Orthopedic Coding Alert

Use these tips to better translate abbreviations into codes Do you know your APL from your ACL? If not, you may need a crash course on orthopedic acronyms. If you can't differentiate between the abbreviations in your surgeon's chart, you could be applying the wrong codes to your claims.
 
Because orthopedic coders encounter various acronyms when reading, coding and evaluating medical charts, we take for granted that we can decipher most of the abbreviations and acronyms that we come across. But even the most experienced orthopedic coder can benefit from a primer that outlines the most common abbreviations.
 
Review the following four examples and see if you can figure out what the surgeon did:

 1. Repaired EPB, APL, BR, FDS ring, FDS long, PL and FPL tendons.
 2. 85 y.o. est. pt. requires THR for AVN.
 3. CTR for dx of adv. CTS on 65 y.o. new pt.
 4. PLIF at L5-S1. The solutions: Translated into real-world terminology, the first surgeon repaired the patient's extensor pollicis brevis (EPB), the abductor pollicis longus (APL), the brachioradialis (BR), the ring finger flexor digitorum superficialis (FDS ring), the middle finger flexor digitorum superficialis (FDS long), the palmaris longus (PL), and the flexor pollicis longus (FPL) tendons.
 
In the second example, an 85-year-old established patient required a total hip replacement (THR) for avascular necrosis (AVN).
 
The third example involves a 65-year-old new patient who required a carpal tunnel release (CTR) for the diagnosis (Dx) of advanced carpal tunnel syndrome (CTS).
 
And in our fourth example, the physician performed a posterior lumbar interbody fusion (PLIF) at lumbar level five (L5) and sacral level one (S1). When in Doubt, Clarify Medical terminology developed over hundreds of years into an ever-increasing number of words and phrases. With the explosion of technologies over time and with the unfortunate explosion of new diseases, injuries and other types of illnesses came the newer and/or modified terms to deal with the various diagnoses and procedures.
 
Because of the extended disease and procedure names, physicians generated a system of communication using acronyms and abbreviations to facilitate more efficient communication among other medical professionals.
 
What is it? An acronym is a word formed from the initial letter (or letters) of words in a phrase or multi-word description. Contractions or abbreviations are shortened forms of a word or phrase, usually used to reduce the amount of time spent writing or dictating.
 
Unfortunately, in addition to being more efficient, the onslaught of acronyms has increased the possibility of error because of misunderstandings of the acronym or abbreviation. Often, the coder can discern the meaning from the usage. For example, coders would rarely confuse the -chief complaint- with -costochondral,- although physicians often document -CC- for both of these. Because of the context of their usage, [...]