Medical Terminology: Prefixes and Suffixes

• Medical terminology provides a standardized language for healthcare professionals
• It ensures clear communication and accurate documentation
• Anatomy is the study of the structure of the body
• Medical coding translates medical information into standardized codes
• Medical coding involves converting diagnoses, procedures, medical services, and equipment into universal alphanumeric codes for billing, statistics, and research

Basic Components of Medical Terms

• Root: The core meaning of the word
• Prefix: Added to the beginning of a word to modify its meaning
• Suffix: Added to the end of a word to modify its meaning
• Combining vowel: Usually an "o", used to connect word parts

Common Prefixes

• a-, an-: Absence, lack of
• hyper-: Excessive, above normal
• hypo-: Deficient, below normal
• dys-: Difficult, painful, abnormal
• inter-: Between
• intra-: Within
• sub-: Below, under
• super-, supra-: Above, excessive
• pre-: Before
• post-: After

Common Suffixes

• -itis: Inflammation
• -ectomy: Surgical removal
• -otomy: Surgical incision
• -ostomy: Surgical opening
• -algia: Pain
• -oma: Tumor
• -pathy: Disease
• -scopy: Visual examination
• -plasty: Surgical repair

Anatomical Terminology

• Anatomical position: Standing erect, facing forward, arms at the sides, palms facing forward
• Anterior (ventral): Front of the body
• Posterior (dorsal): Back of the body
• Superior (cranial): Towards the head
• Inferior (caudal): Towards the feet
• Medial: Towards the midline of the body
• Lateral: Away from the midline of the body
• Proximal: Closer to the point of attachment
• Distal: Farther from the point of attachment

Body Planes

• Sagittal plane: Divides the body into right and left sections
• Midsagittal plane: Divides the body into equal right and left halves
• Frontal (coronal) plane: Divides the body into front and back sections
• Transverse (horizontal) plane: Divides the body into upper and lower sections

Body Cavities

• Cranial cavity: Contains the brain
• Spinal cavity: Contains the spinal cord
• Thoracic cavity: Contains the heart, lungs, and major blood vessels
• Abdominal cavity: Contains the stomach, intestines, liver, pancreas, spleen, and kidneys
• Pelvic cavity: Contains the bladder, reproductive organs, and rectum

Integumentary System

• Skin, hair, and nails
• Protects the body from the external environment
• Regulates body temperature
• Provides sensory information
• Key terms include epidermis, dermis, subcutaneous tissue, melanin, sebaceous glands, sudoriferous glands

Skeletal System

• Bones, cartilage, ligaments, and joints
• Provides support and structure
• Protects internal organs
• Enables movement
• Stores minerals
• Key terms include: bones (e.g., femur, humerus, cranium), joints (e.g., knee, elbow), cartilage, ligaments, tendons

Muscular System

• Skeletal muscles, smooth muscles, and cardiac muscle
• Enables movement
• Maintains posture
• Generates heat
• Key terms include: muscles (e.g., biceps, triceps, diaphragm), tendons

Nervous System

• Brain, spinal cord, and nerves
• Controls and coordinates body functions
• Receives and interprets sensory information
• Key terms include: brain, spinal cord, nerves, neurons, neurotransmitters, cerebrum, cerebellum

Endocrine System

• Glands that secrete hormones
• Regulates various body functions such as growth, metabolism, and reproduction
• Key terms include: glands (e.g., pituitary, thyroid, adrenal, pancreas), hormones (e.g., insulin, estrogen, testosterone)

Cardiovascular System

• Heart, blood vessels, and blood
• Transports oxygen, nutrients, and hormones
• Removes waste products
• Key terms include: heart, arteries, veins, capillaries, blood (red blood cells, white blood cells, platelets), plasma

Respiratory System

• Lungs and airways
• Exchanges oxygen and carbon dioxide
• Key terms include: lungs, trachea, bronchi, alveoli, diaphragm

Digestive System

• Mouth, esophagus, stomach, intestines, liver, pancreas, and gallbladder
• Digests food and absorbs nutrients
• Eliminates waste products
• Key terms include: esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder

Urinary System

• Kidneys, ureters, bladder, and urethra
• Filters waste products from the blood
• Regulates fluid and electrolyte balance
• Key terms include: kidneys, ureters, bladder, urethra, nephron

Reproductive System

• Male: testes, vas deferens, prostate gland, and penis
• Female: ovaries, fallopian tubes, uterus, vagina, and mammary glands
• Enables reproduction
• Key terms include: ovaries, testes, uterus, prostate, sperm, ova

Immune System

• White blood cells, lymph nodes, spleen, and thymus
• Protects the body from infection and disease
• Key terms include: lymphocytes, antibodies, antigens, lymph nodes, spleen, thymus

Understanding Medical Coding

• Medical coding involves translating diagnoses, procedures, and services into standardized codes
• These codes are used for billing and reimbursement, data collection, and research
• Common coding systems include:
  • ICD (International Classification of Diseases) for diagnoses
  • CPT (Current Procedural Terminology) for medical procedures and services
  • HCPCS (Healthcare Common Procedure Coding System) for procedures, services, and supplies not covered by CPT
• Understanding the structure and types of characters is fundamental for accurate coding

ICD Coding

• ICD codes are used to represent diagnoses and medical conditions
• ICD-10-CM is the current version used in the United States
• ICD codes provide a standardized way to classify and report diseases and health conditions
• Understanding the structure and guidelines of ICD-10-CM is essential for accurate coding
• ICD codes can be 3-7 characters long

CPT Coding

• CPT codes are used to report medical procedures and services
• CPT is maintained by the American Medical Association (AMA)
• CPT codes are divided into categories:
  • Category I: Commonly used procedures and services
  • Category II: Supplemental tracking codes for performance measurement
  • Category III: Temporary codes for new and emerging technologies
• Knowing the CPT coding guidelines and the specific codes for different procedures is crucial
• CPT codes are typically 5 numeric characters
• Modifiers mean CPT codes can be extended

HCPCS Coding

• HCPCS codes are used to report procedures, services, and supplies not covered by CPT
• HCPCS is divided into two levels:
  • Level I: CPT codes
  • Level II: National codes for supplies, equipment, and services not included in CPT
• HCPCS Level II codes are maintained by CMS (Centers for Medicare & Medicaid Services)
• HCPCS codes are alphanumeric
• HCPCS Level II codes start with a letter (A-V) followed by four numbers

Importance of Anatomy and Medical Terminology in Coding

• Accurate coding requires a solid understanding of medical terminology and anatomy
• Coders must be able to interpret medical records and identify the correct codes based on the diagnoses, procedures, and services documented
• Knowledge of anatomy and medical terminology helps coders understand the medical context and ensure accurate coding
• Misunderstandings can lead to coding errors, claim denials, and compliance issues

Character Types

• Alphabetic characters use letters (A-Z) and are not case-sensitive
• Numeric characters use digits (0-9)
• Alphanumeric characters use both letters and numbers
• Specific code sets may restrict the use of certain alphabetic characters to avoid confusion with numbers

Coding Guidelines

• These are conventions and rules that provide specific instructions on how to select and assign codes
• Official coding guidelines are updated annually by organizations such as the American Medical Association (AMA) for CPT and the Centers for Disease Control and Prevention (CDC) for ICD
• Accurate coding requires a thorough review of medical record documentation, adherence to official guidelines, and understanding of coding principles
• Start with the Alphabetic Index to find a potential code
• Verify the code in the Tabular List
• Following all instructional notes

Character Representation

• Each character in a medical code contributes to its overall meaning
• The first character of an ICD-10-CM code indicates the broad category of disease or condition
• Subsequent characters provide more specificity regarding etiology, site, severity, or manifestation
• In CPT codes, the initial characters typically denote the section of the CPT manual (e.g., surgery, medicine, radiology), while the following characters specify the exact procedure or service performed
• HCPCS Level II codes use the initial letter to indicate the type of item or service, followed by numbers for further specification

ICD-10-CM Coding Example:

• Scenario: A patient is diagnosed with essential hypertension
• Find 'Hypertension' in the Alphabetic Index
• The index directs you to code I10
• Confirm the code in the Tabular List to ensure it matches the patient's condition

CPT Coding Example:

• Scenario: A patient has a routine office visit with a detailed examination
• Code 99214 may be appropriate
• Code 99214 indicates an established patient, level 4 office visit

HCPCS Level II Coding Example:

• Scenario: A patient requires durable medical equipment, for example, a walker
• Code A7034 may be used
• A7034 indicates a disposable liner for intermittent urinary catheter, each
• Confirm the code description matches the equipment provided