Internal Medicine Coding Alert

Knowledge of terms can make coding less confusing

Every medical coder knows the importance of knowing Greek and Latin roots to understand the medical prefixes and suffixes that adorn many terms.

But in addition to those roots, there are several words that will prove important to your coding efforts.

Once you have these mastered, you'll have a clearer picture of exactly what your physician is doing, and you'll be able to code it correctly.

These words include:

• Anterior -- At or near the front surface of the body.

• Avulsion -- The ripping or tearing away of a part, either accidentally or surgically.

• Benign -- With regard to neoplasms, being nonmalignant.

• Carcinoma in situ -- A localized cancer that has not spread to adjacent structures.

• Coronal -- Vertical body plane, which divides the body into front and back sections.

• Cystocele -- Hernia of the bladder into the vagina.

• Cytopathology -- Study of disease changes within individual cells or cell types.

• Debridement -- Excision of devitalized tissue and foreign matter from a wound to expose healthy tissue.

• Destruction -- Removal or ablation of tissue.

• Distal -- Farther away from the center.

• Endoscopy -- Examining the interior of a canal or hollow area in the body by using a special instrument.

• Exploration -- An active diagnostic examination, usually involving a surgical procedure, to determine conditions present within a body cavity.

• Inferior -- Below.

• Introduction -- Inserting an instrument, such as a needle or tube, into the body.

• Laparotomy -- A procedure performed through an incision (open procedure).

• Lateral -- Side.

• Ligation -- To bind or tie off.

• Malignant -- With regard to neoplasms, being locally invasive and having the properties of destructive growth.

• Medial -- Middle.

• Metastasis -- Spread of a disease process from one part of the body to another, such as secondary carcinoma resulting from tumor cells spread to a remote part of the body through the lymph or blood systems.

• Otitis media -- Middle ear infection.

• Posterior or dorsal -- At or near the back surface of the body.

• Primary carcinoma -- Cancer at the origination site with infiltration of that organ.

• Prone -- Face down or palm down.

• Proximal -- Nearer to the center.

• Rectocele -- Hernia of the rectum into the vagina.

• Sagittal -- Vertical body plane, which divides the body into equal right and left sides.

• Secondary carcinoma -- Cancer that appears in a region remote from the origination site through metastasis.

• Superior -- Above.

• Supine -- Lying with the face or palm upward.

• Transverse -- Horizontal body plane, which divides the body into top and bottom sections.

• Ventral -- Denoting a position more toward the belly surface than some other object of reference.