 34

Building Terms: Rule #1 If the suffix starts with a vowel, a combining vowel is NOT needed to join the parts. arthr/o + -itis = arthritis You don’t need to keep the “o, ” because the suffix starts with a vowel. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 35

Building Terms: Rule #2 If the suffix starts with a consonant, a combining vowel IS needed to join the two word parts. arthr/o + -plasty = arthroplasty Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 36

Building Terms: Rule #3 If a combining form ends with the same vowel that begins a suffix, one of the vowels is dropped. endocardi/o + -itis = endocarditis Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 37

Building Terms: Rule #4 If two or more combining forms are used in a term, the combining vowel is retained between the two, regardless of whether the second combining form is a vowel or a suffix. gastr/o + enter/o + -itis = gastroenteritis Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 38

Building Terms: Rule #5 Sometimes when two or more combining forms are used to make a term, special notice needs to be paid to the order in which the combining forms are joined. esophag/o + gastr/o + duoden/o + -scopy = esophagogastroduodenoscopy Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 39

Review Question Build a term meaning “pain of the ear. ” A. B. C. D. rhinalgia rhinoalgia otoalgia Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 40

Review Question Build a term that means “an instrument to view the eye. ” A. B. C. D. opthalmoscope ophtalmscope ophthalmscope Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 41

Noun Suffixes Structure, thing -is (ex: hypodermis) Structure, thing, membrane -um (ex: endocardium) Small, tiny -icle, -ole, -ule (ex: cuticle, arteriole, venule) Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 42

Adjective Suffixes that mean pertaining to: -ac -al -ary -eal -ic -ous cardiac cervical valvular coronary esophageal hypodermic subcutaneous Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 43

Pathology Suffixes -algia -emia -itis -malacia -megaly cephaloalgia hyperlipidemia agastria tonsillitis chondromalacia splenomegaly Splenomegaly Be Careful! Don’t confuse –malacia, meaning softening, with –megaly, meaning enlargement. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 44

Pathology Suffixes -ptosis -sclerosis -spasm -stenosis hysteroptosis arteriosclerosis bronchospasm arteriostenosis Arteriosclerosis Be Careful! Don’t confuse –sclerosis, meaning hardening, with –stenosis, meaning narrowing. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 45

Pathology Suffixes -rrhage, -rrhagia hemorrhage -rrhea otorrhea Be Careful! Don’t confuse –rrhage and -rrhagia, meaning bursting forth, with –rrhea, meaning discharge or flow. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 46

Root Operations and Suffixes Definition of a root operation – the goal of a procedure Certain suffixes provide a clue as to the type of root operation. Examples: Excision = cutting out or off, without replacement, a portion of a body part (ex. –ectomy) Resection = cutting out or off, without replacement, all of a body part (ex. –ectomy) Repair = restoring, to the extent possible, a body part to its normal anatomic structure and function (ex. –plasty) Alteration = modifying the anatomic structure of a body part without affecting the function of the body part (ex. –plasty) Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 47

Procedure Suffixes -graphy -metry -opsy -scopy mammography spirometry biopsy hysteroscopy Spirometry Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 48

Procedure Suffixes -ectomy -plasty -stomy -tripsy gastrectomy rhinoplasty colostomy osteotomy lithotripsy Colostomy Be Careful! Don’t confuse –ectomy, meaning cutting out, with -stomy, meaning making a new opening, or –tomy, meaning cutting. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 49

Lithotripsy Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 50

Instrument Suffixes -graph -meter -scope electrocardiograph thermometer ophthalmoscope Ophthalmoscope Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 51

Instrument Suffixes -tome -tripter -trite osteotome lithotripter lithotrite osteotome Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 52

Specialties/Specialist Suffixes -logy -logist -er neonatology psychologist dentist polysomnographer Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 53

Specialties/Specialist Suffixes -iatry -iatrist -iatrics -iatrician psychiatry psychiatrist pediatrics pediatrician Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 54

Review Question One who specializes in the study of bones: A. B. C. D. osteiatrician osteologist osteology osteer Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 55

Prefixes modify a medical term indicating: Absence Location Number/quantity State Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 56

Prefixes Are attached directly to the beginning of the term May have more than one meaning Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 57

Prefixes aananteanti- apneic anophthalmia anteversion antibacterial Be Careful! Don’t confuse ante-, meaning forward, with anti-, meaning against. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 58

Prefixes dysendo-, endepi- dystrophy endoscopy epigastric Endoscopy Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 59

Prefixes hyperhypo- hyperglycemia hypoglossal Be Careful! Don’t confuse hyper-, meaning excessive, with hypo, meaning below, deficient. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 60

Prefixes inter- intervertebral intra- intradermal Be Careful! Don’t confuse inter-, meaning between, with intra-, meaning within. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 61

Prefixes para-, parperperipre- paraphilia percutaneous pericardium prenatal Be Careful! Don’t confuse per-, meaning through, with peri-, meaning surrounding, and pre-, meaning before. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 62

Prefixes polypostsub- polyneuritis postictal subhepatic Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 63

Review Question If a patient came in for a checkup before the birth of her baby, it was a/n _____ visit: A. B. C. D. antenatal antinatal postnatal perinatal Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 64

Review Question A patient has a rash around his nose. The physician charts it as a _____ rash: A. B. C. D. prerhinal perirhinal perrhinal polyrhinal Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 65

Singular/Plural Endings Singular vertebra arthrosis appendix arthritis phalanx endocardium digitus therapy Plural vertebrae arthroses appendices arthritides phalanges endocardia digiti therapies Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 66

Review Question The plural of pharynx (the throat) is: A. B. C. D. pharynxes pharyngies pharynges pharynxa Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 67

Categories of Terms Anatomy and physiology Pathology (diseases and disorders) Procedures (tests and treatments) Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 68

Sort These Terms into Their Correct Categories Terms 1. hysteroscopy 2. endocardium 3. gastrectomy 4. hepatitis Categories __ Anatomy and physiology __ Pathology __ Procedures Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 69

Summary of Chapter One A good understanding of medical terminology will help individuals code accurately and efficiently. An exposure to the guidelines, codes, and root operations will prepare students for a smooth transition to coding instruction. Recognizing the suffixes with I 10 compatible definitions will help students transition quickly to PCS coding. Copyright © 2015 by Mosby, Inc. , an imprint of Elsevier Inc. 70