AAPC CPC Prep Course - Chap 2 Notes PDF

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CPC Prep course Chapter 2 Notes

Medical Terminology and Anatomy Review Intro: ●

A thorough knowledge of human anatomy is essential to successful coding, as is the ability to understand medical terminology used to describe and document medical procedures and services

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This chapter introduces the basic elements of human anatomy and reviews medical vocabulary and terminology

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Objectives: ○

Understand the language of medicine

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Review word elements such as combining forms, prefixes, and suffixes

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Acquire an understanding of procedural and diagnostic terms

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Understand anatomy as it relates to coding

Medical Terminology ●

To code medical procedures and diagnoses accurately, you first must learn the language of medicine ○

Many medical terms used today derive from the ancient Greeks and Romans ■

EX: latin phrase - pro re nata, which means when necessary- is the origin of the medical abbreviation PRN

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The best way to learn medical terminology is by understanding word parts and elements of medical language - root words, prefixes, and suffixes - which serve as the foundation of out medical vocabulary ○

When you understand the meanings of each word part, interpretation of tens of thousands of complex medical terms becomes easier

Root ●

The base of the word is the root ○

Root words are terms standing alone as the main portion of a medical term

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A prefix, suffix, and combining vowel may accompany it

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The root word is the word part holding the fundamental meaning of the medical term, and each medical term contains at least on root or base word

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A word can have more than one root and a root may be used for different

meanings based on the body system referred to ●

Combining vowels are attached to root words to link the root word with the suffix, or one root word to another root word ○

Combining vowels also make medical terms easier to pronounce

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The most common vowels are O and I

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Occasionally, these vowels are dropped altogether, such as when the suffix being with a vowel ■

However the combining vowel is always placed between two root words, even when the second root word begins with a vowel

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Combining forms are root words with a combining vowel

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Common root words and their combining forms associated with the body systems include: ○

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Integumentary System Term

Definition

Derm/o

Skin

Dermat/o

Skin

Hidr/o

Sweat, perspiration

Kerat/o

Keratin, horny layer of skin

Melan/o

Dark, black, melanin

Onych/o

Nail

Seb/o

Sebum, sebaceous gland

Trich/o

Hair

Musculoskeletal System Term

Definition

Arthr/o

Joint

Burs/o

Bursa, sac of fluid near joint

Chondr/o

Cartilage

Erg/o

Work

Fasci/o

Fascia

Kin/o, kinesi/o

Movement

○

○

Muscul/o

Muscle

My/o

Muscle

Myel/o

Bone Marrow, spinal cord

Oste/o

Bone

Synov/i

Synovial fluid, joint, or membrane

Ten/o, tendin/o

Tendon

Ton/o

Tone, pressure

Respiratory System Term

Definition

Bronch/o

Bronchus

Laryng/o

Larynx

Pharyng/o

Pharynx

Phren/o

Diaphragm

Phrenic/o

Phrenic nerve

Pleur/o

Pleura

Pneumon/o

Lung

Pneum/o, pneumat/o

Air, gas; respiration, lung

Pulm/o, pulmon/o

Lungs

Rhin/o

Nose

Sept/o

Septum, partition, dividing wall

Spir/o

Breathing

Trache/o

Trachea

Cardiovascular System Term

Definition

Angi/o

Vessel

Aort/o

Aorta

Arter/o, Arteri/o

Artery

○

○

Arteriol/o

Arteriole

Atri/o

Atrium

Cardi/o

Heart

Phleb/o

Vein

Valv/o, Valvul/o

Valve

Vas/o, vascul/o

Vessel, duct

Ven/o, ven/i

Vein

Ventricul/o

Cavity, ventricle

Hemic and Lymphatic Systems Term

Definition

Erythr/o, erythrocyt/o

Red blood cell

Hem/o, hemat/o

Blood

Immun/o

Immunity, immune system

Leuk/o, leukocyt/o

White Blood Cell

Lymph/o

Lymph, lymphatic system

Lymphaden/o

Lymph node

Lymphangi/o

Lymphatic vessel

Splen/o

Spleen

Thromb/o

Blood clot

Thymbocyt/o

Platelet, thrombocyte

Thym/o

Thymus gland

Tonsil/o

Tonsil

Digestive System Term

Definition

Bucc/o

cheek

Chol/e, chol/o

Bile, gall

Cholangi/o

Bile duct

○

○

Cholecyst/o

Gallbladder

Choledoch/o

Common Bile Duct

Enter/o

Intestine

Gastr/o

Stomach

Gloss/o

Tongue

Hepat/o

Liver

Labi/o

Lip

Lingu/o

Tongue

Or/o

Mouth

Sial/o

Saliva, salivary gland, salivary duct

Stoma, stomat/o

Mouth

Proct/o

Rectum and Anus

Uvul/o

Uvula

Urinary System Term

Definition

Cali/o, calic/o

Calyx

Cyst/o

Urinary bladder

Glomerul/o

Glomerulus

Nephr/o

Kidney

Pyel/o

Renal Pelvis

Ren/o

Kidney

Ur/o

Urine, urinary tract

Ureter/o

Ureter

Urethr/o

Urethra

Urin/o

urine

Vesic/o

Urinary bladder

Male Reproductive System

○

○

Term

Definition

Epididym/o

Epididymis

Orchi/o, orchid/o

Testis

Osche/o

Scrotum,

Prostat/o

Prostate

Semin/o

Semen

Sperm/o, spermat/o

Semen, spermatozoa

Test/o

Testis, testicle

Vas/o

Vas deferens, ductus deferens; also vessel; duct

Vesicul/o

Seminal vesicle

Female Reproductive System Term

Definition

Colp/o

Vagine

Episi/o

Vulva

Gyn/o, gynec/o

Woman

Hyster/o

Uterus

Mast/o

Breast, mammary gland

Men/o, mens

Menstruation

Metr/o, metr/i

uterus

O/o

Ovum, egg cell

Oophor/o

Ovary

Ov/o, ovul/l

Ovum, egg cell

Salping/o

Oviduct, tube

Endocrine Term

Definition

Adren/o, adrenal/o

Adrenal gland, epinephrine

Adrenocortic/o

Adrenal cortex

○

○

Endocrin/o

Endocrine glands or system

Hypophys/o

Pituitary gland, hypophysis

Insul/o

Pancreatic islets

Parathyr/o, parathyroid/o

Parathyroid gland

Pituitar/o

Pituitary gland, hypophysis

Thyr/o, thyroid/o

Thyroid gland

Nervous System Term

Definition

Cerebr/o

Cerebrum

Cotic/o

Cerebral cortex, outer portion

Encephal/o

Brain

Gangli/o, ganglion/o

Ganglion

Gli/o

Neuroglial cells

Medull/o

Medulla Oblongata, medulla (inner section), middle, soft, Marrow

Mening/o, Meninge/o

Meninges

Myel/o

Spinal cord and bone marrow

Narc/o

Stupor, numbness, sleep

Neur/o, neur/i

Nervous system, nervous tissue, nerve

Psych/o

Mind

Radicul/o

Spinal nerve root

Somn/o, somn/i

Sleep

Special Senses Term

Definition

Blephar/o

Eyelid

Cochle/o

Cochlea of inner ear

Corne/o

Cornea

Dacryocyst/o

Lacrimal sac

Lacrim/o

Tear, lacrimal apparatus

Myring/o

Tympanic membrane

Ot/o

Ear

Phak/o, phac/o

Lens

Retin/o

Retina

Salping/o

Tube, Eustachian tube

Scler/o

Sclera

Tympan/o

Tympanic cavity (middle ear), tympanic membrane

Prefix ●

Attach a prefix to the beginning of a word to modify or alter its meaning

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Not all medical terms contain prefix

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Prefixes often indicate location, time, or number

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Some Common Prefixes include: ○

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Location Prefix

Definition

Ec-, ecto-

Out; outside

End/o

In; within

Mes/o

Middle

Dextr/o

Right

Ab-

Away from

Ad-

Toward; near

Dia-

Through; complete

Per-

Through

Trans-

Through; across

Infra-

Below

Inter-

Between

Time & Number

Prefix

Definition

Ante-

Before; forward

Pre-

Before, in front of

Pro-

Before, in front of

Post-

After, behind

Mon/o

One, single

Bi-

Two, twice

Tri-

Three

Quadri-

Four

Poly-

Many, much

Suffix ●

The term suffix comes from the Latin word subfigure, meaning to fasten underneath ○

Attach a suffix to the end of a word to modify its meaning

○

Not all medical terms have a suffix

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In medical terms, suffixes frequently indicate the procedure, condition, disorder, or disease

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Some common suffixes meaning “condition of” include -ia, -ism, -sis, and -y

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Suffixes used to show medical specialties include -ian, -iatrics, - iatry, -ics, -ist, and -logy

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Common suffixes for diseases include -itis (inflammation), -oma (tumor), -megaly (enlargement of), and -pathy (disease)

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Throughout procedural coding, you will see common suffixes used for diagnostic procedures and surgical procedures

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To code appropriately, you need to memorize these suffixes: ○

Suffixes for Diagnostic Procedures Suffix

Definition

-gram

A record of data

-graph

Instrument for recording data

-graphy

Act of recording data

-meter

Instrument for measuring

○

-scope

Instrument for viewing or examining

-scopy

Examination of

Suffixes for Surgery Suffix

Definition

-centesis

Puncture tap

-desis

Binding, fusion

-ectomy

Excision, surgical removal

-pexy

Surgical fixation

-plasty

Plastic repair, plastic surgery, reconstruction

-rraphy

Surgical repair, suture

-stomy

Surgical creation of an opening

-tome

Instrument for incising (cutting)

-tomy

Incision, cutting

-tripsy

crushing

■

Three commonly confused suffixes are -ectomy, otomy, and -ostomy

■

In most sections of the CPT code book, there are categories for incision and excision ●

Incision is a cut ○

This category is where you will find -otomy (incision, cutting) and -ostomy (surgical creation of an opening) suffixes

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Excision is to cut something out ○

This category is where you will find -ectomy suffixes

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Likewise, the suffix -rraphy (surgical repair, suture) is found in the repair subsections

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Due to Greek and Latin origins of medical terms, the conventions for changing from singular to plural endings are dictated by a specific set of guidelines, shown below ○

Plural Endings Word Ending

Plural Ending

Singular

Plural Example

Example

●

a

ae

vertebra

vertebrae

en

ina

lumen

lumina

Ex, ix, yx

ices

index

indices

is

es

prognosis

prognoses

ma

mata

stigma

stigmata

Nx (anx, inx, ynx)

nges

phalanx

phalanges

on

a

phenomenon

phenomena

um

a

serum

sera

us

i

thrombus

thrombi

Using the word parts for translation, you will find the approximate meaning of the complete medical term ○

EX: cardiomyopathy means the patient has a diseased heart muscle

○

The combining form cardio informs the reader that this word element pertains to the heart

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It can be used in combination with different word elements to relate a plethora of descriptions, illnesses, and conditions

Introduction to Anatomy ●

The human body contains multiple organ systems ○

An organ system is a collection of body parts depending on one another to achieve a mutual objective

○

The following organ systems will be addressed: ■

Integumentary

■

Musculoskeletal cardiovascular

■

Lymphatic

■

Respiratory

■

Digestive

■

Urinary

■

Reproductive

■

Nervous

■

Organs of sense

●

Eye

●

Ear

■

Endocrine

■

Hematologic

■

Immune

Anatomical Positions and Planes ●

For physicians, nurses, and other healthcare personnel to communicate accurately, they must use a standard form for body directions and orientations ○

This is achieved by using anatomical directions and planes

○

The standard body position is 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

Based on the anatomical position, the following directional terms are pertinent to medical documentation:

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○

Anterior (ventral) - toward the front of the body

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Posterior (dorsal) - toward the back of the body

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Medial - toward the midline of the body

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Lateral - toward the side of the body

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Proximal - nearer to the point of attachment or to a given reference point

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Distal -farther from the point of attachment or from a given reference point

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Superior (cranial) - above; toward the head

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Inferior (caudal) - below; toward to the lower end of the spine

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Superficial (external) - closer to the surface of the body

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Deep (internal) - closer to the center of the body

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Supine - lying face up

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Prone - lying face down

For radiological studies, the body is often cut along a flat surface called a plane ○

Frequently used planes include: ■

Sagittal - cuts through the body from front to back and divides the body into right and left sections

■

Midsagittal - cuts through the midline of the body from front to back and divides the body into equal right and left sections

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Frontal (coronal) - cuts at a right angle to the midline, from side to side,

and divides the body into front (anterior) and back (posterior) sections ■

Transverse (horizontal) (axial) - cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections

Structure of the Human Body ●

The structure of the human body is divided into four categories: ○

Cells

○

Tissues

○

Organs

○

Systems

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Each structure is a highly organized unit of smaller structures

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Cells: ○

The cell is the basic unit of all living things ■

Human anatomy is composed of cells varying in size and shape according to function: ●

Cell membrane forms the boundary of the cell

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Cytoplasm makes up the body of the cell

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Nucleus is the small, round structure in the center of the cell

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Chromosomes are in the nucleus of the cell; they contain genes that determine hereditary characteristics

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Tissues ○

Tissue is a group of similar cells performing a specific task: ■

Muscle tissue produces movement

■

Nerve tissue conducts impulses to and from the brain

■

Connective tissue co...