CODERS' DICTIONARY 2018 - OPTUM360CODING.COM
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Coder`s Dictionary
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2018
SCoders' Dictionary
Defining medical terms from a coding
201 8 and reimbursement perspective
POWER UP YOUR CODING with Optum360, your trusted
coding partner for 32 years. Visit optum360coding.com.
TCD_TCD18_CVR.indd 1 1/12/17 3:42 AMContents
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Introduction ........................................... 1 Cardiovascular System ........................20
Contents .............................................. 1 Lymphatic System ...............................22
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Organization ........................................ 1 Digestive System .................................25
Anatomical Illustrations ....................... 2 Genitourinary System .........................27
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Abbreviations, Prefixes, Suffixe{is, and Endocrine System ...............................31
Acronyms ...................................... 2
Nervous System ..................................33
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Appendixes .......................................... 2
Eye .....................................................37
How to Use Coders’ Dictionary ............. 3
Ear and Lacrimal System ....................38
Unable to Locate a Term ...................... 4
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Abbreviations, Prefixes, Suffixes, and
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Anatomical Illustrations ......................... 5 Acronyms Table ................................... 39
Body Planes and Movements ................ 5
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Metric Conversion Tables ....................613
Integumentary System ......................... 6
An Illustration of Weight ...................613
Musculoskeletal System ....................... 7
An Illustration of Lesion Size .............613
Respiratory System .............................13
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Measures of Length ...........................614
Arterial System ...................................15
Measures of Weight ..........................614
Venous System ...................................18
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Conversions to Celsius .....................614
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© 2017 Optum360, LLC i
CPT only © 2016 American Medical Association. All Rights Reserved.Introduction
Introduction
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Congratulations on your decision to purchase the Organization
ninth edition of Coders’ Dictionary, the only medical
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dictionary designed exclusively for medical coders, Terms and Definitions
billers, and reimbursement professionals. It was The entries in the main body of the book are
created when our own clinical editors discovered organized in numeric and alphabetic order, with
traditional medical dictionaries often did not provide numeric entries preceding the alphabetic entries. The
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answers to their coding questions. Unlike more term being defined will appear in bold, at the
traditional medical dictionaries, Coders’ Dictionary beginning of the entry.
lays the groundwork for understanding medical
Compound nouns will appear in their natural
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terminology from a coding perspective, enhancing the
ability to interpret a medical record and more language order:
accurately code a claim. radiotherapy afterloading
The intention of the Coders’ Dictionary is not to rather than:
provide definitions for all conceivable medical terms,
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but instead to focus on definitions that may afterloading, radiotherapy
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confound a coder or biller. Subsequently, while a Following the bolded term will be a definition
certain basic level of medical terminology knowledge appropriate to coding and reimbursement and
is presumed of a coder, the Coders’ Dictionary is sometimes coding instructions. If the term being
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continuing to include common medical abbreviations defined is an acronym, the first words of the
and anatomical definitions particularly with the definition will provide the acronym’s actual meaning:
implementation of ICD-10. The additional specificity
inherent with ICD-10 places a greater emphasis on TCD Transcranial Doppler. Noninvasive
anatomy and physiology and including these terms ultrasound technology used to evaluate blood
can help ease a coder’s transition by allowing for flow in the major intracranial arteries. TCD done
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quick and easy reference of key anatomic terms and with contrast is performed by intravenous
common abbreviations frequently seen in medical microbubble injection, in which the bubbles
documentation. serve to enhance ultrasound signals, thereby
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producing better visualization. TCD procedures
To create Coders’ Dictionary, Optum360 coding are reported with a CPT code from range
experts generated a list of ambiguous or vexing 93886–93893.
words found in the medical record or in billing and
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reimbursement communications, in addition to Prefixes and Suffixes
standard anatomy and physiology terminology and Prefixes and suffixes used in medical terminology are
common medical abbreviations. The words may be incorporated alphabetically into the main body of the
acronyms, eponyms, or abbreviations, or they may book. These are not complete words; only the
represent generic or brand name medical devices or beginning (prefix) or end (suffix) of a word appears
pharmaceuticals. Unusual procedural, anatomical, with its meaning. Each partial word has a meaning:
or epidemiological terminology from the medical
record is also included. The goal of Coders’ Dictionary cyst- Relating to the urinary bladder or a cyst.
is to provide specific definitions and sometimes (prefix)
instructions that accommodate the narrow focus of -ectomy Excision, removal. (suffix)
the medical coder or biller. In some cases, the
definition may direct the reader to a single, specific These partial words can be put together to define a
code. In other cases, only a general clinical definition complete word:
is necessary to provide a road map to appropriate
cystectomy 1) Excision or removal of the urinary
code selection.
bladder. 2) Excision or removal of a cyst on any
anatomical site.
Contents
Coders’ Dictionary is comprised of different Prefixes and suffixes are typically not seen in medical
segments, including anatomical illustrations, the documentation as stand-alone words.
main body of alphabetically ordered terms with
coding information for ICD-9-CM, ICD-10-CM, CPT®,
and HCPCS Level II coding, and Appendixes of tables
for metric conversions.
© 2017 Optum360, LLC 1
CPT © 2016 American Medical Association. All Rights Reserved.02 TCD Abbreviations Table.fm Page 42 Wednesday, January 18, 2017 3:14 PM
Abbreviations, Prefixes, Suffixes, and Acronyms Table Coders’ Dictionary
Term Definition Term Definition
FP 1) Family planning. 2) Family hor. decub. At bedtime.
practitioner.
HPI History of present illness.
FTT Failure to thrive.
HPV Human papilloma virus.
FUO Fever of unknown origin.
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HR Heartrate.
G Gram.
Abbreviations
HRT Hormone replacement therapy.
gastro- Relating to the stomach and
Table
HSV Herpes simplex virus.
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abdominal region.
HTN Hypertension.
GB Gallbladder.
Hx History.
GDM Gestational diabetes mellitus.
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hydro- Relating to fluid, water, or hydrogen.
GERD Gastroesophageal reflux disease.
I&D Incision and drainage.
GFR Glomerular filtration rate.
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I&O Intake and output.
GI Gastrointestinal.
IBS Irritable bowel syndrome.
GID Gender identity disorder.
IBW Ideal body weight.
GLC Gas liquid chromatography.
ICD Implantable cardioverter defibrillator.
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gm Gram.
ICU Intensive care unit.
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GnRH Gonadotropin-releasing hormone.
IM 1) Infectious mononucleosis.
GP General practitioner.
2) Internal medicine.
grad Gradually; by degrees. 3) Intramuscular.
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GTT Glucose tolerance test. INF 1) Inferior. 2) Infusion.
GU Genitourinary. infra- Inferior to, beneath, under.
H Hertel measurement. INJ Injection.
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h (hora) Hour. Int. Internal.
H&H Hemoglobin and hematocrit. IOP Intra-ocular pressure. High IOP is
glaucoma.
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H&P History and physical.
IPD Intermittent peritoneal dialysis.
h.d. At bedtime.
ISG Immune serum globulin.
h.s. At bedtime.
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IU International units.
h/o History of.
IUD Intrauterine device.
H2 Histamine.
IV 1) Cranial nerve on the brainstem
H2O Water.
responsible for motor control of the
H2O2 Hydrogen peroxide. superior oblique muscle (trochlear).
HAA Hepatitis antigen. 2) Intravenous.
HAV Hepatitis A virus. IVC 1) Inferior vena cava. 2) Intravenous
cholangiogram.
HBV 1) Hepatitis B vaccine. 2) Hepatitis B
IVF In vitro fertilization.
virus.
jejuno- Relating to the jejunum (part of the
HDL High-density lipoproteins.
small intestine).
HDV Hepatitis D virus.
JODM Juvenile onset diabetes mellitus.
HEENT Head, eyes, ears, nose, and throat.
Jt. Joint.
HEV Hepatitis E virus.
JVD Jugular venous distention.
HF Heart failure.
JVP Jugular venous pressure.
HIV Human immunodeficiency virus.
K Potassium.
HOB Head of bed.
KCL Potassium chloride.
42 © 2017 Optum360, LLC
CPT © 2016 American Medical Association. All Rights Reserved.Coders' Dictionary NUBC
to a disease but has not yet contracted it. NPEP is are scientifically sound and consequential, and to assist
reported with codes from ICD-9-CM category V01. in standardizing performance measures.
Associated ICD-9-CM Code(s): V01, V01.0-V01.9 NSAID Non-steroidal antiinflammatory drug. Analgesic
NPF National provider file. and antiinflammatory drug commonly used to mitigate
inflammatory conditions. NSAIDs include aspirin,
NPI National provider identifier. Standard nine-digit
ibuprofen, naproxen, and nabumetone.
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numeric provider identifier implemented under the
Health Insurance Portability and Accountability Act of NSC Non-service connected, as noted on a veteran's
1996 (HIPAA) requirements. Providers are required to chart regarding his ailment.
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report their NPI number for electronic and paper billing. NSD Nominal standard dose.
The NPE is also used to identify the eligible professionals
NSF National standard format.
(EP) billing under the tax identification number (TIN)
NST Nonstress test.
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reported on a claim containing PQRS quality data.
Nplate Brand name for romiplostim, an injectable NSU Nonspecific urethritis. Infection and inflammation
thrombopoietin receptor agonist used to treat low platelet of the urethra, most commonly seen in males. Though
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counts (thrombocytopenia) in patients with idiopathic commonly considered a sexually transmitted disease,
thrombocytopenic purpura (ITP) who have not responded NSU can occur as a result of a urethral stricture, trauma,
well to immunoglobulins, steroids, or removal of the or spreading of another urinary track infection. A
spleen. discussion with clinicians regarding NSU is advised to
ensure coding reflects intent of documentation.
Associated HCPCS Code(s): J2796
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Associated ICD-9-CM Code(s): 099.40-099.49,
NPN 1) Non-par not approved. 2) Nonprotein nitrogen.
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597.80, 646.60-646.64, 647.20-647.24
NPPES National Plan and Provider Enumeration NSV Nonspecific vaginitis. If complicating pregnancy,
System. System that uniquely identifies a health care childbirth, or the puerperium.
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provider and assigns it an NPI.
Associated ICD-9-CM Code(s): 616.10,
NPQ Not physically qualified. 646.60-646.64
NPRM Notice of proposed rule making. Document that NSVB Normal spontaneous vaginal bleeding.
describes and explains regulations the federal
NSVD Normal spontaneous vaginal delivery.
government proposes to adopt at some future date, and
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invites interested parties to submit comments related to NT 1) Nasotracheal. 2) Nontender.
them. These comments can then be used in developing NTD Nitroblue tetrazolium dye test. Primarily used to
J-N
a final regulation. diagnose chronic granulomatous diseases. A slide is
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NPS National provider system. made and the cells are stained using the nitroblue
tetrazolium dye. Normally, the white blood cells turn
npt Normal pressure and temperature.
blue when dye is added. This means that the cells should
NPWT Negative pressure wound therapy. NPWT is
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be able to kill bacteria and protect the person from
used to promote healing of acute or chronic wounds. infections. The specimen is blood.
Associated CPT Code(s): 97605, 97606 Associated CPT Code(s): 86384
Associated ICD-9-CM Code(s): 707.00, 707.01, NTE Neutral thermal environment.
707.02, 707.03, 707.04, 707.05, 707.06, 707.07,
707.09, 707.10, 707.11, 707.12, 707.13, 707.14, NTL Near total laryngectomy.
707.15, 707.19, 998.32 Associated CPT Code(s): 31367, 31368
Associated HCPCS Code(s): A6550, E2402 NTP Normal temperature and pressure.
NQF National Quality Forum. Private, non-profit NTT Near total thyroidectomy.
voluntary consensus building organization with the goal Associated CPT Code(s): 60252, 60271
of improving the quality of health care by establishing
Nubain Synthetic injectable opiate analgesic used to
national priorities and goals for performance
relieve moderate to severe pain caused by acute or
improvement, endorsing consensus standards for
chronic medical conditions including cancer, colic,
measuring health care performance, and reporting on
certain forms of headaches, and postoperative pain. It
that performance and promoting reaching the goals via
may also be used for labor and delivery analgesia. Nubain
education and outreach programs. Endorsement by the
contains nalbuphine HCl.
NQF has become the "gold standard" for health care
performance measures and is relied on by major health Associated HCPCS Code(s): J2300
care companies, as well as CMS, to certify that measures NUBC National Uniform Billing Committee.
Organization, chaired and hosted by the American
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