Orthopedic Coding Alert

Follow this advice to ensure you’re speaking the same language as your physician.

If you find yourself scratching your head when it comes to deciphering terms like TKR or TLIF, then you might need to brush up on common orthopedic acronyms. Otherwise, you could be setting up your claim for a disaster.

“So much education is available and knowing where to go for answers is critical,” says Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for Oklahoma Sports Orthopedics Institute in Norman. Even the most experienced orthopedic coder can benefit from a primer that outlines the most common abbreviations.

Good idea: “Best practices would produce a list of common acronyms used by their physicians. It is important for physicians and coders to speak the same language,” Stilley says.

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, coders can usually distinguish the meaning.

However, if the surgeon documented that he performed “SF analysis,” you may wonder whether he analyzed spinal fluid or synovial fluid. Or, you may see a radiology report that refers to “FS,” which could indicate a “fracture, simple” or may just mean that the film was shot while the patient’s forearm was supinated.

If you are ever confused by a medical acronym, always ask the physician rather than guessing, Stilley says. “I was taught early in my coding career that if you ‘don’t know what it is’ or ‘don’t know where it is’ you won’t be able to code it correctly.”

Compile Internal Acronyms

Best practice: If your office has its own internal acronyms, ask the physician to translate them and distribute the list throughout your office. Many orthopedic offices use their own “unpublished” acronyms and abbreviations that you might know but a newer staff member might not be able to figure out.

Example: A surgeon who mainly performs joint replacements might use completely different acronyms and abbreviations than a surgeon who performs a lot of trauma surgeries. One surgeon told us that he saw a chart in the emergency department with the acronym “HOHcBBB.” Hand or foot surgeons, for example, might not realize that this acronym stands for “hit on head, baseball bat,” whereas trauma surgeons might be familiar with it.

The following list may help you to define some of your surgeon’s favorite phrases, although it does not include every acronym and abbreviation that you’ll encounter. There are too many tendons, ligaments, muscles, bones, diagnoses and procedures to name, but we have left a few blank spaces at the end of the list so that if you post this somewhere in your office, you can add your surgeon’s preferred acronyms as you come across them.

Red flag: Your orthopedic physician should be very careful in his or her use of abbreviations. Many hospital organizations now have proscribed lists of abbreviations that should not be used. Notable among these is MS -- often used for morphine sulfate but which can be confused with magnesium sulfate.

Let This Chart Guide You

We polled our experts and established a list of the most frequently documented abbreviations and acronyms that orthopedic coders encounter. You can decipher your surgeon’s notes a little easier if you use this listing of abbreviations and their meanings.