Medical Coding Specialist: Introduction to Medical Coding Lessons 1

No part of this document may be reproduced or transmitted in any form or by

any means, electronic or mechanical, for any purpose, without the express

written permission of

U.S. Career Institute.

0201693TB01B-43

Acknowledgments

Editorial Staff

Trish Bowen

Elizabeth Munson

Bridget Tisthammer

Kathy DeVault

Georgia Chaney

Brenda Blomberg

Chris Jones

Joyce Jeckewicz

Stephanie MacLeod

Kelly Brown

Carrie Williams

Meloney Biggerstaff

Design/Layout

Connie Hunsader

Leslie Ballentine

Sandy Petersen

D. Brent Hauseman

FOR MORE INFORMATION CONTACT:

U.S. Career Institute

Fort Collins, CO 80525 • 1-800-347-7899

Lesson 1—The World of Health Care
Step 1    Learning Objectives for Lesson 1
Step 2    Lesson Preview
Step 3    Daily Activities in the Medical Office
A Day in the Life of the Medical Office Manager
The Doctor’s Point of View
Step 4    A Little Teamwork Goes a Long Way
Physicians
Nurses
Nurse’s and Physician Assistants
Support Staff
Emergency Personnel
Office Professionals
Step 5    Welcome to Your Career as a Medical Coding Specialist!
But Where Will I Work?
Step 6    Personal Qualities of a Medical Coder
Professionalism
Presentation
Adaptability
Step 7    Medical Records
Parts of a Medical Record
The Flow of Medical Information
Step 8    Lesson Summary
Lesson 2—Medical Insurance
Step 1    Learning Objectives for Lesson 2
Step 2    Lesson Preview
Step 3    The Life Cycle of a Medical Bill
Processing the Bill
Step 4    Insurance
Step 5    Common Insurance Terms
Provider
Claim Form
Deductible
Copayment
Reasonable and Customary
Explanation of Benefits
Electronic Claims
Step 6    Types of Health Insurance
Government Insurance
Private, Traditional Insurance

Managed Care
Blue Cross/Blue Shield
Step 7    Diagnostic Codes—A Piece of the Insurance Puzzle
How Important Is Diagnostic Coding?
Step 8    Procedure Coding—Another Piece of the Puzzle
Step 9    Looking Ahead
Step 10    Lesson Summary
Lesson 3—Introduction to Medical Terminology:
Word Parts
Step 1    Learning Objectives for Lesson 3
Step 2    Lesson Preview
Step 3    Word Parts
Step 4    Root Words
Step 5    Medical Terms
The Combining Vowel
Step 6    Root Words
The Functions of Root Words
Step 7    Pronounce Root Words
Step 8    Write Root Words
Step 9    Meanings of Root Words
Step 10    Prefixes
Step 11    Pronounce Prefixes
Step 12    Write Prefixes
Step 13    Meanings of Prefixes
Step 14    Suffixes
Step 15    Pronounce Suffixes
Step 16    Write Suffixes
Step 17    Meanings of Suffixes
Step 18    Lesson Summary
Just for Fun
Lesson 4—Medical Terminology:
Dividing and Combining Terms
Step 1    Learning Objectives for Lesson 4
Step 2    Lesson Preview
Step 3    Dividing Medical Terms
Consonants, Vowels and the Role They Play
A Little Practice
Word Meanings
Step 4    Pronounce Word Parts

Step 5    Write Word Parts
Step 6    Meanings of Word Parts
Step 7    Combining Medical Terms
Consonants, Vowels and the Role They Play
Step 8    Pronounce Word Parts
Step 9    Write Word Parts
Step 10    Meanings of Word Parts
Step 11    Lesson Summary
Lesson 5—Medical Terminology: Abbreviations,
Symbols and Special Terms
Step 1    Learning Objectives for Lesson 5
Step 2    Lesson Preview
Step 3    Abbreviations
Abbreviations in Hospitals
Office Records
Doctors
Pharmacies
Step 4    Learn Abbreviations
Step 5    Meanings of Abbreviations
Step 6    Slang
Medical Slang
English Slang
Step 7    Slang Terms
Step 8    Meanings of Slang Terms
Step 9    Symbols
Step 10    Special Terms
Eponyms
Brand Names
Acronyms
Step 11    Pronounce Acronyms
Step 12    Sound-Alikes and Opposites
Homophones (Sound-Alikes)
Antonyms (Opposites)
Step 13    Medical Plurals
Medical Rules for Plurals
Step 14    Lesson Summary
Lesson 6—Documenting Medical Records
Step 1    Learning Objectives for Lesson 6
Step 2    Lesson Preview

Step 3    Documentation—The Key Component of Medical Records
Types of Documentation
Commonly Used Narrative Formats
Step 4    The Business of Managing Medical Records
Good Recording Practices
Step 5    Lesson Summary
Lesson 7—Ethics and Legal Issues
Step 1    Learning Objectives for Lesson 7
Step 2    Lesson Preview
Step 3    Confidentiality
Guidelines for Confidentiality of Medical Records
Guidelines for Faxing Medical Records
Step 4    Medical Ethics
Step 5    Health Insurance Portability and Accountability Act
Step 6    Fraud and Abuse
Preventing Fraud and Abuse
Consequences of Committing Fraud
Step 7    Liability Insurance
Insurance Audits
Step 8    Recovery Audit Contractors
Step 9    Legal Concerns
Subpoenas
Arbitration
Medical Testimony
Step 10    Lesson Summary
Endnotes
Lesson 8—Introduction to Anatomy
Step 1    Learning Objectives for Lesson 8
Step 2    Lesson Preview
Step 3    Human Biology
What Is Human Biology?
Anatomy
Physiology
Step 4    Pathology
How Do Anatomy, Physiology and Pathology Relate to One Another?
Step 5    Beginning Anatomy and Physiology Concepts
The Anatomic Position
Planes and Sections of the Human Body
Transverse Planes and Sections

Sagittal Planes and Sections
Coronal Planes and Sections
Planes and Sections
Step 6    Location Terms
Step 7    Pronounce New Terms
Step 8    Write New Terms
Step 9    Meanings of New Terms
Step 10    Organ and Organ Systems
Respiratory System
Circulatory/Cardiovascular System
Nervous System
Muscular System
Skeletal System
Integumentary System
Endocrine System
Digestive System
Urinary System
Reproductive System
The Immune System
Step 11    Lesson Summary
Lesson 9—Anatomy: Landmarks and Divisions
Step 1    Learning Objectives for Lesson 9
Step 2    Lesson Preview
Step 3    Gross Anatomy
Landmarks and Divisions
Step 4    Pronounce New Terms
Step 5    Write New Terms
Step 6    Meanings of New Terms
Step 7    Adjective Forms for Landmark Names
Step 8    Divisions of the Abdomen
An Alternative Division of the Abdomen
Step 9    Internal Landmarks: The Body Cavities
Step 10    Membranes That Line the Body Cavities
Epithelial Tissue Membranes
Connective Tissue Membranes
Step 11    Retroperitoneal Organs
Step 12    Pronounce New Terms
Step 13    Write New Terms
Step 14    Meanings of New Terms
Step 15    Organization of the Body
Step 16    Lesson Summary

Just for Fun
Lesson 10—Cell and Tissue Anatomy and Pathology
Step 1    Learning Objectives for Lesson 10
Step 2    Lesson Preview
Step 3    Cell Components and Their Primary Functions
Cell Membrane
Cilia
Flagella
Villi
Step 4    More Cell Components and Their Functions
Cytoplasm
Step 5    The Nucleus
DNA
RNA
Nucleoli
Step 6    Pronounce New Terms
Step 7    Write New Terms
Step 8    Meanings of New Terms
Step 9    Cell Pathology
Step 10    Etiologies
Developmental Abnormality
Inflammatory Disease
Hyperplasia and Neoplasia
Metabolic Disease
Vascular Disease
Immunologic Disease
Idiopathic Abnormality
Iatrogenic Abnormality
Nosocomial Disease
Step 11    Cell Damage
Hypoxia and Anoxia
Toxic Agents
Microbial Infection
Allergic/Immune Reactions
Metabolic and Genetic Disturbances
Step 12    Cell Response
Atrophy
Hypertrophy
Hyperplasia
Metaplasia
Intracellular Accumulations

Aging
Step 13    Tissue Response
Inflammation
Repair
Damage or Death
Step 14    Pronounce New Terms
Step 15    Write New Terms
Step 16    Meanings of New Terms
Step 17    Lesson Summary
Lesson 11—Diagnostic Coding
Step 1    Learning Objectives for Lesson 11
Step 2    Lesson Preview
Step 3    History of the International Classification of Diseases
The WHO
ICD-9-CM
Step 4    Why Code?
Step 5    ICD-10
Impact for Coders
Step 6    ICD-9-CM vs. ICD-10-CM
Step 7    Lesson Summary
Endnotes

LESSON 1

The World of Health Care

Step 1 Learning Objectives for Lesson 1

When you have completed the instruction in this lesson, you will be trained to do

the following:

Explain an average day in a medical office.

List the different types of medical personnel and explain how each role

helps to ensure quality health care.

Describe your role as a medical coding specialist.

Discuss the job opportunities available in your new career.

Identify several types of medical records found in the healthcare world.

Step 2 Lesson Preview

Chances are that you’ve been to the doctor’s office and maybe even your local

hospital a few times in your life (though hopefully not too often!). You’ve seen

doctors, nurses, and office administrators hard at work in these settings, but how

much do you really know about what they do? Well, in this first lesson, we’ll

introduce you to the activities that go on in doctors’ offices.

We’ll introduce you to the activities that go on in doctors’ offices.

You’ll also see where you, the medical coding specialist, fit in! You’ll learn

about your future job duties and see how you will interact with other

healthcare professionals. We’ll also discuss a few of your many job

opportunities. Lastly, you’ll get a look at the medical records that coding

specialists handle on a daily basis.

Did you know that medical coding specialists are in demand throughout

the country because of the vast numbers of doctors and patients? More

doctors are needed now more than ever to take care of our aging

population. This is where you, the medical coder, come into play.

According to the U.S. Bureau of Labor Statistics, medical coding is one

of the 10 fastest-growing allied health occupations. Doctors need coding

specialists and are willing to pay well for the services they provide.

Well-trained medical coders make a lot of money. Medical coders often

make $35,000 per year or more. And in time, with practice, patience,

and hard work, you could earn more than $50,000 per year!

You are off to a terrific start by choosing this course as your education for

your exciting new career. In fact, the American Academy of Professional

Coders (AAPC), the renowned coding association, recognizes the

comprehensive quality of this course. This means the AAPC allows graduates

of this recommended program to waive one of the two years of coding

experience needed to become a Certified Professional Coder.

As you go through this program, you can feel confident that you are learning

from the experts. The school has been providing quality home

study

education for more than 30 years. We pride ourselves on our students’

accomplishments! People just like you are working in exciting jobs today

because of the investment they made in their education—we are here when

you need us. If you have a question, contact your instructor. It’s that easy.

Now let’s take those first steps on the path to your new career.

Step 3 Daily Activities in the Medical Office

To fully understand what a medical coding specialist does, you first must

understand how medical office personnel gather information. This information

includes patient data; insurance company information; and doctors’ procedures,

diagnoses and other actions.

To illustrate all of this, let’s take a look at a typical day in a medical office, or

an outpatient setting. (Outpatient settings include clinics, physicians’ offices,

outpatient surgery facilities and hospital emergency departments. Inpatient

settings include hospitals—or facilities where patients are admitted for an

overnight stay.) We’ll get the point of view of the first person to see patients

—the office manager or receptionist—and then we’ll look at the doctor’s

perspective.

A Day in the Life of the Medical Office Manager

Hannah is the office manager for Mercy Medical Center, a busy, family

medical clinic that has three doctors. As the first person to see patients, she

tracks them as they arrive and check in for their appointments. Today, each

doctor is scheduled to see about 15 patients. Hannah’s appointment book

contains a different page for each doctor’s schedule. Her day begins with the

8 a.m. appointments. Each doctor has a bright-and-early patient scheduled.

By 7:55 a.m., two of the three patients are in the waiting room. One is a new

patient at the clinic, and she is filling out the “New Patient Questionnaire.”

The other is an established patient.

Hannah pulls out the medical files for the established patient. The

medical files are thick, manila folders and are coded on the tab according

to the patient’s last name. She prints an encounter form or super bill for

the established patient and uses a paperclip to attach it to his folder. She

then places the files in the “Patients to See” stack for the nurse of one of

the doctors.

The new patient brings up her completed questionnaire, and Hannah spends

the next few minutes creating medical files for this new patient. Hannah

makes a new folder for the patient, labels it appropriately and places a copy

of the questionnaire in it. Then she takes the original questionnaire and types

the information from it into her computer. This creates two files for the

patient—one in the computer and one on paper. After Hannah has entered

the information about the patient into the computer, she prints an encounter

form or super bill. She then clips the encounter form to the appropriate folder

and places it in the “Patients to See” stack for the appropriate nurse.

It is now 8 a.m., and one appointment has yet to arrive. At 8:04 a.m.,

Hannah receives a call from the missing patient. He is having car trouble and

can’t make it today. Hannah assures the man he can reschedule. She sets up

a new appointment for him and logs it into the doctor’s appointment book. By

8:06 a.m., both of the other appointments are back in the examination

rooms. The 8:15 a.m. appointments begin to arrive. The routine is similar to

the first group of patients except that this time all three appointments arrive.

They all are established patients, so Hannah pulls their files, prints out

encounter forms, and distributes the folders to the correct nurses.

Medical office managers handle multiple tasks.

At 8:10 a.m. the first doctor is finished with his 8 a.m. appointment—

a man named Jim Burgess. Mr. Burgess walks out of the examination

room and gives the encounter form or super bill to Hannah.

Hannah looks at the procedures that the doctor circled and quickly fills in

an amount next to each one. She totals the bill—$187.50—and has Mr.

Burgess sign it. At Mercy Medical Center, most patients are covered by

insurance. In Mr. Burgess’s case the medical office will send the bill to the

insurance company without him paying an initial copayment or the entire

amount of the bill. Therefore, Mr. Burgess signs the bill to give the

insurance company permission to pay the clinic directly and returns it to

Hannah. She rips off the back copy for him.

As Mr. Burgess picks out a lollipop from the basket on the counter, Hannah

quickly files the completed and signed encounter form in her “To Submit,

Current” folder. The nurse has returned Mr. Burgess’s file, so Hannah puts

it in the “To Be Updated” basket. The folders in this basket are waiting for

the doctors’ dictation to be transcribed. Just then the telephone rings. It is

Mercy Medical Center’s medical transcriptionist calling to verify a patient’s

information. Hannah explains she will have to look up that information and

call the transcriptionist back.

Hannah’s day continues this way until she leaves at 5 p.m. During that time,

she continually checks in patients, enters new questionnaires on the

computer, creates files, retrieves files, completes encounter forms, answers

the telephone, and schedules and reschedules appointments.

Now let’s look at the same day’s events from a physician’s perspective.

The Doctor’s Point of View

Dr. Green is one of the physicians for whom Hannah works. He sees his

first patient at 8 a.m. He examines the patient, a woman in her mid-30s,

and determines the cause of her ailment. Dr. Green’s patient has a broken

arm. When she sees Dr. Green, he listens while she tells him what’s wrong

—this is called the chief complaint. Then Dr. Green looks at her arm and

recommends that x-rays be taken. Finally, since the x-rays show a

fracture, Dr. Green puts her arm in a cast.

This sequence began with a chief complaint—“my arm hurts”—and was

followed by a diagnosis aided by tests—a broken arm as seen on the x-

ray. The sequence is completed with a treatment or procedure—the

fracture care. Doctors perform one or more of these steps with every

patient they see.

Doctors perform many steps when they see patients.

And every time a doctor or nurse performs these duties, the steps must

be recorded into the patient’s history, which is a folder usually called a

chart. The diagnosis and treatment or procedure, along with any tests

done, eventually are coded by you, the medical coding specialist! You will

learn all about coding diagnoses, tests, and treatments as you move

through this course. For now, you just need to understand where you will

gather that information.

After Dr. Green examines the patient, he records some notes about the

encounter. The office’s medical transcriptionist will use this dictation to

transcribe the encounter into a formatted medical report. Dr. Green also

makes some notes on the patient’s history or chart. Now, he is ready to see

his second patient.

Please pause and complete online Practice Exercise 1-1.

Step 4 A Little Teamwork Goes a Long Way

Now you know how information flows in medical settings. You have a basic

understanding as to what some healthcare employees, such as office managers

and doctors, do in a typical day in a medical office. But before we talk about your

role in the healthcare team, let’s identify some of the key players in hospitals and

doctors’ offices and elaborate on what they do.

In most professions, teams of people work together to accomplish goals, and

this is true of physicians as well. In medicine, doctors certainly cannot

perform their jobs alone. Many people work hard, some behind the scenes,

others more visibly, to ensure that the healthcare system runs properly.

When you go to see the doctor, you don’t just see the doctor. You might see

a number of professionals, including a receptionist, an office manager, and a

nurse. Throughout a visit, a doctor may talk to several staff people, including

the medical coding specialist. All of these people are essential members of

the medical care team.

All of these people are essential members of the medical care team.

Physicians

Physicians or doctors are the most prominent members of the medical

care team. They perform life-saving procedures. They cure the sick and

help heal wounds. Becoming a doctor of medicine is one of the most

challenging career paths a person can choose. Not only do doctors earn

four

year college degrees, but they also must complete medical school

and one or more residency assignments. During residency, 85- to 100-

hour work weeks are common. Because of this huge commitment,

doctors deservedly receive much of the attention in the medical field.

Physicians diagnose illnesses and injuries. They prescribe drugs to alleviate

symptoms, treat conditions, and ease pain. They rely on their training to

make quality, accurate decisions. However, as good as physicians are, their

staff ultimately supports them as they provide quality treatment. Nurses are

one essential part of the medical staff.

Nurses

Nurses can give injections.

As professionals who perform a variety of tasks in the medical world, nurses

often must follow through with treatments physicians prescribe. Nurses can

give injections and check a patient’s vital signs, as well as assist in surgery.

It’s also true that nurses must often do the thankless jobs—cleaning up exam

rooms and organizing supplies.

Without nurses, the number of patients a doctor sees in a day would drop

dramatically. Because of their nurses, doctors see more patients and are able

to focus on those patients who require the most care.

Nurse’s and Physician Assistants

Two other categories of personnel in the medical field are nurse’s and

physician assistants. Nurse’s assistants, or nursing aides, help nurses with

daily duties, such as paperwork, general organization and taking a patient’s

temperature, weight, and blood pressure. Some nurse assistants also talk to

patients and make sure they’re comfortable.

Physician assistants or PAs normally are under the supervision of a

doctor, and can perform some of the same functions as a doctor. PA duties

might include stitching up a cut, taking a patient history, and even

performing lab work.

Support Staff

Doctors and nurses rely heavily on support staff to keep a medical office or

clinic running smoothly. As you might guess, each of these positions plays an

important role in the medical world.

Medical Billing Specialists

Medical billing specialists are a perfect example of how interrelated one job is

to the next in a medical office. Remember, coding specialists code what

occurs during a patient’s medical visit, while medical billing specialists use

the codes that a medical coder assigns. Billing specialists then complete the

insurance forms necessary to collect payment from the insurance companies.

These specialists know that the doctor doesn’t get paid unless the form is

completed and filed correctly. Billing specialists have training in medical

terminology, medical records handling, and some basic coding.

Medical Transcriptionists

Do you remember when the doctor in our previous example recorded some

notes about a patient encounter? Well, a medical transcriptionist who

listened to the doctor’s dictation typed what she heard. This then was added

to the patient’s medical record. By using transcriptionists, doctors save time

by speaking their notes.

Medical transcriptionists type the doctor’s dictation.

While you don’t need to know every aspect of medical transcription, you

should be aware as to what transcribed reports look like. As a medical coder,

you often will work from these transcribed reports. Two examples of

transcribed reports follow: one for Laura Brown and one for Johnny Cruz.

Study these reports so that you have a better understanding of a

transcriptionist’s role in the medical records process.

Transcribed Report Example One

Name: Laura Brown

#030311

PROBLEM

Upset stomach with vomiting and fever.

SUBJECTIVE

The patient is a 22-year-old female. She went to breakfast with her friends earlier this

morning. She ordered a cream-filled pastry with her coffee. She stated that no one else had a

pastry. About 4 hours later, she started having an abrupt onset of nausea, vomiting,

abdominal cramps, diarrhea, headache and a slightly elevated fever. Since she had the

symptoms for over three hours, she called her family physician and was able to see him this

afternoon.

OBJECTIVE

Physical examination reveals a well-developed, well

nourished female in acute distress.

Blood pressure: 125/85. Temperature: 99.6 ˚F. Pulse: 88. Respirations: 24. Chest is clear.

Cardiovascular examination: Regular rate and rhythm. Abdomen: Positive bowel sounds.

Diffuse tenderness with slight pain. Laboratory results indicated a slightly elevated white

blood cell count. Abdominal x-ray: Normal.

ASSESSMENT

Staphylococcus toxin gastroenteritis.

PLAN

The patient was sent home and told to get plenty of bed rest and begin clear fluids when

nausea and vomiting cease. If the symptoms continue for more than 3 more hours, she should

contact the office.

_________________________________

Robert Snow, MD

D:02-08-20xx

T:02-08-20xx

RS:CJL

Transcribed Report Example Two

Name: Johnny Cruz

#030315

PROBLEM

Sore throat with fever.

SUBJECTIVE

Johnny, a 5 year old, presents to his pediatrician with a sore throat, fever, loss of appetite

and a headache. His mother said that he has been on the couch all morning and refuses to

eat or play.

OBJECTIVE

After examining the patient, the doctor reports enlargement of the lymphatic glands and a

temperature of 103 ˚F. The oral exam reveals a swollen, bright-red throat. A throat culture is

postitive for strep throat.

ASSESSMENT

Acute follicular pharyngitis.

PLAN

Take erythromycin as directed. Temperature to be taken frequently. Children’s Tylenol every

4-6 hours as needed for fever. Encourage bed rest, modify activities and increase fluid

intake. All citrus juices should be avoided until symptoms subside. Call office if symptoms

persist.

_________________________________

Marikit Makabuhay, MD

D:09-15-20xx

T:09-15-20xx

MM:BDD

Medical Record Technologists

Certified medical record technologists control the flow of medical

records to the various people who need to see those records. These

technologists take a certification test that ensures they have the knowledge

to determine what records are needed, who is authorized to see the records,

and how these records are organized. You may find that medical record

technologists, who are certified, are also called Registered Health

Information Technicians or RHITs.

Emergency Personnel

Emergency personnel are a group of professionals with the sole responsibility

of providing immediate medical assistance and transporting the patient to the

hospital for treatment. When someone is hurt and needs an ambulance,

these people respond. Police officers, firefighters, and other rescue

professionals all have some level of medical training.

EMTs can be ambulance crew members.

You probably have heard of emergency medical technicians (EMTs) and

paramedics. EMTs take classes that enable them to stabilize patients who

have a wide variety of emergency medical conditions. They often are

members of ambulance crews and volunteer firefighting organizations.

Paramedics have more training than EMTs. Paramedics are not only able to

stabilize patients, but they can begin treatments to cure patients, such as

administering medication.

Office Professionals

Do you remember Hannah, the office manager from our previous example?

Hannah is an example of an office professional. Without office managers and

receptionists, many medical offices would grind to a halt! These people

organize schedules, record appointments, and answer patient questions.

Office staff members have terrific communication and organization skills.

They also must make a good first impression. The office manager may be the

first person a patient sees upon entering a medical office, and the manager’s

attitude can mean the difference between a pleasant visit and a nightmare

for the patient.

Please pause and complete online Practice Exercise 1-2.

Step 5 Welcome to Your Career as a Medical Coding

Specialist!

Now that you know the job duties of many of those in the healthcare world, let’s

talk about the role that you, the medical coding specialist, will play in the

healthcare picture. From the scenario you read at the beginning of this lesson, you

know that you will be responsible for assigning medical codes to the information

obtained from a patient’s visit to a medical facility. As the coding specialist, you get

the medical record the physician dictated that we talked about previously. You look

over the complaint, the diagnosis and the treatment performed, and then you code

appropriately. To code, you look up the information in a reference book and find

the right set of numbers that describes exactly what occurred.

You can code at home or work in a doctor’s office or hospital, and some

doctors use independent coding specialists. In fact, there are even companies

that hire coding specialists across the country. These remote coders work

online in distant locations, and the company finds work for them to code. So

much depends on where and when you want to work. What’s exciting is that

you’re in control—just as you are in this course, working toward your new

career!

As you already know, medical coding specialists are in demand. Just by

looking at the number of patients doctors see every day, you can imagine

how many coders are needed. Every appointment needs a code attached!

Experienced medical coding consultants can earn impressive salaries.

Surveys indicate that many medical coding specialists earn $35,000 per year

or more. In fact, some medical coding consultants make more than $100,000

per year. Of course, you shouldn’t expect to make $100,000 your first year.

But with work and dedication, you can earn a tremendous salary in a short

time.

But Where Will I Work?

Someone with the knowledge you’re gaining in this course will not be limited

to simply filling out forms. No, the world of medical coding is very diverse

and, as you already know, it offers full- or part-time job opportunities, at

home or in offices.

Medical Coding Specialist

Mercy Medical Center is looking for a part-time Medical Coding Specialist to accurately assign codes to records.

One year of coding experience is preferred, but those who can show they have real-world training in medical

coding also will be considered. Mercy Medical Center is an equal opportunity employer.

Please send cover letter, resume and references to:

Mercy Medical Center

111 Main Street Suite 1

Avery, Ohio 44444

Find Your Future as our Next Medical Coder!

Hart Family Practice is looking for a full-time medical coder to code medical records. Applicant must have

knowledge of medical terminology, anatomy and medical codes. The position offers a generous benefit

package, and salary is based upon experience. EOE

If interested in applying, please send a cover letter and resume to:

Hart Family Practice

222 Skinner Road

Pittman, Louisiana 23232

Medical coding specialists no longer are restricted to the doctor’s office but

now work in hospitals, pharmacies, nursing homes, mental healthcare

facilities, rehabilitation centers, insurance companies, consulting firms, health

data organizations, and their homes. And remember, if you decide you want

to work at home, you set your own work schedule and save on items such as

child daycare and transportation. So how is it possible that one career offers

so many choices? Let’s take a closer look at two different jobs available to

you in this career.

Medical Coding Specialist

A coding specialist typically works in an office or hospital. In some cases the

physician assigns the code, and the coding specialist simply verifies that

these codes are consistent with what the physician has documented. In other

cases the doctor does not assign codes. Instead, the medical coding specialist

translates the doctor’s written diagnosis and treatment into codes. Then the

coder often routes the codes to a medical billing specialist who sends the

claim to the insurance company.

Medical coders apply codes for x-rays.

For example, a medical coder working for a radiologist might have a super bill

indicating a patient came in for a broken finger, as well as transcription

documenting how the x-ray was performed and the radiologist’s reading of

the x-ray. The medical coder would apply the correct codes for the diagnosis

and the procedure, and the medical billing specialist then would send these

codes to the insurance company.

The Medical Coding Service

A medical coding service is the most common at-home employment

opportunity for a medical coding specialist. Medical coding service

providers use a computer to complete the necessary forms and submit them

to the office manager or medical billing specialist. Typically, the self-

employed medical coding specialist charges by the medical record and has

more than one provider as a client.

The work of an independent medical coder doesn’t vary much from that of

those who work in offices and hospitals. The biggest difference involves how

the work gets to and leaves the medical coding specialist. If the coding

service does work for local providers, the work could be picked up and

dropped off every 24 to 48 hours. The medical coding specialist simply takes

the information home, codes it and then returns it to the physician’s office. If

the physician is having his transcription done online, he is set up for online

communication of all work. The coding work can be exchanged online. The

great thing about this route is the medical coding specialist isn’t limited to

clients in her town or even state!

If you’re going to do your medical coding work from home, there are several

items to consider. You’ll have to purchase equipment and set up a home

office, as well as market yourself to find clients. Consult the Medical Coding

Specialist Career Starter Kit included in this course for more guidance in

setting up a home-based business. For now, let’s talk a bit about the personal

qualities that medical coding specialists should possess.

Step 6 Personal Qualities of a Medical Coder

If you think about it, there are a large number of potential clients available in most

towns. Even small towns usually have one or two doctor’s offices and a hospital.

Many times qualified help is hard to find, and because you have a skill that is in

great demand, you have the opportunity to make good money. Though salaries

vary depending on experience, the number of hours worked, and location, we think

you’ll be pleased to discover the amount of money you can earn as a medical

coding specialist. And remember that as your experience builds, you can add to

your earnings while being a vital part of a medical team and doing work that helps

people.

As a part of the healthcare team, medical coders do much of their work

alone; however, coders still are a vital part of that team. The main

thing to remember when you approach a potential client or employer is

that you are the best medical coding specialist for the job. Your

competence means money—their livelihoods—to your employers!

Coders should remember and practice three qualities: professionalism,

presentation and adaptability.

Professionalism

As with any business, the

image you project

is important.

Professionalism is the conduct, aim or qualities that characterize a

profession or a professional person. As with any business, the image you

project is important. You must be professional. This includes how you dress,

talk, and interact with your clients. When you have an initial meeting with

potential clients, your level of professionalism will affect their impression of

you.

When you select what to wear, be conservative but not bland.

When you select what to wear, be conservative but not bland. Your attire

should be clean, wrinkle free and professional. Try to choose something you

feel comfortable wearing. If you are comfortable, you will be able to

concentrate on other important things such as your presentation and

answering any questions your potential client may have. An uncomfortable

outfit, whether in style, color or both, will distract you.

Another facet of professionalism is delivering what you promise. You’ve

probably heard the saying, “Five minutes early is 10 minutes late.” Basically,

this means if you have a meeting at 10 a.m., be 15 minutes early. Never be

late, especially for a first-time interview. Such promptness shows you are

responsible and considerate. If your client is a little late, be understanding.

Just make sure you aren’t the tardy one. When you are asked for work

samples, be prepared. Explain what you know and how you gained your

knowledge. If you ever are asked to complete a test task, do so promptly.

Presentation

Presentation is the act of bringing or introducing something into the

presence of someone else. Often your initial presentation will decide whether

you gain a client or employer. In addition to being on time and dressed

properly for the meeting, your presentation can go a long way in influencing

your client-to-be—both positively and negatively.

Be sure to present a confident image. Your attitude should say, “I know what

I’m doing” without being arrogant or condescending. Remember, this is the

client’s money you’re talking about. Confidence is a must!

Adaptability

Adaptability is the ability to be modified or changed. To be successful,

you must be able to adapt for each client. Some people want tasks done

a certain way. Others may have exactly the opposite requirements.

Insurance regulations change. Forms are altered. If you get too set in

your ways, you might lose clients who require slightly different

approaches.

Step 7 Medical Records

We’ve all had experiences with a doctor’s office. You’ve probably been asked to fill

out a new patient questionnaire in a doctor’s waiting room, or maybe you’ve called

to reschedule a dentist appointment. But you may not be familiar with the contents

of a medical record. Let’s clear up some of these mysteries. As a coder, you’ll

become a pro at explaining these contents.

A medical record is generated when a patient receives medical care. This

record usually begins its life as a questionnaire or patient data sheet—like

the one the new patient filled out in our example. The questionnaire asks

about a patient’s medical history, insurance coverage, and other important

facts. After the patient completes the form, the office administrator takes it

and any applicable insurance information and enters all of this into the

office’s database, either on a computer or manually in a file cabinet. Then a

medical file or record is created.

What is a medical record?

The medical record contains all of a patient’s medical history related

to that doctor and his office. The medical file includes charts, notes, and

information to identify the patient, support the diagnosis or reason for

the appointment, justify the treatment, and accurately document the

results. The record also contains past and present illnesses and

treatments. Every aspect of a patient’s treatment at a healthcare facility

is documented in this file. In other words, the medical record provides a

complete picture of the health care the patient has received.

Parts of a Medical Record

The most common parts of a medical record include: The patient

questionnaire, registration/admission form, consent for treatment form,

patient history form, plan of treatment form, and progress report form. Let’s

take a moment to discuss each of these briefly, as well as look at a few

examples.

Questionnaire

A medical record is generated when a patient receives medical care. This

record usually begins its life as a questionnaire or patient data sheet. The

questionnaire asks about a patient’s medical history, insurance coverage

and other important facts.

Let’s take a look at an example questionnaire.

Registration/Admission

The registration/admission form is used to record important information,

such as the patient’s name, address and insurance information. This form

may be completed every time a patient sees the provider, or the practice

may keep one on file and update it as necessary.

Consent for Treatment Form

Whenever a patient agrees to a suggested treatment, the patient must

complete a consent for treatment form. The consent for treatment form

includes a statement indicating the patient has been informed of the

treatment plan, including possible side effects and negative outcomes. The

patient signs the form, indicating agreement to the treatment and awareness

of all possible consequences resulting from the treatment.

Patient History

When a patient sees a provider for the first time or hasn’t seen a

particular doctor for a long period of time, the patient is asked to fill out a

patient history form. The patient history contains critical questions

regarding the patient’s health history. The patient’s responses to these

questions enable the doctor and medical staff to give the patient the best

possible care.

Plan of Treatment Form

The doctor records the orders given to the patient regarding treatment on the

plan of treatment form. In our example, the physician’s instructions are for

discharging the patient. Completion of this form helps establish a plan for

recovery and provides the patient with clear instructions to follow.

Progress Report Form

As a treatment plan moves along, or as a patient’s condition changes, the

information is recorded on the progress report form. Providers use this

form to chart changes of all kinds in their patients’ conditions. Changes can

include worsening conditions as well as improvements. Every patient has a

progress report form.

The Flow of Medical Information

Doctors, nurses, and other health professionals use the medical record

to provide patient information for the different segments of the patient’s

care. The record helps the various practitioners involved in treating the

patient to communicate with one another. It’s not necessary for a

doctor to individually speak with each healthcare professional. The

medical record keeps the current healthcare providers abreast of the

patient’s treatment and progress. In addition, the record depicts for

future providers an accurate picture of the patient’s previous care. It

enables one doctor who takes over for another to continue to treat the

patient without interrupting care.

Another important use of the medical record is for reimbursements. The

patient’s file supplies information so the patient and third-party payers

can be billed for services and expenses. The medical record

substantiates laboratory tests, medications, and other services listed on

an insurance claim.

The medical record serves other purposes as well. It’s a legal business record

for the healthcare provider. It gives the patient documentation with which to

make legal claims—for example, the extent of injuries from an auto- or

work

related accident. The record can be used to analyze and review the

quality of patient care. It also can be used for research and education and for

healthcare facility planning and market research. And medical records help

determine problems that the healthcare delivery system needs to address,

such as increases in the occurrence of heart disease or breast cancer.

Medical records first were kept in hospitals. Now, virtually every healthcare

provider maintains such records because complete files are necessary to

verify medical expenses, validate the healthcare provided, and meet

government requirements. Although different types of healthcare providers

maintain medical records, all records still are patterned after the hospital

medical record. The format used, and the information recorded in each record

is similar from one facility to another. The box that follows summarizes the

purpose of the information that medical records provide.

Medical Records:

• Identify the patient

• Record results of tests and treatments

• Justify diagnoses and treatments

• Offer information to all providers involved in the patient’s care

• Detail the patient’s previous care for future providers

• Maintain a record of services for billing third-party payers

• Provide the healthcare facility with a legal business record

• Provide tools for evaluating patient care

• Provide documentation for study and research

• Give healthcare providers data for planning delivery of services and

marketing

Please pause and complete online Practice Exercise 1-3.

Step 8 Lesson Summary

Medical coders are an important part of any medical setting, and the scenario at

the beginning of this lesson showed you how information flows through such

settings. This lesson also gave you a firm understanding as to what each member

of the healthcare team does. Coders work with physicians, nurses, office managers,

and others to contribute to the best possible patient care. You learned that this

care occurs in a three

part sequence: chief complaint, diagnosis, and treatment.

The diagnosis and treatment eventually are coded by you, the medical coding

specialist!

We also discussed a few important points for you to remember as you move

toward your new career. You learned about possible employment

opportunities and settings. You also learned the importance of

professionalism, presentation, and adaptability.

Lastly, this lesson discussed medical records. The medical coding specialist

works closely with medical records to assign the correct codes for the

diagnosis and procedure determined during a patient visit. The accuracy of

the codes determines correctly completed insurance forms, thereby obtaining

the proper reimbursement for the doctor.

As you continue this course, you’ll see in greater detail just how important

medical coding specialists are to those who work in and rely on medical

facilities. Medical coding specialists are in demand! The entire field is

expected to grow by more than 46 percent, and the projected growth for

those coders working directly for physicians is 94 percent! By choosing this

course, you have started on an exciting path toward success.

LESSON 2

Medical Insurance 101

Step 1 Learning Objectives for Lesson 2

When you have completed the instruction in this lesson, you will be trained to do

the following:

Explain how insurance works.

Define the terms common to most insurance carriers.

List the types of insurance programs available today.

Discuss how diagnostic and procedure codes apply to insurance.

Determine the basics of filing electronic claims.

Step 2 Lesson Preview

Most people in America qualify for some sort of medical insurance. In addition to

the various government programs available, hundreds of private companies also

provide medical insurance. Fortunately, a few common threads tie all insurance

companies together, for example, the terminology used and the forms required.

These common threads make the medical coding specialist’s job easier.

A few common threads tie all insurance companies together.

It is important to understand medical insurance concepts. With this

knowledge you will be able to communicate effectively with medical billing

specialists. You will work closely with them to secure the highest

reimbursement for the provider’s services. This is why medical coders are a

vital part of the provider’s support staff.

Additionally, the codes you use play a very important role in health data and

research. Did you know that medical codes help track diseases—and cures—

in our country? These codes are entered into a national database, which is

tracked by health researchers. Much government funding for cancer, AIDS,

and other diseases comes from the codes that you will assign. Not only are

you helping health care providers, but your coding work advances research

and treatment development of many illnesses.

In this lesson we will introduce you to the language of the insurance

world. After that, we’ll move into the different programs available. You’ll

be introduced to the various insurance programs. There are government

insurance programs such as Medicare and Medicaid, the managed care

approaches of health maintenance organizations and preferred provider

organizations.

This lesson will introduce two important concepts—diagnostic coding and

procedure coding—and you’ll learn how these codes relate to medical

insurance. And we’ll discuss electronic claims. Chances are you already know

a little about these terms and programs. If you don’t, fear not! We’ll cover

them here. So let’s get started!

Step 3 The Life Cycle of a Medical Bill

You’ve just started the medical bill’s life cycle.

Let’s first review a little about what you learned in the first lesson. Imagine you are

a patient at a doctor’s office. This is the first time you’ve been to this particular

doctor. When you check in with the front desk, the office manager hands you a

questionnaire to complete. This form asks for your name, address, telephone

number, medical history, and insurance information. After you complete the form,

you give it back to the receptionist. With this process, you’ve just started the

medical bill’s life cycle.

Now the office manager enters your information into the computer. The

computer might then produce a patient encounter form, also known as the

super bill. Remember, this is a standard form that contains a list of the most

common procedures the doctor performs at that office. An encounter form

typically lists many types of procedures and diagnoses, such as office visits,

physical exams, x-rays, blood tests, and common illnesses or conditions.

Based on the information you provided on the questionnaire, the computer

prints your name, billing address, insurance company, and policy number on

the encounter form. When you go back to the examination room, your

encounter form is part of the medical file the doctor works with as she

examines you.

When your examination is complete, the doctor circles on the encounter form

the procedures she performed. Usually, more than one procedure is involved.

For example, the doctor might circle the physical exam—new patient

procedure and the x-ray—lower leg procedure if you had to have x-rays

taken. The circled items let the office manager know what to charge you or

your insurance company for your visit. This form is now your bill.

After the bill is created, the next step in its life cycle is processing. Let’s look

at the details involved in that step.

Processing the Bill

Once the medical bill exists, it goes through several steps on its way to being

paid. A patient and medical facility handle bills for medical care in one of

three common ways:

The insurance company might require the patient to pay the entire bill at the time of service.

1. The insurance company might require the patient to pay the entire bill at

the time of service, before the patient leaves the medical facility. Then the

patient submits a claim to the insurance company for reimbursement.

2. The patient might pay a copayment—a flat amount, such as $10,

determined by the patient’s insurance policy—before he leaves the doctor’s

office. Then the doctor’s office submits a claim to the patient’s insurance

company for the remainder of the bill.

3. The patient might pay nothing at the time of the visit to the doctor’s office.

Following the patient’s visit, the medical facility submits a claim to the

patient’s insurance company for the bill. The doctor’s office is reimbursed

by the insurance company for the charges the patient’s insurance policy

covers. The doctor’s office then sends a bill to the patient for the remaining

costs that the insurance doesn’t cover.

How a medical bill is processed varies slightly depending on whether the

patient pays the bill before or after the insurance company pays its portion. If

the patient must pay the entire bill on the day of the treatment, then it also

is up to the patient to send the bill, together with a completed claim form, to

their insurance company. The insurance company then will pay the patient for

whatever charges the insurance covers. For example, if the bill is $100 and

the insurance policy pays 80 percent of those charges, the patient will be

reimbursed for $80 from the insurance company, leaving the out

of pocket

cost for the bill at $20.

If the doctor’s office bills the insurance company first, then the patient can

leave the office either without paying any of the bill or after paying only the

copayment. The insurance company receives the doctor’s request for

payment and pays the covered amount to the doctor’s office. So if the bill

was $100, and the insurance policy covered 80 percent of that, then the

insurance company would pay the doctor $80. The doctor would bill the

patient for the other $20 or for the difference between the $20 and what the

patient already paid as the copayment.

When the insurance company pays for services, whether it pays the patient

directly or pays the doctor’s office, it is reimbursing the patient or the office.

Reimbursement is the process of paying someone back for services already

performed or payments already made.

This entire process—from the initial questionnaire completed in the doctor’s

office all the way through reimbursement—represents the life cycle of the

medical bill. As you’ve probably guessed, a big part of the medical bill’s life

cycle has to do with the insurance part of the process.

Step 4 Insurance

Medical insurance is a contract between an insurance company or carrier and an individual or a group.

In the first lesson we talked briefly about how the medical codes you assign are

sent to insurance companies so that doctors can be paid. But what exactly is

insurance? Well, the terms medical insurance, health insurance, health care

coverage or some other similar phrase all refer to the same thing. Medical

insurance is a contract between an insurance company or carrier and an

individual or a group—the insured. This contract or policy states that in the case of

certain injuries or illnesses, the insurance carrier will pay some or all of the medical

bills of the insured.

In exchange for this coverage, the insurance carrier collects payments or

premiums from the insured. Premiums are paid in advance—they are paid

monthly, quarterly, semi-annually or annually, depending on the contract

between the carrier and the insured. When an insurance carrier pays for

medical treatment, it pays benefits.

It seems like insurance companies pay out lots of benefits, right? Well,

typically the insurance carrier collects premiums from many people and only

has to pay benefits to relatively few. Therefore insurance companies are

generally profitable and are able to provide their services. Every insurance

company requires an itemized list of procedures, pharmaceuticals, and other

materials before they pay benefits. Every procedure and pharmaceutical has

its own code. This is where you, as a medical coding specialist, enter the

picture. You know from what you read in the previous lesson that you must

code what happens during each patient’s visit. When you’ve completed this

course, you will be able to accurately assign diagnostic and procedure codes

for outpatient services.

But first you need to know the language insurance carriers and medical

coding specialists use to communicate. In the next section, you will learn

some of this language.

Step 5 Common Insurance Terms

Liz is an office manager for Dr. Grant. She is great at making appointments and

keeping track of patients. Yesterday, Dr. Grant’s insurance specialist was out sick,

and Dr. Grant asked Liz to check on some insurance information for him. He asked

her to compare the explanation of benefits for three different patients and see how

much each patient needed to pay. Then he asked if any of the three had a

copayment not yet made. Finally, he asked Liz to check the explanation of benefits

to see whether any of the three patients had met deductibles yet.

Liz understands English very well, but these questions all sounded like another language to her.

Liz understands English very well, but these questions all sounded like

another language to her. She dug through some insurance forms, but she

didn’t have a clue about any of the items Dr. Grant had requested. Finally,

she gave up and asked Dr. Grant to wait until the next day when the claims

specialist returned.

Imagine you were Liz. Could you ask someone from an insurance company

questions—and understand the answers? In this section, you will study some

basic insurance concepts that will help you function intelligently when you

come across insurance terminology in your medical coding work. Let’s review

some of the most frequently used terms and what they mean.

Provider

The provider is the person or organization that provides medical services.

Doctors are an example of providers.

Claim Form

The claim form is the completed document that a provider submits to

an insurance carrier. The medical coder’s job is to assign diagnostic and

procedure codes to each claim. The most common insurance forms are

the CMS-1500 and UB-04.

Deductible

The amount of money an individual must pay before insurance benefits

begin is called the deductible. Usually a policy will pay nothing of the

first $250, $500 or $1,000 of medical charges. They then will pay a

percentage of everything above that amount each year.

Any amount that is “applied to deductible” is a covered charge that is

subtracted from the total deductible amount. The insurance carrier does

not pay any money on “applied to deductible” charges.

For example, imagine that Toby has a medical policy that has a $250

deductible and, after the deductible is paid, 80 percent coverage. So far

this year, Toby has spent $200 of his own money on medical care, and

that medical care has been defined as covered under his insurance

policy. For the insurance company to begin to pay 80 percent of Toby’s

covered medical care costs, he must still pay out $50 more for covered

charges. After he has met the $250 deductible, Toby’s medical insurance

benefits will begin, and the carrier now will pay 80 percent of each claim

submitted for covered charges for the rest of the calendar year.

Copayment

A copayment is a flat amount of money paid by the patient at each visit

or for each prescription. Many policies have a copayment for prescription

drugs or office visits to a doctor. That means every time a person fills a

prescription or visits the doctor, it costs her no more than her copayment;

however, she must pay that copayment every time she fills a prescription

or goes to the doctor. Some policies require copayments even after the

deductible has been met. Other policies have no deductible, but a

copayment is required every time any type of medical care is received.

Copayments are paid at the time of service.

Reasonable and Customary

The phrase reasonable and customary or R&C refers to price

guidelines that insurance carriers use for different procedures. Usually a

carrier only will pay up to the maximum on their reasonable and

customary fee, regardless of the actual cost of a procedure to the patient.

For example, if a patient has knee surgery and the doctor charges

$1,000, the insurance company compares that fee to its reasonable and

customary scale.

If the R&C scale gives a $900 limit for that particular procedure, then the

patient may be responsible for the extra $100, depending on the agreement

the physician has with the insurance company. The physician may accept the

R&C scale amount. Fees that exceed the reasonable and customary scale are

disallowed by the carrier.

How much will he have to pay?

Many private insurance carriers have adopted the reasonable and customary

guidelines for their coverage. Many government insurance programs, which

we’ll discuss momentarily, also use reasonable and customary guidelines.

Explanation of Benefits

The explanation of benefits or EOB is a document that explains how much

the insurance company paid and how much it disallowed. Let’s look at two

samples of EOBs.

Bill from Doctor: $50

Disallowed: $6

Allowable Charge: $44

Applied to Deductible: $15

Amount due from Carrier: $29

The insurance company sends an explanation of benefits every time you

submit a claim. Even if the carrier is paying nothing on the claim, it still

sends this statement explaining why. As you can see from the example

above, the insurance carrier is paying $29 of a $50 charge, which means the

patient is responsible for the remaining $21.

The following table represents a breakdown of the EOB with a line-by-line

explanation of terms and amounts for the above example:

Electronic Claims

Before you dive into specifics, let’s first take a look at how electronic claims

processing works.

The Internet is used to determine eligibility.

Marissa enters her doctor’s office for her appointment. First, the office

manager uses the Internet to visit Marissa’s health plan Web site to

determine Marissa’s insurance eligibility. Next, the office manager prints out

an encounter form for the visit. The doctor sees Marissa, gives her a

prescription, and notes the diagnosis and procedure in her medical record.

Marissa then checks out with the office manager and pays her

copayment. The office manager begins the life of an electronic claim.

During the past several years, electronic claims submission rapidly has

gained popularity. But what exactly is an electronic claim? An

electronic claim is a digitized insurance claim form transmitted from a

computer using a modem and received by an insurance company or

clearinghouse. What does digitized mean? Well, after you, the coder,

code the items for the service, the data is entered into the computer.

Medical billing specialists use computer software to enter patient and

billing information into a claim format. When the data is entered into a

computer record, the information is digitized. That information then is

transmitted to a clearinghouse or insurance company using computer

software and a modem that allows the medical billing specialist’s

computer to communicate with the clearinghouse’s computer.

A clearinghouse is a company that facilitates the processing of claims

information into standardized formats and then submits the claims to the

appropriate insurance companies. Some insurance companies can receive

electronic submission of claims without going through a clearinghouse.

The clearinghouse downloads reports to the medical billing specialist

indicating how many claims it received, and then the electronic claims

are forwarded to the payers. The insurance carriers or payers will report

to the clearinghouse when they receive the claims.

After the insurance company receives the claim from the clearinghouse,

the claim is processed and paid or rejected. As you can imagine,

electronic insurance claims get paid much faster than paper claims.

The Health Insurance Portability and Accountability Act or HIPAA

regulates electronic claims, though this is just one of the many services

the act provides. The goal of HIPAA is that all healthcare workers have

similar ease and efficiency in their own communications. Later in this

course we’ll discuss HIPAA and its other facets in a bit more detail. You’ll

also learn exactly how it regulates electronic healthcare transactions.

Please pause and complete online Practice Exercise 2-1.

Step 6 Types of Health Insurance

Hundreds of private insurance companies provide medical coverage for individuals

and groups. These private insurance companies generally follow standards similar

to the government programs we will cover here. This next part of the lesson is

designed to introduce you to the many types of government-sponsored insurance

programs and each program’s requirements for coverage, along with the basic

types of private insurance.

Government Insurance

Unless otherwise noted, these programs are administered by the federal

government.

There are many types of government-sponsored insurance programs.

Medicare

Medicare is a federal health plan that covers people aged 65 and older and

people with disabilities.

Medicaid

Medicaid is a state-sponsored insurance program for low-income people

who otherwise wouldn’t be able to afford health insurance.

CHAMPUS

Until recently, CHAMPUS, which stands for Civilian Health and Medical

Program of the Uniformed Services, provided medical coverage for the

families of the various uniformed government services, including the armed

forces. Many changes have taken place in the military healthcare system in

the past several years. The most important of these changes is the transition

from CHAMPUS to the TRICARE healthcare system.

TRICARE

TRICARE is the name of the Department of Defense’s regional managed

healthcare program for military service families. TRICARE provides healthcare

options for the families of active-duty service members. These family

members are called beneficiaries. The service member is called the sponsor.

A sponsor can be active-duty, retired, or deceased. As its name suggests,

TRICARE has three options: TRICARE Standard, TRICARE Extra, and TRICARE

Prime.

TRICARE Standard

This is the new name for CHAMPUS. TRICARE Standard pays a share of the

cost of covered healthcare services obtained from authorized civilian hospitals

and doctors.

TRICARE Extra

This is a PPO-type option that provides healthcare services for eligible

participants on a visit-by-visit basis.

TRICARE Prime

This is an HMO-type option and is currently the least costly healthcare option

offered through TRICARE. Eligible persons must enroll for a year at a time

and agree to seek healthcare from the network of healthcare providers,

hospitals, and clinics. There is a fee for enrollment for retirees; active-duty

service members are enrolled automatically.

CHAMPVA

CHAMPVA, which stands for Civilian Health and Medical Program of the

Veterans Administration, provides medical coverage for veterans with

permanent, service-related disabilities. If a service member dies from a

service

related disability, CHAMPVA also provides coverage to the service

member’s family. Although very similar to TRICARE Standard in terms of

benefits, CHAMPVA is a separate program, distinctly different from

TRICARE Standard.

Workers’ Compensation

Workers’ compensation, a state-run program, pays the medical bills for

people with job-related illnesses or injuries.

Workers can be injured on the job.

In addition to the preceding government programs, many private insurance

companies exist. Private insurance companies can be categorized as either

traditional or managed care. In addition, there is Blue Cross/Blue Shield,

which represents a special case.

Private, Traditional Insurance

Twenty-five years ago, the traditional insurance concept was the only one.

The insurance company contracted with an individual to pay his or her

medical bills based on a fee-for-service concept—that is, whatever the

physician or medical provider charged was the amount on which the

insurance company based its reimbursement.

Private insurance companies are in business to earn profits. They pay out

benefits but also take in much more in premiums.

Managed Care

As healthcare costs skyrocketed, many businesses that held group insurance

policies for their employees began looking for ways to save money and still

provide excellent healthcare coverage. The solution was managed care.

Born in the 1980s, managed care introduced the concepts of Health

Maintenance Organizations, or HMOs, and Preferred Provider

Organizations, or PPOs. In both, groups of doctors contract with the

organization to charge set amounts for procedures. These amounts do

not change, and the patient cannot be charged an additional fee beyond

a copayment.

In HMOs, patients pay a fixed periodic rate monthly, quarterly or

annually. Patients then receive whatever health care they need, but they

must see a physician or medical provider who is part of that HMO. HMOs

encourage their members to practice preventive health care, often paying

for routine physicals and tests designed to catch signs of illness before

the person actually becomes sick. The patient is assigned a primary

physician when she joins the HMO. This primary physician then oversees

that patient.

Patients pay a fixed rate monthly, quarterly or annually.

PPOs contract with many doctors who agree to charge rates according to

the PPO scale. These doctors are not “employed” by the PPO. Instead,

they are independent offices, hospitals, and clinics that have joined the

PPO. When patients in a PPO go to a doctor or clinic who is not part of

the PPO, that patient sees a large reduction in benefits.

Blue Cross/Blue Shield

The oldest and largest prepaid insurance carrier is Blue Cross/Blue

Shield. Blue Cross provides hospital, outpatient, and home-care

coverage. Blue Shield covers physician services and provides dental and

vision-care coverage.

Blue Cross/Blue Shield differs from the other private insurance providers in

that it is not a commercial insurance company. Blue Cross/Blue Shield is a

federation of nonprofit community insurance corporations. Even though Blue

Cross/Blue Shield is not technically a government program, it must receive

state-level government approval before it can raise its rates.

Just as the HMO and PPO managed-care companies do, Blue Cross/Blue

Shield contracts with doctors who agree to charge a set fee for procedures

performed. Blue Cross/Blue Shield then reimburses the doctor directly for all

charges.

Step 7 Diagnostic Codes—A Piece of the Insurance

Puzzle

Now that you know about the different types of insurance programs, let’s take a

moment to discuss medical codes and how they apply to insurance.

After a patient’s office visit, tests, and other procedures, the medical billing

specialist fills out a claim form, which we discussed previously in this lesson.

These forms require special codes—diagnostic codes for diagnoses and

procedure codes for procedures performed. When you write a code on an

insurance form, a bill or a patient’s chart, you are “coding that entry.”

When you look at the CMS-1500 form, there are many fields to be filled.

One of the most important fields is Field 21—Diagnosis or Nature of

Illness or Injury. In this field, you must enter some crucial information.

But what information? Do you write in the doctor’s diagnosis? No. You

must use a diagnostic code.

Field 21 is filled in with crucial information—the doctor’s diagnosis. Here, the code listed represents the diagnosis of

congestive heart failure.

Diagnostic codes are numbers that identify the physician’s opinion

about what is wrong with the patient. This is the physician’s diagnosis.

These codes are not random numbers; they are based on a system called

the International Classification of Diseases or ICD. Hospitals, doctors’

offices, and medical coding specialists use ICD codes.

Often a patient is suffering from more than one symptom. In this case,

multiple diagnoses may apply. The doctor will determine a principal

diagnosis—usually the main cause of the symptoms or the main health

problem. When you code, you always enter the principal diagnosis code

first.

When a physician diagnoses more than one condition, the ones that aren’t principal are called concurrent conditions.

When a physician diagnoses more than one condition, the ones that aren’t

principal are called concurrent conditions. That means these conditions

happen at the same time as the principal diagnosis and might affect how the

patient recovers. For example, if Luke comes to the doctor suffering from a

broken leg—both the lower leg bones in his left leg are fractured—and a

sprained ankle.

How Important Is Diagnostic Coding?

It is your accurate and complete coding that ensures maximum

reimbursement to the provider and provides meaningful statistics to

assist our nation with its health needs. You probably think this seems like

a lot of responsibility, but don’t worry! You are not alone in this.

You know the whole process starts with the doctor and the patient. The

doctor has the responsibility to examine, test, and treat the patient as

needed and then document the services, supplies, and diagnosis.

Following the patient’s appointment, a medical transcriptionist types up

all of the information, and a medical coder then translates that

information into codes that support the procedures performed.

The codes and patient data then are transferred to a claim form and sent

to the insurance carrier for reimbursement to the provider based on the

medical necessity, diagnosis, and procedures involved. The types,

frequency of treatments, and diagnoses gathered from the patient

information provide the statistics necessary to depict health care in this

country. The government and insurance companies use these statistics to

establish guidelines to develop the rates of reimbursement paid to

medical practices in the future.

So you see, it’s the analysis of diagnostic codes that determines whether

insurance carriers will provide coverage for a particular procedure or

service. However, in the past, the diagnostic information that insurance

carriers gather has not been consistent. Therefore, the government now

is developing newer methods for collecting this information.

Now you have a bit of an idea as to how your new role affects insurance

reimbursement. Without your coding skills, doctors would not get

reimbursed for their services! We will cover diagnostic coding concepts

later in the course. Now, let’s look at procedure coding.

Step 8 Procedure Coding—Another Piece of the Puzzle

Diagnosis coding is not the only kind of coding you will do. If you look at the

portion of the CMS-1500 form that follows, you will see Field 24D—a column for

Procedures, Services, or Supplies. This column is divided into halves. The first half

is labeled CPT/HCPCS, and the second is labeled Modifier. It is in this field that you

write down the code for the procedures and any modifications of those procedures

or treatments and tests that the doctor performed.

You might be called upon to double check records as they come through your

coding service. Usually double checking means checking to be sure the

diagnosis matches the procedures. Insurance companies use box 24D to

check the procedures and make sure they are consistent with the diagnosis.

If they aren’t consistent, reimbursement from the insurance company may be

delayed, denied or reduced.

Like diagnoses, procedures have their own numerical language. The language

of procedure codes is either the Current Procedural Terminology, CPT, or

the Healthcare Common Procedure Coding System, HCPCS—pronounced

“Hick-Picks.”

CPT coding is the most commonly used set of procedure codes. The CPT

codes, which the American Medical Association produces annually, are divided

into six sections.

CPT Procedure Coding Divisions

Evaluation and Management

Anesthesiology

Surgery

Radiology

Pathology and Laboratory

Medicine

Most procedures the doctor performs will have a code. You will enter the

correct code in the correct column of the CMS-1500 form. We’ll show you

exactly how to find this code later. For now, all you need to know are the

fields that codes go in on the CMS-1500 form.

Please pause and complete online Practice Exercise 2-2.

Step 9 Looking Ahead

Before we conclude this lesson, let’s take a moment to discuss the organization of

this course. You may be wondering why we are introducing you to insurance and

claims processing or why you will be learning medical terminology. You may be

asking, “Why can’t I just start coding?” Medical coding is an integral part of the

healthcare industry. Professionals in this field learn medical terms and language to

be able to communicate with each other effectively. Think about how many

different classes a doctor takes during her college education to practice the

profession. Doctors are the primary care providers you will be supporting in your

role as a medical coding specialist!

As you move through the course, you will learn medical terminology, medical

ethics, medical records handling, anatomy, and physiology. Medical

terminology is the first step to coding accurately. You must understand

medical terms to decide which code is best for each medical record you

receive. Accurate coding supports top-dollar insurance reimbursement for

your employer. If you are doing a good job for your employer, you will be

rewarded for your excellent coding skills. And remember, the job demand for

coders is expected to keep growing, so finding work should be a snap! In no

time you could be earning as much as $40,000 a year.

Have fun as you discover different aspects of the healthcare field! It won’t be

long before you are learning to use your coding manuals and actually coding

medical records. In that part of the course, we will include many examples

and Practice Exercises to help you understand the process. And your

instructors will be just a telephone call or e-mail away if you have questions.

We want you to feel prepared and confident as you enter into this exciting

field of medical coding!

Step 10 Lesson Summary

Medical insurance is a necessary part of America’s health care. Insurance coverage

comes from both government and private sources. Regardless of who provides the

coverage, insurance companies use a specific language to refer to different

insurance concepts.

In this lesson you learned that the different insurance programs available fall

into three categories: government, traditional, and managed care. The

federal government manages programs such as Medicare, TRICARE, and

CHAMPVA. State governments manage Medicaid and workers’ compensation.

In managed care, HMOs and PPOs contract with groups of doctors to provide

care at certain set amounts. These types of healthcare programs were

developed to help control the rising cost of medical care in America. This

lesson also gave you an understanding of diagnostic and procedure codes as

well as how electronic claims are filed.

As you move through this course you will see the important role you’ll play as a medical coder.

Keep in mind that this lesson was a brief overview of insurance programs and

how insurance works. As you move through this course you will see the

important role you’ll play as a medical coder. Your employer will depend on

you to submit the proper coding for filing claims to insurance companies and

federal agencies for reimbursement. The specialized training you get in these

lessons will make you and those for whom you work successful!

Please pause and complete an online Quiz. Good luck!

LESSON 3

Introduction to Medical Terminology: Word

Parts

Step 1 Learning Objectives for Lesson 3

When you have completed the instruction in this lesson, you will be trained to do

the following:

Explain word parts.

Define root word, and describe how the term is used.

Form terms with prefixes, suffixes, and root words.

Use an online medical dictionary.

Step 2 Lesson Preview

Medical coding specialists are in demand, so finding a job should be a snap.

In the first two lessons you learned about the day-to-day procedures in healthcare

settings. You also saw how medical professionals, including coding specialists, work

together as a team. You also became familiar with medical records, insurance and

the role both will play in your new career. Hopefully these lessons also taught you

that medicine is a very rewarding field. You will experience its satisfactions and live

up to its challenges every day that you work as a medical coding specialist. And

you know that skilled medical coding specialists are in high demand. Providers and

clinics all need qualified medical coding specialists. In fact, many such positions

remain unfilled due to a lack of qualified candidates. Most employers look for

coding specialists who have schooling and experience, and with the training you

receive in this course, you can count on learning everything you need to know

about this medical field. Finding the position you want should be a snap!

In the next three lessons, you’re going to focus on one very important

part of medicine—its language. Doctors, nurses and other healthcare

personnel, including coding specialists, communicate in specialized terms

that, at first, might sound like a foreign language. You’ve no doubt

overheard medical conversations in your own visits to the doctor. As a

coding specialist, you’ll hear medical terminology in daily conversation.

More importantly, you’ll use this knowledge as you review medical

records for diagnoses and procedures. Once you determine the correct

diagnoses and procedures, you’ll research those terms in your coding

manuals to find the correct medical code. Just think—you’ll soon be a

medical terminology guru! What used to sound like a foreign language

will someday become as familiar as your everyday conversation.

Doctors communicate in specialized terms.

Fear not—learning medical terminology is a lot easier than learning a foreign

language. Medical terms can be broken down into easy-to-understand parts.

In this lesson, we will introduce you to your new language—the language of

medicine. In these next few lessons, you’ll learn the building blocks you’ll

need so that you can break down any medical term. We’ll discuss root words,

prefixes, and suffixes and explain how these word parts come together to

form medical terms. Throughout the lesson, be sure to have your flashcards

handy as you will need to consult them as you study.

Step 3 Word Parts

Words are all around us. You use them every day to communicate. You use long

words and short words, complex words and simple words. And there always will be

words that are new to you. As a medical coding specialist, you often will be faced

with medical terms. These terms might seem complex at times, but you can

simplify them. In every sentence you speak, every letter you write, the words are

constructed of parts. These parts give clues to the words’ meanings. Because you

know this, you can break words down and figure out their meaning from their word

parts.

Words are all around us.

Look at these words you already know:

telephone

microwave

television

microscope

telescope

It’s easy to split these words into parts:

telephone = tele + phone

microwave = micro + wave

television = tele + vision

microscope = micro + scope

telescope = tele + scope

You see that some of these words contain some of the same parts. Tele/

is in three of the words. Telescope and microscope both have the word

part /scope.

So you see, words can be divided into smaller parts called word parts,

and they are very important in learning medical terminology. Word parts

are like building blocks. A child can take a dozen building blocks and make

many different things, combining the blocks in different ways. The same is

true of word parts. Many different words can be formed from a few word

parts.

Step 4 Root Words

The foundation for all words is the root word. The root word is the basic

component of the terms used to communicate. Many simple words contain only a

root word without any other word parts.

book

read

joy

cook

drive

Word parts are used together with root words to make new and different

words. This is usually done by adding either a prefix or a suffix. A prefix is

a word part added to the beginning of a root word. Conversely, a suffix is a

word part added to the end of a root word.

When other word parts are added to root words, a new word is formed, and

this new word means something slightly different. Below are some new

words that were formed from the root words we just mentioned. A prefix or

suffix has been added to each root word. Remember, a prefix is a word

beginning. A suffix is a word ending.

booklet a little book

reread to read again

joyful having the quality of joy

cooked to cook sometime in the past

driver a person who drives

In addition to prefixes and suffixes, different root words come together to

form new words. Words made up of two or more root words are called

compound words. Here are some examples:

book + shelf = bookshelf

drive + way = driveway

news + paper = newspaper

Understanding word parts helps you understand new words—even long and

complicated words.

You may not know the word recalculate. But if you know what calculate

means, and you know what the prefix re/ means, then you know that

recalculate means to calculate again.

In fact, you probably have made up some new words yourself just by

making new combinations of word parts.

Let’s review the word parts. Think of these word parts as the building blocks

of medical terms.

Word Parts

Root Word The root word is the foundation or cornerstone of the word.

Prefix A prefix is attached to the beginning of a root word to change its meaning.

Suffix

A suffix is attached to the end of a root word to change its word form or

meaning.

Now let’s take the basic concept of word parts and apply it to medical

terms.

Step 5 Medical Terms

Medical terms may appear to be long and complicated, but even the longest

medical term can be broken down into small, easy-to-understand parts. Once you

become familiar with the individual word parts, medical terminology becomes easy.

Try to look at medical terms like little puzzles. You’re putting together different

pieces (root words, prefixes, and suffixes) to form complete words.

Try to look at medical terms like little puzzles.

Understanding some essential word parts will help you recognize

medical terms. You will learn about each of these word parts, one at a

time, in a simple, logical, easy-to-understand sequence. This will make

it very easy for you to spell and understand even the longest and most

complicated terms.

The Combining Vowel

Many medical terms contain a fourth word part that we have not yet

discussed—the combining vowel. The combining vowel joins a root word to

other word parts.

Here is an example of how the combining vowel is used. As you can see, not

all terms have all four parts.

Dermatology means the study of skin.

On the following page are two more medical terms that show examples of

word parts. These are compound words because they contain more than one

root word.

A neonatologist is one who specializes in the study of the newborn.

If you use a different prefix, you will have the following term:

A perinatologist is someone who specializes in the study of the fetus and

newborn (the time around the birth).

These are two types of doctors you may find yourself working for as a

medical coding specialist!

A perinatologist is someone who specializes in the study of the fetus and newborn.

Before you move on, let’s take a moment to look up one of the new terms

you learned in your medical dictionary. Basically, a medical dictionary works

much the same way a regular dictionary does—you simply use it to look up

the spellings and definitions of medical terms. For example, if you came

across the term dermatology and wanted to know what it meant, you’d

thumb through your medical dictionary until you found the term. There is the

definition—the science that deals with the skin. If you find yourself having a

hard time understanding how to use your medical dictionary, feel free to

contact your instructor for guidance.

Tip

If you have access to a computer and the Internet, you can use an online

medical dictionary to look up terms. An online medical dictionary can be

found at http://www.online-medical-dictionary.org/. Feel free to check it out!

Please pause and complete online Practice Exercise 3-1.

Step 6 Root Words

As you previously learned in this lesson, word parts are the building blocks for all

words, including medical terms. Up to this point, word parts were described in a

general manner. Now you will take a closer look at root words—the foundation of

all words.

Root words are the foundation of all words.

You will find many of the root words in this lesson familiar because they are

used in everyday English, as well as in medical terminology. The words

covered in this lesson are the most common of all medical root words.

You may have wondered why medical terms are so long and

complicated. Well, it’s because these terms have very definite meanings.

In medicine, one complicated word takes the place of four or five

common words so that doctors can communicate exactly what they

mean to other health professionals. This prevents misunderstandings

that can interfere with the patient’s care. For example, the words

abdomen and stomach may mean the same thing to you, but they have

different meanings to a doctor. Because of this, doctors use different

words for the stomach and the abdomen. You will learn the root words

for these and other parts of the body in this lesson and in lessons to

come.

Doctors and other healthcare professionals use special medical terms

because they know it’s important to communicate precise information

about a patient’s condition. As you learn to build words, you will be

building your professional skills. You will be an important link in the

healthcare team. Without you, the medical coder, this patient

information would not make it to the insurance companies in the correct

format, meaning that your colleagues may not get properly reimbursed

for their expertise and services.

The medical codes you determine for each patient’s case serve an additional,

critical purpose. These codes enable government health agencies to track

and research life-threatening illnesses, such as various types of cancer, heart

disease, and AIDS. Your important role as a medical coder helps save lives!

The Functions of Root Words

There are three interesting facts about root words.

Facts About Root Words

• Root words are the foundation of medical terms.

• Root words name body parts or body functions that the terms represent.

• Most medical terms have at least one root word.

Look at these examples of root words:

Root Word English Meaning

neur/ nerve

gastr/ stomach

scop/ examine

log/ study of

cardi/ heart

path/ disease

These root words are in the medical terms that follow. Even though you may

not know the meaning of the medical term, you know the meaning of the

root word you saw just a moment ago.

Medical Term Meaning

neuritis inflammation of nerves

gastritis inflammation of the stomach

microscope an instrument to examine small things

logic a method of studying an area of thought

cardiac relating to the heart

pathology the process of the study of disease

Compound Words as Root Words

Some terms have two or more root words in them. They are called

compound words. In the examples below, you will use the same root

words you used previously.

Compound Word Meaning

neuropathy a disease process of nerves

gastroscope an instrument to examine the stomach

cardiologist one who studies the heart

pathologist one who studies disease

Notice that the combining vowel /o/ was used to join the root words.

Combining Forms of Root Words

Root words sometimes are awkward to pronounce. That is why you may see

the combining vowel—usually the letter /o/—between the root word and

other word parts. The combination of the root word and the combining vowel

is the combining form. Look at the combining forms for the root words you

saw previously.

Root Word Combining Form English Meaning

neur/ neur/o nerve

gastr/ gastr/o stomach

scop/ scop/o examine

log/ log/o study of

cardi/ cardi/o heart

path/ path/o disease

In this course, each new root word you learn will be in its combining

form.

Root Word + Combining Vowel = Combining Form

Now that you know the basics about root words, you’re ready to move ahead

and learn more about medical terms. First, you will practice pronouncing root

words using the following exercise.

Step 7 Pronounce Root Words

Follow these steps to learn how to pronounce root words.

a. Take your Quick-Learn Tutor and Set 1 flashcards out of your Quick-Learn

Kit. Each flashcard contains many flashterms.

b. Find the first flashcard. It begins with Flashterm 1-1. Insert the card into

the lower part of Side A of your Quick-Learn Tutor. Push the card up until

Flashterm 1-1 appears in the left window.

c. Access the online portion of your course. Go to the Lesson 3 book, and click

on Lesson 3 Listen to Root Words.

d. Listen to a root word as it is pronounced. After you hear a root word, pause

the audio.

e. Look at the root word in the left window of your Quick-Learn Tutor.

Practice pronouncing it out loud several times until you can pronounce it

correctly and easily. Push the flashcard up until the meaning of the root

word appears in the right window. Read the meaning of the root word.

f. Repeat steps d and e, continuing with all the flashterms on Flashcard 1.

g. When you have completed Flashcard 1, turn the card over for Flashcard 2.

Proceed until you have pronounced all the root words for Set 1.

h. Next, begin with Flashcard 1 and play the audio again. This time,

pronounce each root word in order but do not stop after each term.

i. As you pronounce each root word, look at it on the flashcard. Listen to your

own pronunciation of each root word. If you mispronounce one, put a check

mark next to it with your pencil.

j. Next, practice the root words you mispronounced by listening to the audio

again. Be sure you can pronounce each root word clearly and easily.

After you have finished pronouncing all of the root words for this lesson,

move on to the next exercise—learning to write root words.

Step 8 Write Root Words

Follow these steps to learn how to write root words.

a. Insert Flashcard 1 into Side A of your Quick-Learn Tutor.

b. Look at each root word as it appears in the window and say it out loud.

Write each root word on blank paper. Be sure to put a slash (/) between

the root word and the combining vowel, just as you see it on the flashcard.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the root word. Writing

these root words and meanings will help you learn them more easily. Here

is an example of the first flashterm.

aden/o gland

d. Do this for each flashterm for this set.

Finally, after you have pronounced and written each term, learn the

meanings of these root words in the next exercise.

Step 9 Meanings of Root Words

Follow these steps to learn the meanings of root words.

a. Again insert the flashcard for Set 1 into Side A of your Quick-Learn Tutor.

Beginning with Flashterm 1-1, pronounce each root word out loud. Before

you look at the meaning, see if you can remember it. Check yourself by

pushing the flashcard up until you can see the meaning in the right window.

Do this for each flashterm for this set.

b. Now insert Flashcard 1 into Side B of your Quick-Learn Tutor. Push the card

up until you see the meaning of Flashterm 1-1 in the right window. Read

each meaning out loud. Before you look, see if you can remember the word

part that goes with that meaning. Check yourself by pushing the flashcard

up until you can see the root word in the left window. Do this for each

flashterm for this set.

c. Practice with the flashcards several times until you are familiar with the

root words and their meanings. It’s not necessary to memorize all the

terms now. You will find that you begin to memorize medical terms as you

use them throughout this course.

You may use your flashcards for all Practice Exercises and Quizzes. However,

the time you spend reviewing the flashterms now will mean less time spent

looking them up later.

Tip

After you have finished your activities with a set of flashcards, return the

flashcards, in order, to your Quick-Learn Kit. You can easily refer to them

later, as needed, throughout the course.

Please pause and complete online Practice Exercise 3-2.

Step 10 Prefixes

Now that you’ve learned about root words, let’s learn about another word part—

prefixes. If you consider the root word to be the boxcar on a train, the prefix is the

engine, and the suffix is the caboose. You know that prefixes are added in front of

root words while suffixes are added at the end of root words.

A prefix changes the meaning of a medical term. While the root word names

a body part or body function, the prefix gives additional information about

the medical term.

Facts About Prefixes

• A prefix gives additional information about a medical term.

• A prefix usually tells where, when or how.

Let’s take a look at some examples of prefixes and their meanings. Notice

that prefixes do not have combining vowels.

Prefix Meaning

peri/ surrounding

brady/ slow

tachy/ fast

micro/ small, tiny

a/ without, absent

Now let’s learn more about prefixes.

Fact About Prefixes

A prefix does not change the meaning of a root word. A prefix does change

the meaning of the whole medical term.

In the following list, you see medical terms made from some of the root

words you studied earlier. Notice that the prefix does not change the

meaning of the root word. (Don’t worry about the vowel endings on the root

words for now. This will be explained shortly.)

Medical Term Meaning

renal relating to the kidney

perirenal relating to surrounding the kidney

cardia heart

bradycardia slow heart

tachycardia fast heart

glossa tongue

macroglossa large tongue

gastric relating to the stomach

hypogastric relating to below the stomach

leukocytosis condition of white cells

aleukocytosis condition of absence of white cells

Fact About Prefixes

Many terms do not begin with a prefix.

A prefix is attached to the root word. If there is no prefix, the first word part

you will see is the root word. Look at these examples.

perirenal starts with prefix

renal starts with root word

Remember, a prefix only tells where, when or how. A root word tells

what.

How do you tell if the beginning of the word is a prefix or a root? Well, one

way is to see what happens when you remove the first word part. Look at the

following example. You saw these terms a moment ago. The root word here

means heart.

Medical Term Meaning

cardia heart

bradycardia slow heart

When you take the prefix brady/ away, the meaning of the term changes

from slow heart to heart. However, the meaning of the root, heart, doesn’t

change, so you know that brady/ is a prefix.

Facts About Prefixes and Root Words

• If you take away a prefix, you take away only the where, when or how.

• If you take away a root word, you have taken away the what—the basic

meaning of the term.

Look at the next example. This term is a compound word. The “what” is a

white cell. A white cell is one kind of cell—it is not a red cell or a liver cell.

Look what happens to the meaning of the term when we remove one of the

two root words that make up the compound word.

Medical Term Meaning

leuk/o/cyt/osis condition of white cells

cyt/osis condition of cells

When the root word leuk/o is removed, the meaning of the term

changes from white cells to simply cells. The term cyt/osis means a

condition of any kind of cells: red cells, white cells, liver cells and so on.

The “what” of the term changed from white cells to cells. Therefore,

leuk/o is a root word.

For now, all the prefixes you learn are followed by a slash. Look at these

examples.

brady/ micro/ peri/

All the root words you learn have a slash between the root and the combining

vowel. Look at these examples.

cardi/o leuk/o cyt/o

Step 11 Pronounce Prefixes

Follow these steps to learn how to pronounce prefixes.

a. Take your Quick-Learn Tutor and your Set 2 flashcards out of your Quick-

Learn Kit.

b. Find the first flashcard for Set 2. Insert the card into Side A of your Quick-

Learn Tutor. Push the card up until the first prefix appears in the left

window.

c. Access the online portion of your course, and click on Lesson 3 Listen to

Prefixes.

d. Listen to each prefix as it is pronounced. After you hear a prefix, pause the

audio.

e. Look at the prefix in the left window of your Quick-Learn Tutor. Practice

pronouncing it out loud several times until you can pronounce it correctly

and easily. Push the flashcard up until the meaning of the prefix appears in

the right window. Read the meaning of the prefix.

f. Repeat steps d and e, continuing with all the flashterms on the flashcard.

g. When you have completed the flashcard, turn the card over. Proceed until

you have pronounced all the prefixes for Set 2.

h. Next, begin again with the first flashcard and play the audio. This time,

pronounce each prefix in order but do not stop after each term.

i. As you pronounce each prefix, look at it on the flashcard. Listen to your own

pronunciation of each prefix. If you mispronounce one, put a check mark

next to it with your pencil.

j. Next, practice the prefixes you mispronounced by listening again. Be sure

you can pronounce each prefix clearly and easily.

After you have finished pronouncing all the prefixes in this set, move on to

the next exercise—learning to write the prefixes.

Step 12 Write Prefixes

Follow these steps to learn how to write prefixes.

a. Insert the first flashcard for Set 2 into Side A of your Quick-Learn Tutor.

b. Look at each prefix as it appears in the window and say it out loud. Write

each prefix on blank paper. Remember to include the slash.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the prefix.

d. Do this for each prefix for this set.

Finally, after you have pronounced and written each term, learn the

meanings of these prefixes in the next exercise.

Step 13 Meanings of Prefixes

Follow these steps to learn the meanings of prefixes.

a. Again insert the flashcard into Side A of your Quick-Learn Tutor. Pronounce

each prefix out loud and then say the meaning. Check yourself by pushing

the flashcard up until you can see the meaning in the right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud and then say the prefix. Check yourself by

pushing the flashcard up until you can see the prefix in the left window. Do

this for each flashterm for this set.

c. Practice with the flashcards several times until you are familiar with the

prefixes and their meanings. Don’t struggle to memorize them. The more

times you review your flashcards, the more familiar they will be to you.

Tip

Remember to keep your flashcards in order even after you’re finished with

an activity so you can refer back to them easily.

A handy way to review flashcards from previous lessons is to read down the

flashcard without inserting it into the Quick-Learn Tutor.

Please pause and complete online Practice Exercise 3-3.

Step 14 Suffixes

A suffix is the word part that is attached to the end of a root word.

Why do we use suffixes? A suffix can change the word form or the meaning of

a term. The word form tells you how the word functions in the sentence.

Word forms also are referred to as parts of speech.

Two important parts of speech are the noun and the adjective.

A noun is the name of a person, place or thing. An adjective is a word that

describes a noun. Here’s an example.

The words candle and smell are nouns because they name a person,

place or thing. The words green and distinct are adjectives because

they describe nouns.

Some root words can function as both nouns and adjectives. All you have to

do is change the suffix. Here’s an example.

Noun Adjective

courage courageous

Compare these two sentences:

Courage is an important quality for a soldier to have. The courageous man

saved the boy’s life.

In the first sentence, courage is a noun. It is a thing, a quality. In the second

sentence, the word man is the noun, and the word courageous describes the

man, making courageous an adjective.

Look at these examples of medical terms that can be changed from nouns to

adjectives just by changing the suffix.

Noun Adjective

cardi/a cardi/ac

gastr/ia gastr/ic

muc/us muc/ous

neur/osis neur/al

Fact About Suffixes

A suffix can change a root word to a noun or an adjective.

The suffix determines whether a word is a noun or an adjective. Suffixes

that make a word a noun are called noun suffixes. Suffixes that make

a word an adjective are called adjective suffixes. No matter what root

word they are joined to, a noun suffix always changes the word into a

noun, and an adjective suffix makes the word an adjective.

Here is a table of some common medical suffixes. Notice that some of the

suffixes are noun suffixes and some are adjective suffixes. Many noun suffixes

don’t really have a meaning. They are just used to show that the word is a

noun.

When you learn suffixes later in this lesson, the flashcard will tell you which

are noun suffixes and which are adjective suffixes.

Did you notice that many of the suffixes have the same meaning? If they

have the same meaning, how do you know which one to use? Well only

certain suffixes and certain root words can be combined. For example, each

root word generally can be combined with only one adjective ending. Cardi/o

is joined with /ac to form cardiac. Cardi/o is never joined with /ic, /al or /ous.

The words cardiic, cardial and cardious do not exist.

To help you learn which suffixes go with which root words, we have taken

many root words and combined them with the correct suffix. This will help

you remember which suffixes go with which roots.

In the next few lessons, you not only will be learning individual word parts

but also complete medical terms—both nouns and adjectives.

Often a root word + suffix combination can itself be used as a word ending.

You can think of this as a combined suffix. For example:

path/o + /y = /pathy

The combined suffix /pathy can be joined to many other words.

cardiopathy myopathy neuropathy

These combined suffixes will be written on your flashcards as regular suffixes,

but if you look closely, you’ll be able to see the root word + suffix

combination. Look at these examples.

Before you move on, let’s pretend for a moment that you know the term

cardiopathy, which means heart disease, but you aren’t sure if

cardiopathy is in fact the correct spelling—you suspect it may be spelled

cardiapathy instead. So what should you do? Well, simply look in your

medical dictionary, following the terms until you find the correct spelling.

In your dictionary you see that you were right the first time. The term is

spelled cardiopathy!

Fact About Suffixes and Root Words

Most root words need either a noun suffix or an adjective suffix at the end of

them.

Most root words can’t stand alone as complete words—they need a suffix at

the end of them. But like everything else in life, there are exceptions. For

some root words, you don’t need a suffix of any kind to form a complete

word. These roots already are complete words. By dropping the combining

vowel, these root words stand alone. They also work as suffixes themselves.

Listed are three examples of root words that don’t need a suffix.

Root Word Suffix (Noun) Meaning

gram/o /gram picture, record, tracing

graph/o /graph

machine that creates a tracing or

recording

derm/o /derm skin

In this course you will be given more noun and adjective suffixes.

Whenever you learn a new term, look to see which suffixes are used with

which roots. That way you will begin to recognize which roots and

suffixes belong together.

Now let’s learn how to pronounce suffixes.

Step 15 Pronounce Suffixes

Follow these steps to learn how to pronounce suffixes.

a. Take your Quick-Learn Tutor and your Set 3 flashcards out of your Quick-

Learn Kit.

b. Insert the first flashcard for Set 3 into Side A of your Quick-Learn Tutor.

Push the card up until the first flashterm appears in the left window.

c. Access the online portion of your course, and click on Lesson 3 Listen to

Suffixes.

d. Listen to a suffix as it is pronounced. After you hear a suffix, pause the

audio.

e. Look at the suffix in the left window of your Quick-Learn Tutor. Practice

pronouncing it out loud several times until you can pronounce it correctly

and easily. Push the flashcard up until the meaning of the suffix appears in

the right window. Read the meaning of the suffix.

f. When you have completed the flashcard, turn it over for the next flashcard

for this lesson. Proceed until you have pronounced all the suffixes for Set 3.

g. Next, begin again with the first flashcard and play the audio again. This

time, pronounce each suffix in order but do not stop after each term.

h. As you pronounce each suffix, look at it on the flashcard. Listen to your

own pronunciation of each suffix. If you mispronounce one, put a check

mark next to it with your pencil.

i. Next, practice the suffixes you mispronounced by listening again. Be sure

you can pronounce each suffix clearly and easily.

Step 16 Write Suffixes

Follow these steps to learn how to write suffixes.

a. Insert the first flashcard for Set 3 into Side A of your Quick-Learn Tutor.

b. Look at each suffix as it appears in the window and say it out loud. Write

each suffix on blank paper.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the suffix.

d. Do this for each suffix for this lesson.

Finally, after you have pronounced and written each term, learn the

meanings of these suffixes in the next exercise.

Step 17 Meanings of Suffixes

Follow these steps to learn the meanings of suffixes.

a. Again insert the first flashcard for Set 3 into Side A of your Quick-Learn

Tutor. Pronounce each suffix out loud. Before you look at the meaning, see

if you can remember it. Check yourself by pushing the flashcard up until you

can see the meaning in the right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud. Before looking, see if you can remember the

suffix that goes with that meaning. Check yourself by pushing the flashcard

up until you can see the suffix in the left window.

c. Practice with the flashcards several times until you are familiar with the

suffixes and their meanings. You may use your flashcards for all Practice

Exercises and the Quizzes.

Please pause and complete online Practice Exercise 3-4.

Step 18 Lesson Summary

Understanding how to “decipher” medical terminology is a special link to becoming

an effective medical coding specialist. Understanding medical terminology will

allow you to find the correct diagnosis and procedure provides those healthcare

professionals and insurance companies with the information they need to get

properly reimbursed. Although medical terms might seem complex, you now know

that you can simplify them by breaking them down into word parts and then

figuring out the meanings of the parts. Word parts are like building blocks because

many different words can be formed from a few word parts.

You learned how to build medical terms, which will help you in your future career.

The foundation for all words is the root word, the basic component of terms.

The root word names the body part or body function that the term

represents. Most medical terms have at least one root word.

We use word parts together with root words to make new and different

words. This is usually done by adding either a prefix or a suffix. Prefixes

are word parts added to the beginning of a root word. A prefix gives

additional information about a medical term, and a prefix usually tells

where, when, or how. A prefix does not change the meaning of a root

word—but a prefix does change the meaning of the whole medical term.

A suffix is a word part added to the end of a root word. The suffix

determines whether a word is a noun or an adjective. Most root words

need either a noun suffix or an adjective suffix at the end of them.

Combining vowels are word parts that join a root word to another word

part. Combining vowels make terms easier to pronounce.

It’s important that you understand word parts as a medical coding

specialist. While this lesson may have strained your brain a little more

than the previous ones, you’ve now learned about the building blocks

you’ll need to “build” many medical terms! The Practice Exercises in this

lesson are important. If you skipped any or struggled to complete some

of them, take a few moments to go back and work on them again. Doing

so will prepare you for the upcoming Quiz and build upon your medical

foundation of knowledge.

Just for Fun

After a long day of helping people, most health professionals take a break to

smile and have fun. Having fun after working hard has four benefits.

It relieves stress.

It exercises your face muscles.

It isn’t fattening.

It is free.

If anything else in this world gave you these four benefits, you’d take as

much of it as you could get. So every once in a while we’ll take a fun break—

just like this.

Some Just for Fun pages are for enjoyment. Some will tell you interesting

things about language and the medical field. Some will give you a warm

smile.

Most people use words that come from Greek and Latin every day. Here are

some examples.

Greek Latin

telephone plumber

chemistry alibi

therapy medium

skeleton honor

The English language has more ways to say something than any other

language. That is because it contains words from so many languages. In fact,

there are a lot of words in English that come from French. Here are some

examples.

French

humility

liberty

image

The English language also uses words that are Anglo-Saxon. They are

usually three or four letters long. When you use a “four-letter word,” you

are probably using an Anglo-Saxon word. Look at these examples of

common three- and four-letter words.

Anglo-Saxon

cat

dog

free

Medicine has been around a long time. The word parts you are learning

come from Greek and Latin.

A long time ago, no one in England spoke English. The peasants spoke

Anglo

Saxon. Peasants couldn’t read or write. They could only speak their

language. It was very simple. Speaking Anglo-Saxon meant you hadn’t

been to school and didn’t have much in the way of gold and diamonds, or

even food, for that matter. Anglo-Saxon words became our everyday

words.

The only people who were educated were the clergy. They read and

wrote Latin. They studied Greek when they wanted to do something

really exciting. Therefore, anyone who spoke Latin or Greek was

considered educated. As science developed, scientists used Latin and

Greek so everyone would know they were educated. Greek and Latin

words became our professional terms.

In 1066, the French invaded England. The French ruled England and

owned the land. The French language gained importance. Eventually

French words became our elegant words.

After many years, the English language grew from these roots. That’s why

in English today, there are usually three words (at least) for everything. If

you consider where the different words come from, you can see why

different words for the same thing may sound everyday, scientific or

elegant. Look at these examples.

Anglo-Saxon Latin or Greek French

fire conflagration blaze

job profession affair

happy felicitous joyous

behind posterior derriere

Today, by choosing different words, English can still sound everyday,

professional or elegant. Don’t be afraid of long words. You soon will learn

easy, step-by-step ways of breaking them down to the building blocks

you have learned. In this section, you are learning the building blocks. In

future sections, you will learn what the terms mean. Soon you will be

using medical terms like a professional because you will be a

professional.

LESSON 4

Medical Terminology: Dividing and

Combining Terms

Step 1 Learning Objectives for Lesson 4

When you have completed the instruction in this lesson, you will be trained to do

the following:

Divide common medical terms into parts, and provide the meaning of

each part.

Properly combine prefixes, root words, and/or suffixes to form medical

terms that describe certain diagnoses and procedures.

Step 2 Lesson Preview

So far, you have learned the word parts that fit together to form medical terms:

prefixes, root words, and suffixes. In this lesson you’ll learn how to take complete

terms and divide them. You’ll also learn how to combine word parts correctly to

create new terms.

You may recall the train example in the last lesson—the root word is the

boxcar, the prefix is the engine and the caboose is the suffix. When you

divide medical terms, you can look at the entire train and determine the

prefix, suffix, and root word. This is important because you sometimes will be

faced with unfamiliar terms. If you can look at an unfamiliar word and divide

it properly, you then can determine its meaning based on the word parts.

As a medical coding specialist, you might review medical records that

don’t have the correct medical term spelled out for you. It will be your

job to determine the exact procedure or diagnosis—which we talked

about in the first two lessons—from the medical records. Without those

key terms coded, which you’ll soon learn how to do, the doctors for

whom you work could not get reimbursed by insurance companies for

their time and expertise. You are the link between the healthcare

provider and his salary! This lesson shows you how to take “plain

English” descriptions and combine word parts to form the correct

medical term. As you read this lesson, keep in mind that you are

learning both the meanings of and how to assemble words.

Throughout the lesson, be sure to have your flashcards handy as you will

need to consult them as you study the following material, do the Practice

Exercises, and take the Quiz. Your knowledge of medical terms will make you

a valuable resource in the medical field—you will be able to communicate

effectively with health care providers and insurance companies. Now, let’s get

started!

Step 3 Dividing Medical Terms

You have learned about word parts—the building blocks of medical terms—and you

can identify these building blocks in medical terms. By dividing these terms into

their word parts, you can recognize new or complicated medical terms. Then you

can look them up in a dictionary more easily and spell them correctly.

Fact About Dividing Words

When you are looking for the word parts in a medical term, read from the end of the

term to the beginning. This simple technique lets you “see” word parts more easily.

Let’s look at the following example.

thermometer

By dividing medical terms, you know the meaning of thermometer.

If you read from the end of the word, the first word part you see is the suffix

meter. Draw a slash to the left of meter.

thermo/meter

Continue reading from right to left. Next you see an o. This may be a

combining vowel. Put in another slash. Continue reading from right to left.

You see the root word therm.

therm/o/meter

Now give the meaning of thermometer starting with the suffix.

Word Part Starting with End of Word Meaning

/meter instrument to measure

o (combining vowels have no meaning)

therm/ heat

A thermometer is an instrument to measure heat.

The following three examples further show you how to divide a medical term,

reading from end to beginning, to find the meaning.

Word Part Starting with End of Word Meaning

/genesis creating

o (combining vowels have no meaning)

carcin/ cancer of gland tissue

Carcinogenesis means creating cancer of gland tissue.

Word Part Starting with End of Word Meaning

/plasty restore through surgery

o (combining vowels have no meaning)

maxill/ upper jaw

Maxilloplasty means restoring the upper jaw through surgery.

Of course, whenever you are pronouncing a term, you should read from the

beginning of the term to the end, just as you would read any new word in

English.

Consonants, Vowels and the Role They Play

When you divide medical terms it is important to remember that a

consonant is any letter of the alphabet except a, e, i, o, u and, for the

purposes of working with medical terms, y.

Fact About Dividing Medical Terms

When a suffix begins with a consonant, there is a combining vowel between the root

word and the suffix.

Let’s take a look at a few examples.

Term with Suffix Beginning with Consonant Meaning

cardi/o/ + gram tracing of the heart

thromb/o/ + plasty surgical repair of blood clot

thorac/o/ + centesis withdrawing fluid from the chest

gastr/o/ + megaly enlargement of the stomach

Because all the suffixes in these examples begin with a consonant, the

combining vowel is used. (Did you notice in these examples that dividing

slashes (/) were placed between each word part?)

Fact About Dividing Words

When the suffix begins with a vowel, there is no combining vowel between the root

word and the suffix.

You already learned that vowels are the letters a, e, i, o and u. Also, y is

considered a vowel when working with medical terms. Let’s look at some

examples.

Term with Suffix Beginning with Vowel Meaning

arthr/ + algia pain in joints

bi/ + opsy look at living (tissue)

cardi/ + ac relating to the heart

hemat/ + oma blood tumor (lump)

cardi/o/path/ + y disease of the heart

As you can see, the combining vowel was not used in the terms above

before the suffix. The last term, cardiopathy, ends with the suffix /y. The

suffix /y follows this vowel rule because it acts like a vowel here.

Fact About Dividing Words

There is a combining vowel between two root words in a compound word.

As you learned previously, a compound word has two or more root words in

it. Look at these examples. Notice the combining vowel between the root

words. Also notice that the combining vowel remains even if the second root

word begins with a vowel.

Compound Word with Combining Vowel Meaning

cardi/o/log/ist heart specialist

gastr/o/enter/o/logy study of the stomach and bowels

therm/o/meter instrument to measure heat

A Little Practice

Let’s get a little practice in dividing medical terms. Look for word parts in the

examples that follow. Read each term from the end of the term—from right

to left. Put in slashes between word parts. Pay special attention to whether

or not a combining vowel is present. Be careful. Not every o is a combining

vowel, so use your flashcards if you need help.

perirenal

hemostasis

neuritis

hepatitis

cranium

pararenal

appendectomy

paraneural

cardiology

hepatomegaly

Here is how you should divide these terms. Either way is correct as the

combined suffix does not always need to be divided.

peri/ren/al

hem/o/stasis

neur/itis

hepat/itis

crani/um

para/ren/al

append/ectomy or append/ec/tom/y

para/neur/al

cardi/o/logy or cardi/o/log/y

hepat/o/megaly or hepat/o/megal/y

Now give the meaning of these terms. Start at the end of the term and work

to the left. Write the meaning in the blank lines. (The meaning you give

doesn’t have to be exactly the same as the one provided. We will use the

meanings from your flashcards.)

peri/ren/al ____________________________________

hem/o/stasis ____________________________________

neur/itis ____________________________________

hepat/itis ____________________________________

crani/um ____________________________________

para/ren/al ____________________________________

append/ectomy ____________________________________

para/neur/al ____________________________________

cardi/o/logy ____________________________________

hepat/o/megaly ____________________________________

The meanings for each of the previous terms are listed here:

peri/ren/al around (surrounding) the kidney

hem/o/stasis control (hold in) blood

neur/itis inflammation of nerve(s)

hepat/itis inflammation of the liver

crani/um (structure of the) skull

para/ren/al beside (beyond) the kidney

append/ectomy (the process of) removal of the appendix

para/neur/al relating to beside a nerve

cardi/o/logy (the process of) the study of the heart

hepat/o/megaly (the process of) enlargement of the liver

The words “the process of” are enclosed in parentheses because they usually

are left off when the word is defined in common speech. For example,

hepatomegaly commonly is defined as enlargement of the liver, not the

process of enlargement of the liver.

Now that you know the meaning of hepatomegaly, would you like to see

what code you would assign for this diagnosis?

789.1 Hepatomegaly

See how a medical term is translated into a diagnostic code? This code would

be entered on the medial claim form required for the insurance company.

Without it, the insurance company processing the medical claim would not

know what is wrong with the patient. A medical coding specialist’s job is very

important!

Word Meanings

People who work in the medical field often use shorter and simpler

meanings of words to save time. As you become more familiar with

medical terms, you probably will use simpler meanings also. Sometimes

a simpler meaning of a word can be formed by reading the word from

beginning to end.

Compare these simpler meanings that were given by an experienced coding

specialist to the meanings derived from word parts.

Term

Meaning Derived from Word

Parts

Simpler Meaning

thermometer instrument to measure heat heat-measuring instrument

paraneural relating to beside a nerve next to a nerve

cardiology

(the process of) the study of the

heart

heart specialty

hepatomegaly

(the process of) enlargement of the

liver

liver enlargement

For now, simply start at the end of a word that is new to you. This will help

you look for word parts that you recognize and help you give meanings for

word parts. This is the easiest way to find word parts and give meanings. As

you become more familiar with various word parts, feel free to use simpler

meanings.

Now let’s examine a few word parts and their meanings. Remember, you may

use your flashcards to find word part meanings, and as you learn more word

parts, dividing medical terms will become easier!

Word Part Meaning

bi/ two

/malacia softening

syn/, sym/ together with

gynec/o female

sarc/o nongland tissue, flesh

vit/o living, alive

chem/o chemical, drug

meta/ change, beyond

maxill/o upper jaw

nect/o bind

/oma tumor, mass

Examine the two boxes that follow. The boxes list common prefixes and

suffixes and their meanings. These boxes will help you as you divide and

combine terms.

Please pause and complete online Practice Exercise 4-1.

Step 4 Pronounce Word Parts

Now that you know the basics about dividing medical terms, practice pronouncing

word parts using the following exercise.

a. Take your Quick-Learn Tutor and your Set 4 flashcards out of your Quick-

Learn Kit. Insert the first flashcard for Set 4 into Side A of the Tutor.

b. Access the online portion of your course, and click on Lesson 4 Listen to

Word Parts.

c. Listen to a word part as it is pronounced. After you hear a word part, pause

the audio.

d. Look at the word part in the left window of your Quick-Learn Tutor and

practice pronouncing it out loud several times until you can pronounce it

correctly and easily. Push the flashcard up and read the meaning of the

word part.

e. Continue this process for all the flashcards for this set.

f. Next, put the flashcards in order and play the audio again. This time,

pronounce each word part in order but do not stop.

g. As you pronounce each word part, look at it on the flashcard. Listen to your

own pronunciation of each word part. If you mispronounce one, put a check

mark next to that flashterm.

h. Next, practice the word parts you mispronounced by listening again. Be

sure you can pronounce each word part clearly and easily.

Step 5 Write Word Parts

The next step in your lesson is to practice writing the terms you have just learned.

Follow these instructions:

a. Insert the first flashcard for Set 4 into Side A of your Quick-Learn Tutor.

b. Look at each word part as it appears in the window and say it out loud.

Write each word part on blank paper. Remember to include the slash.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the word part.

d. Do this for each flashterm for this set.

Step 6 Meanings of Word Parts

Follow these steps to learn the meanings of the terms you have pronounced and

written.

a. Again insert the first flashcard for Set 4 into Side A of your Quick-Learn

Tutor. Pronounce each word part out loud and then say the meaning. Check

yourself by pushing the flashcard up until you can see the meaning in the

right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud. Before you look, see if you can remember the

word part that goes with that meaning. Check yourself by pushing the

flashcard up until you can see the word part in the left window. Do this for

each flashterm for this set.

c. Practice with the flashcards several times until you are familiar with the

word parts and their meanings. You may use the flashcards for the Practice

Exercises and the-in Quizzes.

Please pause and complete online Practice Exercises 4-2 and 4-

Step 7 Combining Medical Terms

Combining word parts to form medical terms is just the reverse of dividing medical

terms into word parts.

When you learned to divide medical terms, you gained the skill of recognizing

long or complicated terms by dividing them into their word parts. Sometimes

when doctors fill out bills and charts, they may use a term unclearly or

incorrectly. If you know how to combine word parts, you can put together the

correct medical term from its everyday English meaning. This is the reason

for learning how to combine medical terms.

Knowing just a few word parts allows you to combine them into many

different medical terms. Look at this example of the number of new terms

you can form each time you add a new word part to your list.

Let’s see now. You only needed to learn eight word parts to build 16 medical

terms! Not bad. Just stick to the steps and before you know it, you will have

learned many word parts the easy way. Word parts, like nickels and dimes,

add up fast.

Would you like to see another example of a medical term that is coded? How

about gastritis? A patient visits the doctor because he has a stomachache.

After examination and testing, the doctor diagnoses him with acute gastritis.

You know that the meaning of gastritis is inflammation of the stomach. That

sounds painful!

535.00 Acute gastritis; without mention of hemorrhage

Isn’t it fun to see how what you are learning about combining medical terms

will later help you assign diagnostic and procedure codes? Keep working hard

and before you know it, you will be coding those medical records that we

learned about in the first lesson!

Consonants, Vowels and the Role They Play

Let’s go over the important things to remember when combining medical

terms. These rules will help you when combining most Latin terms.

Fact About Combining Word Parts

Use a combining vowel between a root word and a suffix that begins with a consonant.

Look at these examples of terms built from their English meanings. Each

suffix begins with a consonant. That’s why the combining vowel was used.

Meaning

Term with Suffix Beginning with

Consonant

Combined Term

tracing of the heart cardi/o/ + gram cardi/o/gram

surgical repair of a blood clot thromb/o/ + plasty thromb/o/plasty

to cut into the stomach gastr/o/ + tomy gastr/o/tomy

Facts About Combining Word Parts

• Do not use a combining vowel between a root word and a suffix that begins

with a vowel.

• Do not use a combining vowel between a prefix and a root word.

Thromboplasty is the surgical repair of a blood clot.

Look at these examples. The combining vowel is not used.

Meaning

Term with Suffix Beginning with

Vowel

Combined Term

blood tumor (lump) hemat/o/ + oma hemat/oma

look at living (tissue) bi/o/ + opsy bi/opsy

relating to the heart cardi/o/ + ac cardi/ac

Fact About Combining Word Parts

Use a combining vowel between two root words in a compound word even when the

second root word begins with a vowel.

Look at the following examples. The combining vowel is used between two

root words. All of the root words are in boldface type.

Meaning Compound Word Combined Term

heart specialist cardi/o/log/ist cardiologist

instrument to measure heat therm/o/meter thermometer

study of the stomach and intestines gastr/o/enter/o/log/y gastroenterology

relating to water electrical activity hydr/o/electr/ic hydroelectric

When dividing and combining terms in this course, it’s helpful to identify the

prefixes and suffixes in addition to the root words. For example:

Read from the beginning of the term to the end when you are

pronouncing a term you have created. And remember, read from the

end of the term to the beginning when you are checking the meaning of

a term you have created.

Now, let’s reinforce what you’ve learned so far with a few Practice

Exercises.

Please pause and complete online Practice Exercises 4-4 and 4-

Step 8 Pronounce Word Parts

Follow these steps:

a. Take your Quick-Learn Tutor and your Set 5 flashcards out of your Quick-

Learn Kit. Insert the first flashcard for Set 5 into Side A of the Tutor.

b. Access the online portion of your course, and go to Lesson 4.

c. Listen to a word part as it is pronounced. After you hear a word part, pause

the audio.

d. Look at the word part in the left window of your Quick-Learn Tutor and

practice pronouncing it out loud several times until you can pronounce it

correctly and easily. Push the flashcard up and read the meaning of the

word part. Continue this process for all the flashcards for this set.

e. Next, put the flashcards in order and play the audio again. This time,

pronounce each word part in order but do not stop.

f. As you pronounce each word part, look at it on the flashcard. Listen to your

own pronunciation of each word part. If you mispronounce one, put a check

mark next to that flashterm.

g. Next, practice the word parts you mispronounced by listening to the audio

again. Be sure you can pronounce each word part clearly and easily.

Step 9 Write Word Parts

These are the steps to follow:

a. Insert the first flashcard for Set 5 into Side A of your Quick-Learn Tutor.

b. Look at each word part as it appears in the window and say it out loud.

Write each word part on blank paper. Be sure to include the slash.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside each word part.

d. Do this for each flashterm for this set.

Step 10 Meanings of Word Parts

Follow these steps:

a. Again insert the first flashcard for Set 5 into Side A of your Quick-Learn

Tutor. Pronounce each word part and then say the meaning. Check yourself

by pushing the flashcard up until you can see the meaning in the right

window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud, and then say the word part. Again, check

yourself by pushing the flashcard up until you can see the term in the left

window.

c. Practice with the flashcards several times until you are familiar with the

words and their meanings.

d. When you feel comfortable with the spelling, pronunciation, and meaning

of each word part, go on to the next step.

Please pause and complete online Practice Exercise 4-6.

Step 11 Lesson Summary

Previously, you saw that medical terms are constructed of root words, prefixes, and

suffixes. By learning these word parts, you can divide a medical term into its word

parts and derive its meaning. You can take an unfamiliar medical term, separate its

root word from any prefixes or suffixes, and determine what that word means. This

is important because you cannot—and should not—memorize every single medical

term healthcare providers use. But you can learn to divide and combine medical

terms, and this skill will enable you to become a competent, professional medical

coding specialist. You’ll be able to break up unfamiliar medical terms so that you

can look them up in your medical dictionary and coding manuals to determine the

correct spelling and meaning.

Now don’t get discouraged if you found this lesson a little challenging. The

Practice Exercises in this lesson are important. If you skipped any or

struggled to complete some of them, go back and work on them again. Doing

so only will help you with the upcoming Quiz. U.S. Career Institute

successfully has graduated thousands of men and women from its program,

and we want you to be one of these success stories! If you need a helping

hand, call your instructor. And remember that we offer support even after you

graduate and as you advance in your new career.

LESSON 5

Medical Terminology: Abbreviations,

Symbols and Special Terms

Step 1 Learning Objectives for Lesson 5

When you have completed the instruction in this lesson, you will be trained to do

the following:

Recognize common medical abbreviations.

List and explain common symbols.

Describe eponyms and acronyms.

Differentiate between terms that sound alike.

Determine terms that are opposites.

Convert singular medical terms to plurals, and recognize medical plurals.

Step 2 Lesson Preview

Imagine you run into a good friend who has a hard time keeping in touch with his

family. When you ask him, “Did you write that e-mail to your brother?” he shakes

his head no. Now look closely at the question you asked. The sentence, “Did you

write that e-mail to your brother?” illustrates the complexity of the English

language.

You (not ewe) also will learn some common medical abbreviations and symbols.

Your question contained three sound-alikes—the words you, write, and to

sound the same as other words (ewe, right or rite, and too or two).

Sound

alikes, medical plurals, and opposites are just three types of medical

terms we’ll cover in this lesson. You (not ewe) also will learn some common

medical abbreviations and symbols.

As a medical coder, you will often encounter terms that may sound or look

alike, such as hypertension and hypotension. Not only do these terms sound

alike, but they’re also opposites. Hypertension refers to high blood pressure,

and hypotension refers to low blood pressure. It will be your job to determine

if the term you see is, indeed, the correct term. Additionally, as you’ll soon

find out, healthcare providers use many abbreviations and symbols. It seems

only natural since many medical terms are long and complex! If you are

familiar with these abbreviations and symbols, you’ll easily be able to convert

them into the correct medical terms so that you can code them properly.

Hypertension refers to high blood pressure, and hypotension refers to low blood pressure.

It’s amazing how much you already know about medical terminology from the

previous two lessons. This knowledge will allow you to understand all the

facets of your new career in medical coding. Healthcare providers will

appreciate your knowledge. So let’s get started with this lesson about special

terms!

Step 3 Abbreviations

Doctors frequently use shortened versions of longer words or phrases. These

shortened versions of words and phrases are called abbreviations. Abbreviations

are extremely useful to a doctor because they save valuable time. However,

abbreviations are not helpful unless you, the coding specialist, can determine the

names for the procedures the doctor performed. Because it is important to be

completely accurate, doctors and hospitals get together and produce lists of

approved abbreviations—abbreviations they all agree on and understand.

Abbreviations in Hospitals

The Joint Commission is an independent, not-for-profit organization that

regulates hospitals and other healthcare facilities. Hospitals are required by

the Joint Commission on Accreditation of Healthcare Organizations (also

known as The Joint Commission) to keep a list of acceptable abbreviations.

Only the accepted abbreviations may be used in the medical records for that

hospital.

Office Records

The rules for abbreviations are more relaxed for the records in individual

offices. However, any bills or insurance forms that are typed must follow the

hospital’s list of abbreviations.

Doctors

Doctors sometimes have their own personal abbreviations. As a medical

coding specialist, you will need to learn these personal abbreviations. This

will help you communicate more effectively with your clients or employer.

Pharmacies

Lists of medications and treatments that a pharmacy prepares are included in

the medical bill, and they appear on the insurance forms filed by the doctor’s

office or hospital. Usually Latin abbreviations are used for these medications

and treatments.

On your flashcards, beside each Latin lower case abbreviation you will see

the full Latin phrase. You will not need to learn the Latin words—just the

punctuation and the everyday meaning.

Step 4 Learn Abbreviations

It’s important to be familiar with common medical abbreviations, so take some

time to practice saying and writing medical abbreviations using the following

exercise. Because pronunciation is not an issue with abbreviations, there is no

audio to go with this flashcard set.

a. Take your Quick-Learn Tutor and your Set 6 flashcards out of your Quick-

Learn Kit. Insert the first flashcard into Side A of the Tutor.

b. Look at each abbreviation as it appears in the window and say it out loud.

Write each abbreviation on blank paper.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside each abbreviation.

d. Do this for each flashterm for this set.

Step 5 Meanings of Abbreviations

Follow these steps:

a. Again insert the first flashcard for Set 6 into Side A of your Quick-Learn

Tutor. Pronounce each abbreviation and look at how it is spelled. Then say

the meaning. Check yourself by pushing the flashcard up until you can see

the meaning in the right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud and then say the abbreviation. Again, check

yourself by pushing the flashcard up until you can see the meaning in the

left window.

c. Practice with the flashcards several times until you are familiar with the

abbreviations and their meanings. Don’t struggle to memorize them. You

may always look up abbreviations.

Please pause and complete online Practice Exercise 5-1.

Step 6 Slang

There are two types of slang you may encounter in the medical field—medical

slang and English slang.

Medical Slang

The laboratory is the lab.

Medical slang words are informal abbreviations for longer medical terms.

For example sedimentation rate is called sed rate. The laboratory is the lab.

Doctors use medical slang frequently for the same reason they use

abbreviations—to save time.

Fact About Medical Slang

If you encounter slang on a medical form, use the full term the slang represents. For

example: If the doctor wrote, “The patient was prepped for appy,” you would know to code

for an appendectomy.

Some medical slang terms are used so frequently that they become accepted

medical terms. Exam and prep are two examples of this.

What code would you use for appendectomy? An appendectomy is a surgical

procedure and is coded from a different manual than a diagnosis. The code

would look like this:

44950 Appendectomy

This code would be entered on the medical claim form to tell the insurance

company exactly what procedure the doctor performed for the patient.

Remember, the diagnosis is the reason the patient sees the doctor, and the

procedure is what the doctor decides to do to help the patient.

English Slang

English slang words are highly informal words not often used in

professional writing.

Facts About English Slang

Obscene or offensive statements are never put in any medical report, including patient

files, insurance forms, and patient charts, unless the patient is being quoted (in this

case, use quotation marks around the quoted statement). If the patient is not being

quoted, the offensive or obscene statement would be deleted.

• Correct: The patient said, “I fell down and hurt my ass.”

• Incorrect: The patient is a pain in the ass. (Leave out this entire sentence.)

Step 7 Slang Terms

Follow these steps:

a. Take out your Quick-Learn Tutor and your Set 7 flashcards. Insert the first

flashcard into Side A of your Quick-Learn Tutor.

b. Look at each slang term as it appears in the window and say it out loud.

Write the slang term on blank paper.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside each slang term.

d. Do this for each flashterm for this set.

Step 8 Meanings of Slang Terms

Follow these steps:

a. Again insert the first flashcard for Set 7 into Side A of your Quick-Learn

Tutor. Pronounce each slang term and then say the meaning. Check

yourself by pushing the flashcard up until you can see the meaning in the

right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud; then say the slang term. Again, check

yourself by pushing the flashcard up until you can see the meaning in the

left window.

c. Practice with the flashcards several times until you are familiar with the

words and their meanings.

Step 9 Symbols

The symbols used in medicine are no different from those used in everyday life.

When you use symbols, you must be sure the symbol is well known. To give you a

better understanding of which symbols are acceptable, we will go through the main

rules you need to remember.

Facts About Using Symbols

• When you use symbols, do not leave a space between the symbol and the numeral.

• However, do leave a space between a numeral and the symbol x. This symbol means “by” in

dimensions, as in 6 x 9.

Let’s take a look at the following list of symbols, what they mean, and how

they are used.

Symbol Meaning Example

degrees Celsius

degrees Fahrenheit

98.6

& and (between capital letters only) D&C

x times, by x 3 days, 2 x 3 x 5

+ plus (urine; reflexes) 3+

: ratio; ___ to ___ 1:2

/ per, vision test 2/day; 20/20

/ over (blood pressure) 120/80

– minus, ___ to ___ (range), through –2, 4–5, II–XII

- suture size 3-0 (000) silk

# number #16 Fr, #3-0 silk

Please pause and complete online Practice Exercises 5-2 and 5-

Try the online Practice Exercises to test your knowledge of slang words.

Step 10 Special Terms

In medical terminology, just as in the rest of the English language, there are

special terms that have specific rules. These special terms include proper nouns

and other capitalized words, sound-alikes, and opposites. Now we’re going to talk

about which words require special treatment, such as capitalization. You also will

learn about two special classes of terms: eponyms and acronyms.

Eponyms

In addition to the medical terms you learned to combine and divide in

previous lessons, medical reports contain other information, such as

laboratory test results, special medical abbreviations, and the names of

medical equipment and procedures. Often these words include proper

names—that is, brand names or the names of people. You must capitalize

proper names.

It was the custom in the past to use a person’s name to identify the

medical inventions or discoveries. The kinds of things named for people

include:

a new disease; a symptom or sign of disease

an anatomical structure

a new instrument, test or examination method

An eponym is a term that is formed from a person’s name. The person’s

name is given to the name of his or her discovery or invention to indicate

that person did the research and made the discovery. One example is

Bell’s palsy.

Fact About Eponyms

An eponym has two parts:

1. The person’s name as an adjective.

2. The type of invention or discovery as a noun.

Eponym Adjective Eponym Noun Meaning

Bell’s palsy facial paralysis

Pott’s clamp surgical instrument

Chiba needle long biopsy needle

McBurney’s point examination location

for the

appendix

Kaposi’s sarcoma unusual skin cancer

Because an eponym includes a person’s name, you won’t be able to divide it

into medical word parts. You do, however, capitalize the proper name in the

term, but not the noun.

If you use an eponym frequently enough, you probably will memorize how it

is spelled. Otherwise, you will have to look in your medical dictionary for the

proper spelling of eponyms.

Because it is difficult to remember the meanings of eponyms, it is becoming

less common for medical discoveries or inventions to be named for people. It

is now considered more professional to use a properly combined medical

term rather than an eponym. Nonetheless, doctors use eponyms frequently.

Brand Names

In the past, an eponym told you the name of the person who took credit for a

discovery or an invention. Some names of medical products indicate that a

company owns the patent for an invention or discovery. Brand names are

like eponyms because they demonstrate who discovered the procedure,

diagnosis, or disease. The kinds of new brand name eponyms you see today

are for the following:

General Electric CT scanner

a genetic cell line or tissue culture product

equipment or instruments

drugs or therapy methods

Look at these examples: General Electric CT scanner, Pen.Vee K penicillin and

Phillips’ milk of magnesia.

Don’t worry if you can’t pronounce some eponyms. All you need to be

able to do is to find the correct spelling in the dictionary. Before you

move on to acronyms, let’s take one more look at some common

eponyms.

Common Eponyms

Babkin reflex Halsted suture

Cantor tube Hodgkin’s disease

Charcot’s syndrome Hodgkin’s sarcoma

Colles’ fracture Kaposi’s sarcoma

Cooley’s anemia Legg’s disease

Epstein-Barr virus McBurney’s point

Erb’s palsy Miller-Abbott tube

Gordon’s reflex Pauley’s point

Laennec’s cirrhosis West Nile virus

Acronyms

An acronym is a word formed using the initials from a group of words or

from word parts. Here are some acronyms you probably already know:

Acronym Stands for

IRS Internal Revenue Service

USA United States of America

DMV Department of Motor Vehicles

Acronyms are a special kind of abbreviation. Doctors use acronyms because

they save time. Instead of writing the very long names of some diseases and

procedures, the doctor simply uses the acronym. Here are some examples of

some common medical term acronyms.

Medical Term or Phrase Acronym

cardiopulmonary resuscitation CPR

complete blood count CBC

USA is the acronym for United States of America.

Acronyms are formed by taking the first letter of each word in a phrase or by

taking the first letter of the word parts. For example, FTD stands for Florist

Telegraph Delivery, and NG stands for nasogastric. Not every word in the

phrase has to be represented in the acronym. Small, nonessential words are

usually omitted. For example, EENT stands for eye, ear, nose, and throat.

Acronyms usually are pronounced by saying the letters one by one. However,

if the letters of the acronym spell a word or can be pronounced as a word,

then the acronym may be pronounced as if it were a word. Let’s take a look

at a few examples.

Acronym Pronounced

EEG Say the letters—Ee-ee-gee

ELISA Pronounce the word—El-ee-sah

Scuba stands for self-contained underwater breathing apparatus.

In fact, some acronyms that are pronounced like words actually become

words if they are used often enough. The word laser began as an acronym for

the phrase Light Amplification by Stimulated Emission of Radiation. No one

bothers to say the whole phrase any more because laser is an accepted word.

The same is true of the word scuba, which stands for self

contained

underwater breathing apparatus.

Fact About Acronyms

Write acronyms in capital letters with no periods or spaces between the letters. For example,

CBC stands for complete blood count, and NSVD stands for normal spontaneous vaginal

delivery.

When you hear a new acronym, be sure to look it up and find out for what it

stands. This helps you write, type, and spell acronyms correctly. Most

common acronyms can be found in a medical dictionary.

Please pause and complete online Practice Exercise 5-4.

Step 11 Pronounce Acronyms

Follow these steps:

a. Access the online portion of your course, and click on Lesson 5. Listen to

Flashcard Set 8.

b. Put the first flashcard for Set 8 into Side A of your Quick-Learn Tutor.

c. Listen to each acronym as it is pronounced. Pause after each acronym.

d. Practice pronouncing each acronym until you can pronounce it clearly and

easily. You do not need to memorize the meaning of an acronym—only be

able to form it and look up its meaning on the flashcard.

e. Do this for each flashcard for this set.

Step 12 Sound-Alikes and Opposites

Two types of word pairs occasionally may present challenges for the medical

coding specialist. They are homophones and antonyms.

Homophones (Sound-Alikes)

At the beginning of this lesson, we called the words “to” and “too” sound-

alikes. Well, the more technical term for words that sound alike is

homophone. These words are not spelled alike, and they have different

meanings, but when homophones are pronounced, they sound the same. The

English language is full of homophones.

Look at these examples:

principle—principal

seen—scene

two—too

meddle—medal

As you can see, each of these four pairs of words looks different, but they

sound the same. As you work with medical records, doctors, insurance

companies, and others be careful that you distinguish between homophones

when you hear information. You certainly wouldn’t want to meddle in the

business’s principle scene when you really needed to know if the principal had

seen the medal. Okay, so that’s a stretch, but you get the idea!

Antonyms (Opposites)

Antonyms are words or word parts that have opposite meanings.

Sometimes these words sound similar to each other, which can cause

problems for someone with no training. Let’s take a look at these two

antonyms:

hypotension (low blood pressure)

hypertension (high blood pressure)

In your work as a medical coding specialist, make sure the terms you see

used make sense. Did the doctor mean what she wrote? If you have a

question, call the doctor’s office and check. Insurance companies will deny

claims for inaccurate codes!

Consider the following situation. If you know that normal blood pressure is

120/80, which term below is correct?

The patient has hypertension with a blood pressure of 90/60.

The patient has hypotension with a blood pressure of 90/60.

In this context, hypotension is correct because 90/60 is lower than 120/80.

The patient has hypotension with a blood pressure of 90/60.

The codes for hypotension and hypertension are different. You can see by the

following example how important it is to pay attention to the medical terms

and interpret the information in the coding manuals correctly.

458.9 Hypotension unspecified

401.9 Hypertension unspecified

Step 13 Medical Plurals

Many medical terms follow special medical plural rules. Some medical words even

have two plural forms, one which follows the normal English rule and one which

follows the medical rule. When there are two ways to make a medical term plural,

generally doctors use English rules when dictating reports for patients or other non-

medical people, and they use medical rules when reports go to other doctors or

into the medical chart. Since medical plurals and English plurals sound very

different, it will be easy for you to tell which rule the doctor is following.

Medical terms follow special medical plural rules.

Medical Rules for Plurals

In some cases, medical plurals are formed by changing suffixes. In other

cases, letters in the root word must be changed in addition to changes in the

suffix. The following chart shows you how to form medical plurals. Follow this

chart to form medical plurals.

Ending With Change To Example

/um /a medi/um—medi/a (mee-dee-uh)

/us /i calcul/us—calcul/i (cal-cue-lie)

/a /ae lamin/a—lamin/ae (lam-in-ee)

/is /es diagnos/is—diagnos/es (dy-ag-no-seez)

/itis /itid/es arthr/itis—arthr/itid/es (ar-thrit-a-deez)

i/on i/a criteri/on—criteri/a (cry-teer-ee-ah)

ax ac/es thorax—thorac/es (thore-a-seez)

ix ic/es cervix—cervic/es (serv-eh-seez)

ex ic/es index—indic/es (in-deh-seez)

yx yc/es calyx—calyc/es (kay-luh-seez)

Please pause and complete online Practice Exercises 5-5 and 5-

Step 14 Lesson Summary

Congratulations! You’ve almost completed the last of three lessons that have

introduced you to the language of medicine—medical terminology you need to

effectively and professionally perform your job as a medical coding specialist. You

learned about word parts (root words, prefixes, and suffixes), and how to divide

and combine a medical term and derive its meaning using its word parts. In this

lesson, we talked about how to use abbreviations and symbols in your work. This

lesson also presented information about such special medical terms as eponyms,

acronyms, homophones (sound-alikes), antonyms (opposites), and plurals.

Now that you have learned the essential building blocks of medical

terminology, you’re one step closer to coding medical records. All of this

knowledge will make your coding job that much easier. You’ll be able to

figure out and research complex or unfamiliar medical terms, abbreviations,

and symbols so that you can assign the correct code to medical records.

Healthcare providers view those codes as extremely valuable information.

Without them, without you, healthcare providers could not get reimbursed.

Nor could government healthcare agencies track serious or terminal illnesses,

which in turn leads to research funding dollars that help save lives!

Please pause and complete an online Quiz. Good luck!

LESSON 6

Documenting Medical Records

Step 1 Learning Objectives for Lesson 6

When you have completed the instruction in this lesson, you will be trained to do

the following:

Describe the importance of documentation in medical records.

Identify the various types of medical record formats.

Explain how healthcare personnel manage medical records.

Step 2 Lesson Preview

Previously in this course, you learned about medical records and what they mean

to healthcare facilities, as well as your new career! You know how these records

are created, why they exist, and their key components. But there is one part of the

medical record that we have not yet discussed—the physician dictation.

Doctors record notes about patient encounters.

In this lesson, we’ll look in detail at physician dictation, a primary component

of a patient’s healthcare records. Do you remember our example with Dr.

Green in that first lesson? At the end of the patient’s appointment, Dr. Green

recorded some notes about the encounter. This is called physician

dictation. This lesson also will address how medical records are documented

and managed. You’ll come to understand just how significant all of this is to

your job as a coder! So let’s get started by discussing the importance of

documentation.

Step 3 Documentation—The Key Component of

Medical Records

You know from a previous lesson that medical records serve as a valuable source

of communication. In addition, medical records act as an important resource for

legal protection, financial reimbursement, education, quality assurance, and

medical research.

As a medical coding specialist, you’ll use doctor’s dictation to substantiate the

charges on a medical bill. You see, patients are charged for services received

based on what the physician documents. Documentation is the written

record of the services that the provider performs. When the physician dictates

the diagnosis and procedure for the medical records, these eventually end up

on the medical bill.

A physician’s dictation substantiates the charges on the medical bill. Because

dictation records diagnoses and procedures, it contains a lot of the

information that ends up on medical bills. This is the information you will use

to assign the correct medical codes for reimbursement purposes.

Look at the following example of dictation that notes the diagnosis and

procedure of Becky Johnson’s physician visit.

Don’t worry if you didn’t understand everything in the previous example. Just

remember that the diagnosis, or problem, and procedure, or what was done

about the problem, are what you will use to assign codes in your work as a

medical coding specialist.

Physician documentation has another important function; it represents a

database for reimbursement decisions for Medicare, Medicaid, third-party

insurance coverage, workers’ compensation, and pension payments. If

services are provided but not documented, the healthcare provider will not be

reimbursed. In other words, if it’s not documented, it didn’t happen. Let’s

take a look at a quick example.

Dr. Green biopsies a skin lesion on a patient’s face and removes two skin

tags. A biopsy means to remove and examine a living tissue sample. Dr.

Green documents the biopsy but fails to document the removal of the skin

tags. The insurance company receives a claim indicating both procedures and

then requests the medical record to confirm the procedures performed. But

remember, the doctor only documented the biopsy. Because Dr. Green failed

to document the removal of the skin tags, the insurance company only will

reimburse for the biopsy procedure. Ah! Not a pleasant outcome for the

doctor! However, as a coder, you’ll be trained to notice that the physician left

off the procedure in his dictation.

Doctors document exams performed.

Let’s look at another example—this one also illustrates the importance of

documentation. A new patient comes to a local clinic with a complaint of ear

pain. The physician takes the patient’s history, and he then performs an

exam. He circles the level of service on the encounter form and discharges

the patient with a prescription for antibiotics. After the patient leaves, the

doctor dictates the service; however, he is interrupted and ends the dictation

after documenting the patient’s history.

This dictation goes to the medical transcriptionist, whom you learned about

in our first two lessons. She transcribes the dictation and then gives this

document to the medical coder. The coder reads the dictation and notes that

the level of service that the physician circled on the encounter form does not

match what was documented. In this case, the coder will contact the

physician to correct this error. Later in this lesson when we discuss how to

handle medical records, you’ll learn the proper procedures healthcare

professionals use to correct an error.

So as a medical coding specialist, you can see how important the

accuracy of documentation—written and verbal—is to everyone working

in the healthcare field. Now let’s move on to study the different types of

documentation and narrative formats you may encounter in your daily

work.

Types of Documentation

The type and format of a physician’s dictation vary among facilities, but all

dictation contains the date and time the entry was written, the patient’s

complaint, the problem, and what the physician did during the service.

Study the following sample of traditional dictation.

Name: Yasuyo Mora

#030601

Dr. Anne Jones

HISTORY

CHIEF COMPLAINT

Exacerbation of CLL and lymphoma.

HISTORY OF PRESENT ILLNESS

This is a 78-year-old Asian woman who presented with symptoms of chronic lymphocytic

leukemia and was treated with chemotherapy. She went into complete remission and then

relapsed into a lymphomatous state. She has received chemotherapy on an intermittent basis.

The last chemotherapy was three months ago. Now she is seen in the office because of

increasing general malaise, leukocytosis, weight loss, cough, multifocal adenopathy and right

pleuritic chest pain. History of prior aortic aneurysm repair.

REVIEW OF SYSTEMS

Appetite and weight have been poor. Denies nausea, abdominal pain or changes in bowel

habits. No genitourinary or musculoskeletal complaints.

PHYSICAL EXAMINATION

GENERAL: Skin was normal in color and turgor.

HEENT: Normocephalic. Good dental hygiene.

NECK: The neck is supple, but there is submandibular adenopathy.

CHEST: The chest is clear to percussion and auscultation. The heart has regular sinus rhythm

without murmurs or gallops.

ABDOMEN: Abdomen is soft and nontender with inguinal and femoral adenopathy. There is

no hepatosplenomegaly. There is fullness in the left iliac fossa.

IMPRESSION

Exacerbation of chronic lymphocytic leukemia, lymphomatous type.

PLAN

Admit to hospital for chemotherapy including VP-16, Oncovin, bleomycin and methotrexate.

____________________________________

Anne Jones, MD

D:02/04/XX

T:02/04/XX

AJ:BM

Commonly Used Narrative Formats

Providers use a common dictation format with some variations, of course.

Aside from the loosely structured traditional narrative, the frequently used

format is identified by the acronym—SOAP.

The SOAP format stands for subjective, objective, assessment, and plan. If

you see dictation that includes something like “S: Pt. has no burning on

urination...,” then the doctor or nurse is using a SOAP format.

Subjective means the patient’s point of view or complaint.

Objective refers to the clinical findings.

Assessment is the examiner’s diagnosis based on the clinical

findings.

Plan refers to the doctor’s order.

You might encounter other dictation formats as well. For example, you might

see dictation with the following headings:

CC, which stands for chief complaint and is the same as Subjective in

the SOAP format.

Px, which stands for physical examination and is the same as Objective

in the SOAP format.

Dx, which stands for diagnosis and is the same as Assessment in the

SOAP format.

Rx, which stands for prescription and is the same as Plan in the SOAP

format.

Rx stands for prescription.

Before you move on, let’s look at an example of SOAP dictation:

Name: Sheryl Brown

#030314

PROBLEM

Acute chest pain.

SUBJECTIVE

The patient has long-standing osteoporosis and rheumatoid arthritis, under treatment with

prednisone 40 mg p.o. daily. Yesterday she experienced the onset of severe left chest pain in

the left midaxillary line. She has had pleuritic pain and dyspnea since that time. There is no

history of trauma. In addition, there is pain in the right ankle.

OBJECTIVE

There is pinpoint tenderness in the midaxillary line over ribs 4-6. There is 3/5 limitation of

motion of right ankle secondary to pain. Inversion-eversion motion 3/5. The femoral, popliteal,

posterior tibial, dorsalis pedis pulses are full and equal bilaterally. The Achilles tendon

reflexes are equal bilaterally. There is pronation deformity of the right ankle and minimal

swelling of the right ankle. The tibiotalar joint appears to be well maintained. The

taloscaphoid area has more swelling.

ASSESSMENT

1. Rule out spontaneous rib fractures secondary to prednisone therapy.

2. Rheumatoid arthritis with destructive disease of the subtalar joint.

3. Osteoporosis.

PLAN

Rib series and rib taping if fractures are present. Bone survey with attention to the right ankle

and foot. Orthopedic consultation for evaluation of right ankle and foot.

____________________________________

Ryo Miyamoto, MD

D:12/20/XX

T:12/20/XX

RM:JEF

Step 4 The Business of Managing Medical Records

Different medical facilities manage medical records in various ways—each method

is designed to promote good recording practices. Good recording practices

include those activities and procedures that the medical facility and staff do to

ensure that a patient’s medical record is legible, understandable, timely, error free,

and reproducible. Let’s look more closely at the medical-records-handling elements

that are likely to affect you as a medical coding specialist.

The doctor might have to rewrite the entry if key elements of the health record actually cannot be deciphered.

Good Recording Practices

Every medical record must be:

Legible. The doctor might have to rewrite the entry if key elements of

the health record actually cannot be deciphered. This action should be

reserved for only the critical elements of the health record, and the

request must be made very diplomatically. If the illegible part of the

record has been documented legibly elsewhere, or is clear on the

dictation, no rewrite should be requested.

Understandable. For medical records to be understandable,

abbreviations and arrangement of forms in the medical record must be

consistent with the medical facility’s standards and procedures. Everyone

on the medical staff should know the facility’s rules for the use of

abbreviations in the medical record. In fact, personnel should have an

official list of acceptable abbreviations and their meanings.

Timely. Timeliness of entries is critical to the accuracy of the health

record. The medical coder must return the coded document in a timely

manner, and the bill must be submitted in a reasonable amount of time.

This way if information is lacking or incorrect, the sooner it gets to the

provider, the sooner the situation can be remedied.

Error free. How errors are corrected is extremely important in terms of

patient care, as well as for legal purposes. When an error is made in the

medical record, several protocols should be taken:

Timeliness of entries is critical to the accuracy of the health record.

• The entry should be crossed out with a single line.

• The source of the error should be noted, such as indicating that the

entry pertains to another patient or noting another specific reason for

the error.

• The initials of the person making the correction should be noted.

• The date and time the error was discovered should be noted.

Let’s look at an example of how an error would be corrected. The original

dictation indicates the arm was cut. It was discovered the leg, not the arm,

was cut. The dictation would be corrected as follows. You’ll see the initials of

the person making the corrections at the top of the record, with the time in

military format and the date.

JL, 1547,

12/07/XX

SUBJECTIVE leg

Jeff complains of a 3.5 cm wound on his arm that he received while cutting wood.

OBJECTIVE

Superficial wound measuring approximately 3.5 cm. The wound is cleaned and then repaired

with a simple closure.

ASSESSMENT leg

The patient is diagnosed with a 3.5 cm simple arm laceration.

PLAN

Patient to watch for signs of infection such as redness or oozing. He is to return in a week for

the removal of the sutures.

Correcting an Electronic Health Record

Correcting an error in an EHR should follow the same basic principles as

correcting a written medical record. The system must have the ability to track

corrections or changes to the entry once the entry has been entered or

authenticated. When correcting or making a change to an entry in an EHR, the

original entry should be viewable, the current date and time should be

entered, the person making the change should be identified, and the reason

should be noted. In situations where there is a hard copy printed from the

electronic record, the hard copy must also be corrected.

Reproducible. A medical record must be correctly formatted and clear.

Medical records may be photocopied, microfilmed, or even scanned

electronically for storage. Consequently, handwritten entries must be

made in black ink, and computer-generated reports must be reproducible.

Computer-generated reports must be reproducible.

Well, now you have an idea of what types of documentation you’ll primarily

use to “get your facts” on each patient. Don’t worry if you didn’t recognize

some of the terminology in the reports; you’ll continue to add to that

knowledge throughout your course and throughout your career!

Please pause and complete online Practice Exercise 6-1.

Step 5 Lesson Summary

In this lesson you learned how important doctor dictation and accurate

documentation are to medical records. You know that you, the medical coding

specialist, will use doctor dictation to ensure that providers get reimbursed for the

services they provide. We also talked about the different types of documentation,

and you studied examples of the types of documentation that you might encounter

in your work.

You also know how essential it is that all medical facilities have standardized

processes and procedures in place to ensure that patient healthcare records

are legible, understandable, timely, error free, reproducible, complete, and

confidential. In our next lesson we’ll talk further about medical records and

the lengths taken to protect the information they contain.

And, by the way, keep up the great work!

LESSON 7

Ethics and Legal Issues

Step 1 Learning Objectives for Lesson 7

When you have completed the instruction in this lesson, you will be trained to do

the following:

Explain the importance of confidentiality in the healthcare profession.

Describe the concept of ethics.

Outline the main purposes of the federal HIPAA regulations.

Explain fraud, and determine some common fraudulent situations that

you must avoid.

Explain the development of and need for Recovery Audit Contractors.

Discuss the basic ideas surrounding liability and malpractice, including

insurance coverage.

Step 2 Lesson Preview

Legal issues include confidentiality and ethics—concepts you need to keep in mind

always. No matter how well you do your job as a medical coding specialist, you

must also be ethical. A big part of that code of ethics is ensuring that a patient’s

private health information remains private.

Confidentiality and ethics are concepts you always need to keep in mind.

Patients depend on workers in the healthcare field to protect their privacy

from creditors, employers, insurers and others. If an employer learns of a

potential employee’s family history of diabetes, would the employer refuse to

hire the person? Would a life insurance company that learned of a client’s

transfer to hospice care find a loophole to terminate coverage? Questions like

these are certainly on the minds of many people today.

Step 3 Confidentiality

Do you remember the last time that you went to the doctor? Even if it was just a

regular check up, you wouldn’t want your doctor to discuss your appointment at

dinner with his friends, would you? As a healthcare professional, you have access

to many medical records. It is essential that you understand that these records are

confidential.

Confidential originates from the Latin word meaning with trust.

When something is confidential, it means that it is kept secret.

Confidentiality goes hand in hand with ethics, which will be detailed shortly.

You have learned a bit about medical records, and you’ve probably guessed

that because of their sensitivity, these records are confidential. That means

you can only release them to authorized persons. A medical facility must

consider a wide range of factors to ensure confidentiality of patient records.

These factors include:

hiring trustworthy, responsible staff;

ensuring information stored on computerized systems is secure and

available only to authorized individuals; and

having standardized, secured procedures in place for transferring patient

information within the facility, between facilities and to outside

individuals.

Guidelines for Confidentiality of Medical Records

Beginning with the people it employs, a hospital, physician’s office or

other healthcare facility must ensure that sensitive patient information is

only accessible to reliable people. It’s important that all the policies and

procedures that relate to confidentiality and release of all medical

records be written down and available for reference.

Review the following security procedures that help ensure confidentiality

of medical records and information:

Employees are prohibited from working on records of acquaintances.

New employees are required to sign confidentiality pledges before

they can access confidential information, and a system must be in

place to ensure that such statements are signed.

Security procedures are in place for accessing medical record

storage areas that aren’t under continuous supervision by

authorized staff.

All computerized patient information must only be accessible with a

unique password, and information system users must not share their

passwords.

A written plan is developed to deal with suspected breaches of

confidentiality.

All physicians who use the computer system should agree, in writing,

to keep their ID codes confidential and be responsible for

authenticating their dictation.

Guidelines for Faxing Medical Records

Procedures help ensure confidentiality when faxing medical records.

In addition to following the guidelines previously mentioned, it is

important to guard against unauthorized access to records in situations

where a fax machine is used. Even if the information is sent to an

authorized person, it is possible for someone else to receive the

information. Procedures that help ensure the confidentiality of faxed

medical records include the following:

Always follow the rules set out by the provider or client with whom

you are working. If there is a policy that prohibits sending records by

fax, then do not do it. If there are no such restrictions, follow the next

guideline.

Always have an original release form on file before sending any

patient records via fax. Do not accept a faxed copy of a patient

release form; although the form appears to be signed, you have no

way of knowing if that signature is valid because you are looking at a

copy of the form and not the form itself.

Send faxes only to a secure fax machine. This means you have to

verify with the receiving person that the fax either will be picked up

immediately or that the fax is in a secure area away from people who

are not authorized to see what you are sending.

Never send sensitive test information via fax. This includes HIV and

pregnancy test results.

Always use a fax cover sheet. The cover sheet must list your name,

company name, telephone number, fax number and the number of

pages sent.

Now that you have a better understanding of the sensitivity of medical

records, let’s talk about being ethical.

Step 4 Medical Ethics

Medical ethics include confidentiality, accuracy, integrity and completeness of

medical records and the proper storage of these records. Medical ethics also

involve guarding against fraud and misleading claims.

Being ethical means that you strive to do what’s right and that you are

dependable and trustworthy. As a medical coding specialist, you will have

access to confidential information regarding patients, physicians, insurance

companies and government insurance programs. Handling this information

correctly and appropriately establishes your credibility and level of

professionalism. To work in the medical field, you must maintain your

credibility and have a very high level of professionalism.

It’s important to maintain your credibility and have a high level of professionalism.

Most organizations have a code of ethics, which is a document that

outlines specific ethical guidelines. This statement usually is posted where

it easily can be read and lists specific behaviors and efforts that members

or employees are expected to uphold. A code of ethics helps the

employees of a company know what is expected of them but also helps

patients or consumers relax and know that they are dealing with a

credible, responsible office or business. Take a look at the sample code of

ethics from the American Academy of Professional Coders that follows.

Source: AAPC Code of Ethics: http://www.aapc.com/AboutUs/code-of-ethics.aspx 19 July 2012

Confidentiality and ethics go hand in hand with the Health Insurance

Portability and Accountability Act, which you’ll learn about next. You’ll

learn who must abide by the act, the details of the act and how the act

applies to you as a medical coding specialist.

Step 5 Health Insurance Portability and Accountability

Act

In 1996, Congress enacted the Health Insurance Portability and

Accountability Act (HIPAA). This bill has two main objectives. The first

objective is portability, which is to ensure the continuation of health insurance

coverage for workers and their families during times of job change or loss. The

second, accountability, is to increase the effectiveness of the healthcare system

while protecting health data integrity, confidentiality and availability, as well as

preventing fraud and abuse. We’ll focus on the second objective, accountability.

The Health Information Technology for Economic and Clinical

Health (HITECH) Act, enacted as part of the American Recovery and

Reinvestment Act (ARRA) of 2009, was signed into law on February 17,

2009, to promote the adoption and meaningful use of health information

technology.

HIPAA (as modified by the HITECH Act of 2009) requires

compliance to privacy standards and security in the maintenance and

electronic exchange of administrative and financial healthcare

information.

Many experts call HIPAA the most sweeping healthcare legislation in

years. Its provisions touch nearly everyone who works in health care.

Providers, payers and clearinghouses—anyone who deals with

confidential patient information is affected.

Covered Entities

Those that must follow HIPAA regulations are called covered entities.

Covered entities include health plans, healthcare clearinghouses and

healthcare providers who transmit any health information in electronic

form. A medical coding specialist who is a member of the covered entity’s

workforce is also known as a covered entity.

However, a medical coding specialist who is, for example, an

independent consultant providing coding services to a physician is not a

covered entity, but a business associate. A business associate is a

person that performs, or assists in the performance, of a function or

activity involving the use or disclosure of individually identifiable health

information. This includes claims processing or administration, data

analysis, utilization review, quality assurance, billing, benefit

management and practice management.

The contract between a

covered entity and a business associate must contain specific elements

describing the permitted and required uses of protected health

information. A sample business associate contract can be found at the

Department of Health and Human Services Web site at

www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/businessassociates.html

Now that you know who must comply with HIPAA, let’s look at the rules

that covered entities and their business associates must follow. Keep in

mind that when covered entities are referred to, it’s assumed that

business associates are included in the rule, as well, due to the contract

between covered entities and business associates.

Administrative Simplification Compliance Act

The different sections of HIPAA are known as titles. It is Title II, Subtitle

F that is probably the most important to the healthcare professional. This

part is called the Administrative Simplification Compliance Act. When

healthcare professionals talk about HIPAA and being HIPAA compliant,

they are usually referring to this section. The Administrative

Simplification Compliance Act (ASCA) sets up nationally consistent

regulations in four main areas:

Transaction and Code Sets Standards

Privacy Standards

Security Standards

Unique Identifier Standards

We’ll examine each of these standards in more detail and explain how it

affects you as a medical coding specialist. Let’s begin with transaction and

code sets standards.

Transaction and Code Sets Standards

According to HIPAA, a transaction is an electronic exchange involving the

transfer of information between two parties for a specific purpose.

transaction is electronic if it is transmitted with an electronic medium,

which includes Internet, Extranet, leased lines, dial-up lines and private

networks. Information physically moved from one location to another with

storage media, such as magnetic tapes, disks or CDs, is also considered an

electronic transaction. Telephone voice response or faxback systems are

not electronic transactions, according to HIPAA.

Transaction and Code Sets Standards simply outline the format and

codes used for electronic transmissions. At one time, there were about 400

formats for electronic health claims being used in the United States. This

lack of standardization made it difficult and expensive to develop and

maintain software to process claims. Today, it’s required that all covered

entities doing business electronically use the same transactions and code

sets. Let’s look at the standard code sets first.

Under HIPAA, specific code sets were adopted for diagnoses and

procedures to be used in all healthcare transactions. These code sets

include HCPCS (ancillary services/procedures), CPT (physician

services/procedures), CDT (dental terminology), ICD-9 (diagnoses and

hospital inpatient procedures), ICD-10 (replacement of the ICD-9) and

NDC (National Drug Codes). You’ll become more familiar with the HCPCS,

CPT and ICD-9 coding manuals later in the medical coding specialist

program. For now, it’s just important to know that these are the

recognized code sets used in the industry.

Now, let’s look at the standard transactions. You know about the CMS-1500

and UB-04 claim forms; however, when claim information is transmitted

electronically, it’s not submitted in the same format as you see on the paper

claim. Electronic data interchange (EDI) is the electronic transfer of

information in a standard format between trading partners. Basically, EDI is

the process of submitting a claim electronically in a standard format to an

insurance company for reimbursement for the provider’s services. Here is an

example of a claim submitted to an insurance carrier for Robert Daly seen

at the Medical Care Center:

Wow! That looks like gibberish, doesn’t it? As a medical coding specialist, it’s

not your responsibility to understand, describe or maintain this information.

You simply need to know that the claim information sent to an insurance

carrier is not transmitted in the same format as the paper CMS-1500 or UB

claim forms but in a standard form that HIPAA requires.

Finally, it’s helpful to recognize the terminology associated with these

electronic transactions. Since October 16, 2003, all healthcare businesses

that submitted claims electronically have been required to use version

4010. In 2012, version 5010 replaced version 4010 with improvements,

such as correcting technical issues, accommodating new business needs

and eliminating inconsistencies in reporting requirements.

All of this technical information may seem overwhelming to you.

However, keep in mind that it’s not the specifics that you need to know,

but the big picture. There are standards in the healthcare industry. These

standards define the codes you use, the forms you complete and how

information is submitted electronically. You may hear the term 5010 in

your work, and now you know that 5010 refers to the current standard

version of electronic transmissions!

Privacy Rule

The HIPAA Privacy Rule establishes national standards to protect

individuals’ medical records and other personal health information that

applies to covered entities.

The Privacy Rule addresses the use and

disclosure of a patient’s protected health information. Protected Health

Information (PHI) is individually identifiable health information, or

information that can be used to identify an individual, that is held or

transmitted by a covered entity or its business associate in any form,

whether electronic, paper or oral.

We’ll be talking about protected

health information a lot in this section, as it’s the foundation of the

privacy rule.

HIPAA requires that covered entities provide patients a notice of

privacy practices, which is a form that defines how the provider can

use PHI. A notice of privacy practice in plain language that describes the

following is necessary.

How the covered entity may use and disclose PHI about an individual.

The individual’s rights with respect to the information and how the

individual may exercise these rights, including how the individual may

complain to the covered entity.

The covered entity’s legal duties with respect to the information,

including a statement that the covered entity is required by law to

maintain the privacy of PHI.

Whom individuals can contact for further information about the covered

entity’s privacy policies.

In addition, the notice must include an effective date, and providers are

required to provide the notice on a patient’s first visit.

The basic principal of the Privacy Rule is to define and limit the

circumstances in which PHI may be used or disclosed by covered entities.

This rule allows healthcare providers to obtain a consent, or written

permission, to use or disclose a patient’s health information for

treatment, payment and healthcare operations, often referred to as TPO.

Written authorization is required for any use or disclosure of PHI that is

not for TPO or not otherwise specified in the Privacy Rule.

Authorization to disclose information forms must contain:

A specific description of the health information that will be used

The name or specific identification of the person or people to whom

the healthcare facility may disclose the information

The name or specific identification of the person or people who are

authorized to use the information

An expiration date that pertains to the individual or purpose of the

disclosure of the health information

A statement of a person’s right to rescind the authorization in writing

A statement that outlines the exceptions to the right to rescind

A statement that outlines how a person may rescind the

authorization right

A statement that the Privacy Rule would no longer protect health

information that the recipient redisclosed, even if authorization

disclosed it previously

The individual’s signature and the date

The following results in an invalid authorization:

The expiration date on the authorization to disclose information has

passed

The authorization to disclose information form is not completely filled

out

The authorization to disclose information form lacks one or more

required elements

The authorization to disclose information form covers more than one

request

The healthcare facility knows the patient or the patient’s legal

representative has rescinded authorization

The healthcare facility knows that some or all of the information in the

form is false

There are only two instances in which the patient may not rescind

authorization to disclose healthcare information: when the person or

people to whom the healthcare facility disclosed the information have

already taken action or when the authorization was given so that a

patient could receive insurance coverage, and the insurance company

contests a claim under the policy.

The Privacy Rules states that healthcare providers must make reasonable

efforts to use, disclose and request the minimum necessary amount of

PHI needed to accomplish the purpose of the authorization. Minimum

necessary limits unnecessary or inappropriate access to and disclosure

of PHI. Let’s look at an example to clarify this point.

A medical billing specialist that processes the billing for Weston Medical

Clinic does not require the entire documentation (medical record) to

submit a claim. The patient name and insurance information, as well as

the medical codes, are needed to create a claim for the reimbursement

process. Meanwhile, a medical transcriptionist does not need to know the

patient’s insurance information; she just needs to know who the patient

was, when the service was performed and what the provider did during

the service.

So, aside from our previous example, how does the Privacy Rule affect

you as a medical coding specialist? Well, in your healthcare profession,

you probably won’t be checking for consents or authorization, but you do

need to protect the patient’s medical record. Look at the following

scenario, and think about how the medical coding specialist should have

handled the situation differently.

Elizabeth does medical coding from home. Elizabeth’s home office is in the

living room of her townhome. She begins her day by connecting to an EHR to

pull the dictation that was transcribed the previous day. As she’s working on

assigning codes, Elizabeth’s neighbor, Alice, knocks on the door. Elizabeth

invites Alice in the living room for a cup of coffee. Forgetting to log off of the

EHR, Elizabeth runs to the kitchen to make the coffee. While alone in the

living room, Alice notices the name of a co

worker on the screen. Her

curiosity gets the best of her, and Alice inches closer to read the details on

the screen.

This is a violation of the Privacy Rule. It’s important that you, as the

medical coding specialist, keep the patient’s protected health information

private. After all, consider how you would feel if you were the patient in

one of these examples!

Security Rule

While the Privacy Rule focuses on protected health information in general,

the Security Rule deals with electronic protected health information

(ePHI). The Security Rule establishes a national set of security

standards for protecting health information that is held or transferred in

electronic form. This rule does not apply to PHI transmitted orally or in

writing.

Prior to HIPAA, no formal security standards or requirements

existed for protecting health information. As technology evolved,

computers became standard in the healthcare profession, allowing medical

information to become more mobile and efficient, but also increasing the

potential security risk. Computer hackers and viruses can wreak havoc on

computer systems; they can corrupt files, make information public and

change critical data.

The Security Rule has two primary purposes:

Require appropriate security safeguards to protect ePHI that may be

at risk.

Promote access and use of ePHI while protecting an individual’s health

information.

Specifically, HIPAA notes: A covered entity must have in place appropriate

administrative, technical and physical safeguards to protect the privacy of

protected health information. This includes any intentional or unintentional

use or disclosure of ePHI. HIPAA requires each covered entity to assess its

own security needs and implement the measures that best meet those

needs. Administrative, physical and technical concerns must be examined

when these entities protect privacy. This doesn’t mean that every employee

must now have top-secret clearance. Some changes can be simple. For

example, a good security step is to ensure that unauthorized people cannot

view computer monitors and faxed pages. Other security measures are more

complicated, such as using proper electronic data encryption. Encryption

means the electronic information is put into a coded form while transmitted.

The encrypted electronic information cannot be understood without the

appropriate decryption equipment. Take a look at the example that follows.

In your career as a medical coding specialist, you will have access to

protected health information. While electronic health records provide ease

of access, you must have in place appropriate administrative, technical

and physical safeguards to protect the privacy of protected health

information. How will you do this? Passwords, key cards and encryption

are a few ways.

Healthcare organizations must control access to their files. A small

physician’s office might simply provide passwords for its personnel to

meet this requirement. The medical coding specialist working from home

could log onto the computer system to access coding information with her

password, while the nurse practitioner at the office could renew

prescriptions and view and modify health histories with her password.

In a large hospital, the access requirements have a more complex set of

tools. Key cards might be used for personnel to access particular rooms

that house information databases within the multi-building complex. A

security officer might view daily printouts that detail who accessed

certain files with their passwords. She also might require password

changes every few months. The feature of the security standards may

vary to ensure that compliance is economically feasible for organizations

of every shape and size.

Using encryption software is a simple safeguard for the healthcare profession

to ensure patient privacy. When PHI is encrypted, even if a hacker is able to

gain access to medical records, he won’t be able to read or interpret the

information. The patient’s privacy is protected because a key is required to

unscramble the information.

Let’s look at the final standard in the Administrative Simplification

Compliance Act, which is the Unique Identifier Standard.

Unique Identifier Standard

The Unique Identifier Standard establishes the implementation

specifications for obtaining and using the standard unique health identifier

for health care providers. At this time, there are two standards when it

comes to unique identifier: the Employer Identification Number and the

National Provider Identifier.

In 2002, HIPAA adopted the Employer Identification Number (EIN),

which was issued by the Internal Revenue Service (IRS) to identify employers

on standard transactions, which includes CMS-1500 and UB-04 claims, as well

as all electronic transmissions of claims. The billing provider includes his EIN

on the claim to be used for 1099 taxable income reporting purposes.

HIPAA mandated the adoption of a standard unique identifier for

healthcare providers in 2007. The National Plan and Provider

Enumeration System (NPPES) collects identifying information on

healthcare providers and assigns each a unique National Provider

Identifier (NPI). The NPI regulation seeks to eliminate multiple

identifiers. At one time, health care providers, such as Medicare and

Medicaid, assigned identifiers for providers to submit with claims. These

identifiers were known as UPIN, OSCAR and PIN. The identifiers were not

standardized, resulting in one provider having multiple identification and

billing numbers. These legacy numbers complicated the claims

submission processes and resulted in the assignment of the same

identification number to different health care providers by different health

plans.

According to CMS, the NPI is a 10-position, intelligence-free numeric

identifier (10-digit number). This means that the numbers do not carry

other information about healthcare providers, such as the state in which

they live or their medical specialty. Once assigned, NPI is associated with

the same provider forever; it will not change, regardless of job or location

changes.

The use of standard identifiers is expected to ease the administrative

challenges associated with all aspects of patient healthcare records. These

challenges include documentation, maintenance and billing requirements.

These standard identifiers will allow the various entities within the

healthcare system to most effectively and efficiently perform their respective

financial, clinical, preventive and research functions. To put it simply, a

healthcare entity can devote more time to its own particular business and

patients and less to general paper pushing when using an NPI.

Now that you have a better understanding of the standards associated with

the Administrative Simplification Compliance Act, let’s look at what happens

when patient privacy is breached, which means there was a violation or

infraction of a standard.

Breach of Privacy

What happens when there is an intentional or unintentional use or

disclosure of ePHI? The HITECH Act requires covered entities to provide

notification in the event of a breach of unsecured protected health

information. Unsecured means the information hasn’t been encrypted.

For instance, if a computer hacker gained access to patient information

that hasn’t been encrypted, the practice would have to inform all patients

and the Department of Health and Human Services (HHS) of that breach.

In some cases, the practice is also required to notify the media. However,

if the ePHI is encrypted, patients do not need to be notified.

Following are two examples of data breach notifications. The first is a

notice from TRICARE posted to its Web site alerting the public of the

breach. The second is a news article, also notifying the public of the

breach, as required by HIPAA.

Letters are being mailed from Science Applications International Corporation

(SAIC) to affected military clinic and hospital patients regarding a data

breach involving personally identifiable and protected health information

(PII/PHI). On Sept. 14, 2011, SAIC reported the loss of backup tapes

containing electronic health care records used in the military health system

(MHS) to capture patient data from 1992 through Sept. 7, 2011 in San

Antonio area military treatment facilities (MTFs), including filling pharmacy

prescriptions and other patients whose laboratory workups were processed

in these same MTFs, even if the patients were receiving treatment

elsewhere. The data may include Social Security numbers, addresses and

phone numbers, and some personal health data such as clinical notes,

laboratory tests and prescriptions. There is no financial data, such as credit

card or bank account information, on the backup tapes

ref: http://www.tricare.mil/breach/

This breach affected nearly 5 million patients, making it the largest medical

data breach since the HHS began tracking incidents in 2009.

On May 14, 2012 federal prosecutors charged one of the hospital’s medical

technicians with violating the Health Insurance Portability and Accountability

Act, or HIPAA. Prosecutors say that over a 17-month period Laurie Napper

used her position at the hospital to gain access to patients’ names,

addresses and Medicare numbers in order to sell their information.

ref: http://www.kaiserhealthnews.org/Stories/2012/June/04/electronic-health-

records-theft-hacking.aspx

The first case was an example of an unintentional breach of ePHI, while it

was clearly an intentional violation in the second.

Now, let’s look at the organization that has the right to enforce, audit,

fine and charge covered entities for violations of HIPAA, such as those

you just examined.

Office for Civil Rights

HIPAA and HITECH are administered by the HHS in the Office of the Civil

Rights (OCR). The OCR enforces the Privacy and Security Rules by

investigating complaints and conducting compliance reviews, as well as

performing education and outreach to foster compliance with the rules’

requirements. Since the compliance date in April 2003, HHS has received

more than 71,849 HIPAA complaints. The OCR has resolved 91 percent of

complaints received (more than 65,460). The OCR has investigated and

resolved more than 16,708 cases by requiring changes in privacy

practices and other corrective actions by the covered entities. Of the

remaining complaints, 8,514 were investigated, and no violation was

found; 40,238 complaints were resolved through closure of cases that

were not eligible for enforcement because the entity wasn’t covered

under the Privacy Rule, the complaint was not filed in a timely fashion or

the incident described wasn’t in violation of the Privacy Rule.

HIPAA Privacy & Security Rule Compliant Process

The HIPAA complaint process includes possible criminal violations being

reported to the Department of Justice (DOJ).

Let’s look at those complaints that were resolved through investigation and

enforcement. If the evidence indicates that the covered entity was not in

compliance, the OCR will attempt to resolve the case with the covered

entity by obtaining voluntary compliance, corrective action and/or a

resolution agreement.

A resolution agreement is a contract signed by HHS and a covered

entity in which the covered entity agrees to perform certain obligations

(e.g., staff training) and make reports to HHS, generally for a period of

three years.

The HHS monitors the covered entity during these three

years to ensure that the entity is in compliance with the obligation.

According to the OCR, most Privacy and Security Rule investigations are

concluded to the satisfaction of the OCR. However, if the covered entity

does not take action to resolve the matter in a way that is satisfactory,

the OCR may decide to impose civil money penalties (CMPs) on the

covered entity. Under the HITECH Act, mandatory penalties have been

and will be imposed for willful neglect. According to HIPAA, willful

neglect means conscious, intentional failure or reckless indifference to

the obligation to comply with the administrative simplification provision

violated. Civil money penalties for willful neglect can extend up to

$250,000, with repeat or uncorrected violations extending up to $1.5

million.

You’ve learned a lot in this section! You studied the basics of HIPAA and

the HITECH Act. You know the standards associated with the

Administrative Simplification Compliance Act and understand how they

apply to your career as a medical coding specialist. And you found that

the OCR has the right to enforce, audit, fine and charge covered entities

for violations of HIPAA.

The last section about the violations of HIPAA may have seemed a bit

daunting, but it’s important to know that there will be ramifications for

willful neglect. However, the key is remembering to act in an ethical

manner and keep patient information private. As a medical coding

specialist, you know not to share a chart note you’ve reviewed earlier

that day with your family during dinner. You understand that coding a

chart of a close friend isn’t the best idea; it should be coded by someone

else! And you would never share your neighbor’s medical conditions with

another neighbor. These safeguards will keep you from breaking any of

the rules you’ve just learned about! Now, let’s pause for a quick review.

Please pause and complete online Practice Exercise 7-1.

Step 6 Fraud and Abuse

One of the government’s top priorities is to eliminate healthcare fraud.

Unfortunately, investigations of fraud and abuse are on the rise. Fraud occurs

when inaccurate information is used to wrongfully gain compensation. Fraud is a

crime. In the medical field, this often can occur in the medical record itself. For

example, a patient’s insurance coverage becomes effective June 15. The patient

receives service from a provider on June 1. The medical record is altered to

indicate the date of service as June 20 to allow the treatment to be covered by

insurance. This is fraud.

To guard against fraud, you must do one simple thing: Be accurate. Don’t

be tempted to change information on medical records if that information

already is correct. If you do change correct information, you are

committing fraud, and the consequences can be severe.

The U.S. General Accounting office estimates that $1 out of every $10

spent on Medicare and Medicaid is lost to fraud and abuse. With the

increasing costs associated with health care, the reduction of fraud and

abuse has become a point of focus for CMS.

Fraud examples:

Billing for services or supplies that were not provided

Altering claims to obtain higher payments

Soliciting, offering or receiving a kickback, bribe or rebate

Provider providing services for fictitious patients

Using another person’s Medicare card to obtain medical care

Abuse examples:

Excessive charges for services or supplies

Claims for services that are not medically necessary

Breech of the Medicare participation or assignment agreements

Improper billing practices including billing Medicare when Medicare is not

primary

Fraud and abuse can be reported to the federal Office of Inspector General,

OIG. This governing body then makes a decision as to the penalty. The

penalty can be monetary, criminal, administrative or a combination of any of

the three. The Office Inspector General is also responsible for notifying the

state intermediaries of any new scams.

As a medical coding specialist, you need to be sure you are coding properly,

that you are not coding for medically unnecessary services, that the Medicare

patient is who she says she is and that you are using an appropriate fee

schedule. Keep in mind you are human and may make a mistake from time to

time. Medicare is not after you; they are looking for those who are purposely

defrauding the system.

Preventing Fraud and Abuse

The Federal False Claims Act (FCA) was signed into law in 1863 by

Abraham Lincoln and is the basis for prosecution of healthcare fraud and

abuse claims. The FCA prohibits anyone from presenting a false or

fraudulent claim to be paid by the government, using a false record or

statement to conceal or avoid paying money to the government or

conspiring to defraud the government.

The FCA was not originally intended to investigate healthcare providers,

but in recent years, this has become increasingly necessary, as well as

very costly. In 1986, Ronald Reagan signed amendments into law that

significantly strengthened the government’s ability to successfully

prosecute for fraud. Damages increased from double to triple, and the

FCA was extended to include unintentional misconduct.

To prevent fraud and abuse, many healthcare providers have created

corporate compliance plans. Compliance plans are formalizations of

processes that identify, investigate and prevent violations in various

healthcare services.

In addition, the government has created model compliance plans for hospitals

and clinics. These include structure, standards, oversight, education,

monitoring and enforcement.

Insurance rates increase when an insurance company pays fraudulent

claims. When codes are not correct, the insurance company will not pay

the correct amount, which delays doctors’ payments and leads to

increased healthcare costs. Thus, insurance companies often try to collect

damages when they discover fraudulent claims.

Consequences of Committing Fraud

Fraud is a crime and, therefore, punishable by law. If the fraud was

intentional and systematic, and if the effects of the fraud were far-

reaching, the justice system can impose harsh penalties, including jail

time.

The criminal side of fraud is only half of the picture. There are also civil

consequences to fraud. Fraud affects us every day. When insurance

companies pay fraudulent claims, rates increase unnecessarily. Insurance

companies often try to collect damages when they discover fraudulent

claims. These damages include compensatory damages and punitive

damages.

Compensatory damages are damages directly related to the fraud. For

example, if a claim submitted to an insurance company with charges for

$700 worth of procedures that were not performed, the civil courts might

award the insurance company $700 in compensatory damages.

Compensatory damages represent the compensation a plaintiff receives

from a defendant for the actual damage caused (in our example, $700 in

overcharges). The plaintiff is the person who files the claim and initiates

a lawsuit, while the defendant is the person named in the claim or

charged with the crime. However, if the insurance company feels the

fraud was intentional or perhaps negligent, it might ask for punitive

damages.

Doctors and other healthcare professionals can be liable for damages in some situations.

Punitive damages are damages awarded to the plaintiff to punish the

defendant and, theoretically, deter the defendant from repeating the fraud in

the future. Punitive damages can far exceed compensatory damages. In our

$700 example above, a court might award punitive damages for five times

that amount ($3,500) if the fraud was intentional. Punitive damages are

awarded above and beyond any compensatory damages. That means our

original $700 judgment has now swelled to $4,200! This is a high cost for a

lapse in judgment. In addition, whoever committed the fraud is responsible

for paying all damages.

Doctors and other healthcare professionals can be liable for damages in some

situations, whether their actions were intentional or not. To help protect

healthcare professionals, insurance companies offer a variety of liability

insurance coverage.

Step 7 Liability Insurance

When you drive a car, you run the risk of being in an accident. Obviously, you don’t

set out to intentionally hit another car, but accidents happen. To protect yourself

and the other drivers on the road, you carry some form of automobile insurance.

No doubt you’ve heard of people being awarded thousands of dollars by courts for

damages suffered in accidents. If you have insurance, then your insurance

company pays for these damages. (After all, that’s what insurance is for.) If you

aren’t covered by insurance, then you pay the entire amount!

Doctors and other healthcare professionals can be covered by medical

liability insurance. The physician you work with usually carries this

insurance. In case there are damages suffered as a result of an accident or

negligence, the insurance covers the doctor, the doctor’s staff and anyone

the doctor contracts with for services relating to the practice.

In the medical world, physicians are legally responsible for their actions,

as well as the actions of their employees and anyone they contract with

for services relating to their practice. This protects you, the medical

coding specialist, as long as you stay within the scope of your duties,

which means as long as you are doing the job you were hired to do.

However, if you knowingly submit fraudulent claims or break the law in

some other manner, you are liable, and insurance won’t cover you. Let’s

look at two situations.

Example 1 While coding from a complex dictation, Julia accidentally

transposes two numbers, causing an error that results in overpayment by

the insurance company.

Example 2 Hillary works with Dr. Gregg. Dr. Gregg hands her his

dictation and says, “Don’t use the surgical package code. I never do

because I get more money if I code everything separately.” Hillary does

as Dr. Gregg asks.

Which example represents fraud? The answer is Example 2. When Hillary

knowingly goes along with Dr. Gregg, she is submitting codes she realizes

are false. This should be reported, not complied with. How do insurance

companies catch fraudulent claims? They conduct company-auditing

procedures.

Insurance Audits

Insurance companies guard very closely against fraud. Even with

safeguards, some fraudulent claims sneak through. However, through

insurance audits, many of these claims are caught. An insurance audit

is a thorough review by the insurance company of a claim and all related

documentation. Auditors compare and search the records for

inconsistencies and alterations.

What triggers an insurance audit? Well, the insurance company might find

the claim suspicious or notice that the doctor files an unusual number of

similar claims. On the other hand, the patient might bring a questionable

claim to the attention of the insurance company.

Many insurance companies encourage their clients to review medical

records and bills to ensure that the procedures listed were performed and

the diagnosis is accurate. If a patient has a question, the insurance

company has a toll-free number to call for that purpose. If there is an

overcharge on a claim that a patient notified the insurance company

about, that patient usually gets some kind of cash reward from the

insurance company. This encourages patients to review their records.

As a medical coding specialist, you may be interested in an auditing

position. Auditing ensures medical necessity, correct coding and

compliance. The knowledge you learn in this program will provide you the

skills for an entry

level position.

Step 8 Recovery Audit Contractors

According to the OIG, it is estimated that $16.4 billion in improper payments and

error rates were made in 2000.

The Medicare Modernization Act of 2003 created

a three-year project to recover Medicare overpayments and identify

underpayments. The three-year project focused on California, Florida, New York,

South Carolina and Massachusetts. In March 2008, the program ended with more

than $1.03 billion recovered from improper payments. Approximately 96 percent of

the improper payments were overpayments collected from providers, and the

remaining four percent were underpayments paid to providers.

The Tax Relief and Health Care Act of 2006 expanded this project to all 50

states, creating a permanent and nationwide program by 2010. CMS

contracted Recovery Audit Contractors (RACs) to recover overpayments.

RACs are paid on a contingency fee basis, receiving a percentage of the

improper payments they collect from providers.

RACs may review the last

three years of provider claims for the following types of services: hospital

inpatient and outpatient, skilled nursing facility, physician, ambulance and

laboratory, as well as durable medical equipment.

In 2011, CMS reported that it has collected more than $313 million in

Medicare overpayments through its recovery audit program since October

2009.

However, RAC decisions can be appealed. Look at the following

report:

The Centers for Medicare & Medicaid Services (CMS) has released appeals

data for Medicare fee-for-service Recovery Audit Contractors (RACs). For

claims originating in fiscal year 2011 (Oct. 1, 2010-Sept. 30, 2011),

providers appealed 56,620 repayment demands, over 6.25 percent of the

903,372 claims with overpayment determinations. Of these, 24,548 (43.4

percent) were decided in providers’ favor. Approximately 2.7 percent of all

claims with overpayment determinations were overturned on appeal.

ref: http://www.aapcps.com/news-articles/RAC-appeals-won.aspx

As with liability concerns, there are several legal concerns to consider when

working with medical records. Let’s take a closer look.

Step 9 Legal Concerns

The legal system in the United States is very complex. Attorneys study it for years

and still may not understand everything there is to know about law. While we will

cover some of the basic concepts regarding medical records and the law, you

should always consult an attorney if you have to deal with the legal system. By

doing so, you receive expert advice from someone who knows the system. This

section gives you an overview of some very basic concepts, which will enable you

to effectively communicate with other medical professionals.

Subpoenas

A subpoena is a legal document issued by the court requiring the person

named on the subpoena to appear in court or to supply certain

documents or both. A subpoena can authorize the legal release of

confidential medical records.

A subpoena cannot be mailed. Instead, it is served personally by an

authorized person. If you are served with a subpoena and fail to respond,

you can be arrested and charged with a crime. A subpoena is a legal

document and must never be ignored.

When you follow the directions contained in the subpoena, you have

complied with it. To comply with a subpoena for medical records, you

generally have a specified amount of time to produce the records. You

make copies of the appropriate records, and supply the copies to

whoever is named on the subpoena. Usually, this is an attorney.

If you receive a subpoena to testify, it means you must appear at the

designated court on the assigned day and time. You cannot be late, and

you cannot ignore the subpoena. Sometimes you are paid for your time,

and the fee is included with the subpoena. Remember not to get angry

with the person serving the subpoena. The server is usually neutral, not

involved with the case at all and “just doing a job.”

When a subpoena is issued, it usually means someone is headed to court and

needs the medical records for a case. Sometimes, however, disputes don’t

end up in court. Instead, they may be heard in arbitration.

Arbitration

Arbitration is an alternative to a court of law. In arbitration, two disputing

parties meet with an arbitrator, or a person chosen to decide a dispute or

settle differences. Each party tells its side of the situation, and the arbitrator

issues a ruling. In binding arbitration, the ruling is final and must be

obeyed. In nonbinding arbitration, the ruling is merely a suggestion from

an objective person. Many contracts now specify that disputes must be

settled in binding arbitration rather than in court. Arbitration is much less

expensive and usually resolves problems faster than the court system.

Medical Testimony

If arbitration is not an option, or if someone insists on going to court, then

people may have to provide testimony. Testimony is the sworn statements

of witnesses and experts given while on the witness stand in court. Witnesses

give statements under an oath of truth, and people who lie during testimony

can be charged with perjury, a serious crime.

In medical cases, doctors are sometimes called to testify. Often, doctors

testify as expert witnesses—people who know about the circumstances

surrounding a case, but not necessarily about the case itself. For example,

imagine a trial involving physical evidence, such as DNA. The DNA is analyzed

and the results brought to court. The side presenting the evidence might

have an expert talk about DNA in general. That expert is someone who

knows about DNA but has no other connection to the case. This person is an

expert witness.

Now it’s time to review what you’ve learned about fraud and abuse with the

following Practice Exercise.

Please pause and complete online Practice Exercise 7-2.

Step 10 Lesson Summary

We covered a lot of information in this lesson. Ethics and credibility are interwoven

like threads in a rug. When you are in business, whether it is your own or someone

else’s, you must always keep a strong code of ethics foremost in your mind. If you

follow the principles of these ethics, you can relax and do your job. You have

credibility. People can count on you.

Privacy and security are major concerns as more and more healthcare

data is transmitted and maintained electronically. The Health Insurance

Portability and Accountability Act is, in part, is federal legislation that

governs health information in electronic form. Here, legal and ethical

issues are joined. As a medical coding specialist, you must be sure that

you follow strict guidelines in protecting the confidentiality of the patient

information entrusted to you. A signed patient consent, obtained by the

physician, permits you to release information for purposes of treatment,

payment and healthcare operations. You must not make any other

release of information unless the patient has provided a signed

authorization allowing such release.

Even the most ethical person can make a mistake. Mistakes can be

covered by liability insurance carried by the physician with whom a

person works. Fraud, however, is an intentional misrepresentation of

facts. Fraud usually is committed to try to gain more money or some
other undeserved benefit. Fraud is illegal. When illegal acts are
committed or if two parties have a disagreement that cannot be settled,
the legal system might come into play.
The legal system, as you’ve learned, settles disputes and upholds laws.
Subpoenas are often used to present all the facts. A subpoena is a
document that is served to a person who is in possession of vital
information. This information might be in the form of medical records, or
it might be in the form of expertise in the field. If you are in charge of
records that are listed on a subpoena, you should make sure you are
authorized to release the records to the appropriate party, and then you
may do so.
Arbitration is used when two parties disagree and cannot settle their
disagreement. Binding arbitration means the arbitrator’s decision is final and
must be followed. In nonbinding arbitration, the decision of the arbitrator is
treated as a suggestion. Finally, you learned that sometimes a physician has
to go to court to provide medical testimony.
Now, let’s test your understanding of this lesson with a Quiz.
 Please pause and complete online Quiz. Good luck!
Endnotes
1
 HITECH Act Enforcement Interim Final Rule, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.html
2
 The Definition of Business Associate, Health Insurance Portability and Accountability Act, http://www.hipaa.com/
2009/05/the-definition-of-business-associate/, 2009
3
 Transaction & Code Sets Standards, Centers for Medicare & Medicaid Services, http://www.cms.gov/Regulations-
and-Guidance/HIPAA-Administrative-Simplification/TransactionCodeSetsStands/index.html?
redirect=/TransactionCodeSetStands/, March 22, 2012
4
 The Evolution of the ANSI ASC X12N 837 format from the UB-92 Flat file format, Public Health Data Standards
Consortium, http:/www.phdsc.org/standards/pdfs/EvolutionofANSI.pdf, Jan. 13, 2004
5
 The Privacy Rule, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html
6
 Summary of the HIPAA Privacy Rule, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf, May 2003
7
 Notice of Privacy Practices for Protected Health Information,U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/notice.html, April 3, 2003
8
 Summary of the HIPAA Security Rule, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html

9
 How OCR Enforces the HIPAA Privacy Rule, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/enforcement/process/howocrenforces.html
10
 Case Examples and Resolution Agreements, U.S. Department of Health & Human Services,
http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/index.html
11
 Centers for Medicare & Medicaid Services’ Use of Medicare Fee-for-Service Error Rate Data to Identify and Focus on
Error-Prone Providers, U.S. Department of Health & Human Services,
http://oig.hhs.gov/oas/reports/region5/50800080.pdf, Oct. 29, 2010
12
 Recovery Audit Contractors (RAC), American Health Information Management Association,
http://www.ahima.org/resources/rac.aspx
13
 Recovery Audit Contractor (RAC) Program, American Hospital Association, http://www.aha.org/advocacy-
issues/rac/index.shtml
14
 CMS collects $162 million in overpayments in first three months of 2011, Modern Healthcare, March 14, 2012

LESSON 8

Introduction to Anatomy

Step 1 Learning Objectives for Lesson 8

When you have completed the instruction in this lesson, you will be trained to do

the following:

Explain the basic components of human biology.

Describe the human body, including how it works and how it is put

together.

Define the terms used to locate parts of the body.

Step 2 Lesson Preview

Leonardo da Vinci’s human form

When Leonardo da Vinci drew his sketches of the human body back in the 15th

century, he probably didn’t anticipate just how important the study of the human

body would become. In this lesson, you will be introduced to the basic components

of human biology, including anatomy, physiology and pathology. Keep in mind that

we do not expect you to memorize every term. The more familiar you are with your

terminology, the quicker and easier it will be to complete some of your tasks as a

medical coding specialist. However, it is important you use your research tools. If

you don’t remember a word while completing your lessons or while working, use

your materials or flashterms to help.

Today many people use anatomy daily in their professions. Athletic coaches

must be well versed in anatomy because their knowledge of muscles and

bones helps their players achieve top performance and avoid injury. Doctors

must know vast amounts of anatomy, from the top of the human head down

to the little toe, and all the nerves, blood vessels, and organs in between.

Medical coding specialists must know anatomy to understand the terms they

see in their work. Your knowledge of medical terms, as well as anatomy,

work together to make you a competent coder.

In this lesson, you will see how anatomy affects our everyday lives. We’ll

begin with an introduction to the science of life—biology. After you learn

about basic human biology, we will move into the more specific science of

anatomy, including physiology—the study of how the body works. Don’t

worry! We will move at a comfortable pace, and we’ll carefully cover each

detail you must know.

Step 3 Human Biology

For the next several lessons, you will learn about the study of human living things.

Because you are a human, you’ll learn a lot about yourself. In doing your Practice

Exercises and studying your flashterms, you’ll grow in your understanding of the

human body and the specialized terms doctors use to talk about the body.

What Is Human Biology?

Human biology is the study of how the body is put together and how

it works in health and disease. As a medical coding specialist, you do

not need to become an expert in biology. However, understanding the

basics of biology gives you a good background for the terms doctors

use, such as those you learned about in your medical terminology

lessons!

Human biology in the healthy state covers two basic concepts: anatomy and

physiology. Human biology in disease deals with pathology. Look at how

these concepts are related in the diagram on the following page.

We will discuss each of these topics in more detail. Remember, the idea is

not to become an expert in biology, but to understand the context of the

terms you might see in your daily work.

Biology deals with health and disease.

Anatomy

Anatomy is the science of the structure of the body—the appearance and

relationships of body parts. The two kinds of anatomy are gross anatomy and

microscopic anatomy.

Gross anatomy includes parts of the body that we can see with our

eyes. It is also called macroscopic anatomy.

Microscopic anatomy, or cell anatomy, includes parts of the body

that are too small to be seen with the naked eye.

The two kinds of anatomy are gross anatomy and microscopic anatomy.

Gross Anatomy

Gross anatomy focuses on the presence and appearance of a body

part. The study of the form of body parts is called morphology. The

form of a body part includes its size, shape, color, contour, and texture.

For example, when a kidney is normal in size, shape, color, contour, and

texture, it has normal morphology.

There is a morphologic difference between a jockey and a basketball player.

A basketball player and a jockey both have the same anatomic structure;

both have five fingers on each hand. However, there is a morphologic

difference between them. For example, the hand of the basketball player is

larger than the hand of the jockey.

Gross anatomy also deals with the location and position of the organs and

body parts. For example, not only should the heart be in the chest, but it

should be in the left side of the chest.

Fact About Gross Anatomy

The terms used to describe gross anatomy include:

• The names of the body parts

• Where the body parts are located

• How the locations of two body parts are related

Microscopic Anatomy

Microscopic anatomy is the science of the body’s individual cells and

tissues. This study is done with a microscope. The microscopic study of

cells is called cytology. The microscopic study of tissues is called

histology.

Fact About Microscopic Anatomy

The terms used to describe microscopic anatomy include:

• The names of different cell parts and cell types

• The colors cells become when they are dyed for microscopic examination

• The ways cells are arranged in different types of tissue

Physiology

Physiology is the study of how the body works; it describes the function of

the body, and its organs, tissues, and cells.

Each organ, cell or tissue has its own special physiologic function. For

example, kidneys make urine, but they cannot think. The brain thinks, but it

cannot make urine.

Physiology also can be divided into macroscopic physiology and microscopic

physiology.

Macroscopic physiology usually is called gross physiology.

Microscopic physiology usually is called cell physiology.

Physiology can be broken into gross physiology and cell physiology.

Step 4 Pathology

Pathology is the study of human biology when anatomy and/or physiology are

abnormal.

Facts About Pathology

• Abnormal physiology sometimes is called pathophysiology.

• Abnormal anatomy is called pathology or pathologic anatomy.

Pathology deals with abnormal anatomy and abnormal physiology. Look at

the relationships in the chart that follows. In the next section, we will

describe the relationships represented by the circles.

Pathology deals with abnormal anatomy and abnormal physiology.

How Do Anatomy, Physiology and Pathology Relate to

One Another?

In this section, we’ll examine normal anatomy and physiology.

Normal Anatomy/Abnormal Physiology

A person can have abnormal physiology but normal anatomy. For

example, a diabetic has abnormal physiology—the person cannot make

insulin—but the diabetic may have normal anatomy. The insulin-making

function is abnormal but the appearance and location of the organ that

makes the insulin is normal.

Abnormal Anatomy/Normal Physiology

A person can have abnormal anatomy but normal physiology. For

instance, a healthy dwarf has abnormal anatomy but normal physiology.

The anatomy is abnormal, but it functions normally.

Abnormal Anatomy/Abnormal Physiology

When an anatomic abnormality lasts long enough, it may lead to a

physiologic abnormality. For example, in early alcoholism, the liver changes

by containing more fat and enlarging. These are anatomic abnormalities. The

function is normal. If alcoholism continues long enough, the liver slowly stops

functioning. This is a physiologic abnormality.

The effects of a cold are physiologic abnormalities.

On the other hand, when a physiologic abnormality lasts long enough, it may

lead to an anatomic abnormality. For example, at the start of a cold, you

have sniffles and a loss of smell. These are physiologic abnormalities. The

function of the nose is abnormal. The anatomy of the nose, its size and color,

is normal. Later, you may have a swollen, red nose from the cold. Swelling

and redness are pathologic changes in anatomy. Because swelling and

redness are changes in size and color, they also can be called morphologic

changes.

For most disease processes, anatomy and physiology both are abnormal by

the time a diagnosis is made. For example, in the early stages of alcoholism,

the liver functions well, and the liver function tests are normal. The diagnosis

of alcoholic liver disease usually is not made. The patient feels fine and

cannot believe that the liver is abnormal. When both the anatomy and

physiology are pathologic, the patient feels sick, and the liver function tests

are abnormal. So you can see that the diagnosis is not usually made until

both the anatomy and physiology are pathologic.

Likewise, in the early stages of a cold, when you just have sniffles, you say,

“I think I’m getting a cold.” When your nose is red, swollen, stuffy, and runny,

you say, “I have a cold.” Again, the diagnosis isn’t usually made until both

anatomy and physiology are abnormal.

So even though diseases can be divided into anatomic pathology and

pathophysiology, medicine often deals with both anatomic and physiologic

pathology at the same time.

Please pause and complete online Practice Exercise 8-1.

Step 5 Beginning Anatomy and Physiology Concepts

Now that you have a basic understanding of human biology, you are ready to move

on to the more specific science of anatomy and physiology. Anatomy and

physiology are two key components in the medical world. Remember:

Anatomy refers to the structure of the body—the appearance and

relationships of body parts, such as muscles, bones, organs, and other

systems.

Physiology is the study of how these body parts work together to

sustain life—the functions of the body and its organs, tissues, and

cells.

The Anatomic Position

Doctors use a system to describe the location of anatomical parts. This

system assures that there is no confusion about the location of any body

parts. The location of body parts is always described as if the patient were in

the position shown in the following figure. This body position is called the

anatomic position.

Notice the position of the hands in the figure. The palms face forward, and

the thumbs face outward. No matter what the position of the patient, the

doctor describes the location of anatomic parts as if the patient were in this

position. Stand up and put your body in the anatomic position.

The anatomic position

Be sure you remember the anatomic position. The terms you learn in this

lesson are based on the relationships of body parts when the body is in this

position. When you are working as a medical coding specialist, understanding

the anatomical position and the relationship to body parts will help you

assign correct diagnostic and procedure codes.

Planes and Sections of the Human Body

The human body has three dimensions: height, width and depth.

Fact About Dividing the Body

The body can be divided in three different ways:

• Superior and inferior (top and bottom) sections

• Right and left sections

• Anterior and posterior (front and back) sections

Dividing the body like this helps you understand where organs or parts are

located. You can divide the body into these sections by making a mental

“slice” or “cut.”

Transverse Planes and Sections

The transverse or horizontal plane divides the body into superior (above)

and inferior (below) sections. A transverse plane can be made anywhere in

the body from the feet to the head.

A transverse plane made at the neck divides the body into superior and

inferior sections. The head is superior to the plane. The chest, arms,

abdomen, and legs lie inferior to the plane.

A transverse plane made at the waist also divides the body into superior

and inferior portions. The head, chest, and arms are superior to the

plane. The pelvis and legs are inferior to the plane.

A transverse plane made at the level of the knees divides the body into

superior and inferior sections, too. The thighs, abdomen, chest, arms,

and head are superior to the plane. The calves and toes are inferior to

the plane.

Transverse sections

Sagittal Planes and Sections

A sagittal or longitudinal plane divides the body into right and left

sections. A midsagittal or median plane divides the body into equal

right and left sections. A midsagittal plane is the midline of the body. A

parasagittal plane divides the body into unequal right and left sections.

A sagittal plane can be made at any point of the body from the right side

to left side.

Sagittal sections

Coronal Planes and Sections

A coronal or frontal plane divides the body into anterior (front) and

posterior (back) sections. A coronal plane can be made at any point from the

front of the body to the back of the body.

Coronal sections

A coronal plane at the level of the ears divides the body into anterior and

posterior sections. The face, abdomen, and knees are anterior to the

plane. The back, buttocks, and ankles are posterior to the plane.

A coronal plane at the level of the nose divides the body into anterior

and posterior sections. Almost everything else is posterior to the plane.

You can divide the body and each organ using planes. For example, a

midsagittal plane of the liver divides the liver into equal left and right

sections.

Study the definitions of these planes until you can form a mental image of

them. You’ll remember these concepts more easily if you picture the planes

using your own body.

Planes and Sections

You can divide the body and each organ using planes. For example, a

parasagittal plane of the liver divides the liver into unequal left and right

sections.

A parasagittal plane of the liver

Please pause and complete online Practice Exercise 8-2.

Step 6 Location Terms

The location terms you learn in this lesson are important to you, the coder,

because doctors use them to describe what they see when they examine a patient.

You will learn how to pronounce the terms later in this lesson.

Providers use location terms to document the examination.

When doctors describe the location of anatomic parts, they use terms that

compare the location of one part to another part. A number of terms describe

the relative location of body parts and organs. These terms rely on the

anatomical position and the anatomic sections you just learned.

Fact About Location Terms

These terms usually come in antonym pairs. Each word of an antonym pair

means the opposite of the other word, such as the antonym pairs above and

below or left and right.

Transverse plane

If you draw a transverse plane through the body or an organ, these words

describe anything above or below that plane.

Superior means above.

Inferior means below.

Cephalad means toward the top of the head.

Caudad means toward the soles of the feet.

Sagittal plane

If you draw a midsagittal plane through the body or an organ, these words

describe anything closer to or farther away from that plane.

Medial means closer to the midsagittal plane or middle.

Lateral means farther away from the midsagittal plane or middle.

Coronal plane

If you draw a coronal plane through the body or an organ, these words

describe anything in front of or behind that plane.

Anterior means in front of.

Posterior means in back of.

Ventral means on the belly side.

Dorsal means on the back side.

The following chart summarizes these location terms and how they

are used.

Look at some sentences showing how these words are used. Compare these

statements to your own body. Be sure your body is in the anatomic position

when you do so.

The lungs are superior to the liver.

The liver is inferior to the heart.

The incision was made in a cephalad direction.

The arteries for the lower extremities travel in a caudad direction.

The nose is medial to the eye.

The right thumb is lateral to the right index finger.

The sternum is anterior to the heart.

The lungs are posterior to the sternum.

The ventral hernia was repaired.

The spine is dorsal to the stomach.

The following terms are used for the body or an organ as a whole. They

describe parts that are nearer the center or parts that are nearer the

surface of the body or an organ. Examples of how these words are used

follow the terms.

Proximal means nearer to the center of the body or organ.

The knee is proximal to the foot.

Distal means farther away from the center of the body or organ. The

foot is distal to the knee.

Superficial means on or closer to the skin or surface of an organ.

The wound was superficial, not involving the muscles, and did not

require sutures.

Deep means under or farther away from the skin or surface of an organ.

The wound was deep and penetrated the liver.

Central means within or near the center.

The heart is central within the rib cage.

Peripheral means at or near the rim or edge.

The peripheral veins of the arms and hands can be seen easily.

Parietal means the outer wall of a body cavity.

The parietal pleura forms the outer layer that surrounds the lungs.

Visceral means the covering of an organ.

The visceral pleura covers the lungs.

External means outside or closer to the skin or surface of an organ.

The pericardium is external to the heart.

Internal means inside or farther away from the skin or surface of an

organ.

The lungs are internal to the ribs.

Ipsilateral means situated on or affecting the same side of the body.

The left leg and left arm are ipsilateral.

Contralateral means situated on or affecting the opposite side of the

body.

The right leg and left arm are contralateral.

The lungs are internal to the ribs.

Some things in the body, like blood cells, fluid or nerve messages, can move.

The next two terms describe body parts that carry things that move.

Afferent means carrying toward a body part or the center of an organ.

An afferent neuron is a nerve that carries nerve messages to the brain

from a muscle.

Efferent means carrying away from a body part or the center of an

organ.

An efferent neuron is a nerve that carries nerve messages away from

the brain to a muscle.

An afferent neuron is a nerve that carries nerve messages to the brain from a muscle.

Step 7 Pronounce New Terms

Follow these steps:

a. Take your Quick-Learn Tutor and your Set 9 flashcards out of your Quick-

Learn Kit. Insert the first flashcard for Set 9 into Side A of the Tutor.

b. Access the online portion of your course and go to Lesson 8.

c. Listen to the flashterm. Pause the audio.

d. Practice pronouncing the term out loud. Take your time. Push the flashcard

up and read the meaning of the word part or term.

e. Do this for each term in this set.

f. Put the flashcards in order and play the audio again, pronouncing each

word part or term after you hear it. Don’t forget to listen to your own

pronunciation of each term. If you mispronounce one, put a check mark

next to that flashterm.

g. Practice the terms you mispronounced by listening again. Be sure you can

pronounce the terms clearly and easily.

Step 8 Write New Terms

Follow these steps:

a. Insert the first flashcard for this set into Side A of your Quick-Learn Tutor.

b. Look at each term as it appears in the window and say it out loud. Write

the flashterm on blank paper. Remember to include the slash if it is a word

part.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the flashterm.

d. Do this for each term.

Step 9 Meanings of New Terms

Follow these steps:

a. Again insert the first flashcard into Side A of your Quick-Learn Tutor.

Pronounce each word part or term and then say the meaning. Check

yourself by pushing the flashcard up until you can see the meaning in the

right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud, and then say the term. Again, check yourself

by pushing the flashcard up until you can see the term in the left window.

c. Practice with the flashcards several times until you are familiar with the

flashterms and their meanings. You may use the flashcards for the Practice

Exercises and Quizzes.

d. When you feel comfortable with the spelling, pronunciation, and meaning

of each flashterm, go on to the next step.

Step 10 Organ and Organ Systems

Now that you’ve laid a foundation in basic anatomy concepts, let’s take a look at

the body’s major organs and organ systems.

Tissues are grouped together to form an organ. In an organ, all the tissues

work as a team. Each type of tissue has its own job to do, but together the

tissues have a common purpose: the function of the organ.

Organ tissues work as a team.

Each type of tissue does its own job. For example, the liver contains tissues

from each of the basic tissue groups (epithelium, connective, muscle,

nervous). The epithelium covers and protects the organ and makes the

glands of the organ. Connective tissue holds the organ together and provides

support or repair. Muscle tissue provides motion, contraction or pressure in

ducts and vessels. Nervous tissue provides connection to the brain and

warning of danger. Then, all the groups of tissues in the liver work together

to perform the functions of the liver.

In the same way, the heart contains tissues from each of the tissue groups,

all acting together to perform the function of the heart. However, from a

practical point of view, when a patient has a problem, the problem is not with

a tissue type but with a particular organ, such as the liver or the heart.

An organ usually interacts with other organs that help it perform its

function. For example, the liver, pancreas, stomach and bowel are

organs that all work together to digest food. Thus, organs with similar

functions or physiology are grouped together in organ systems. In fact,

the different specialties of medicine represent the various organ

systems. You can probably recognize some of these systems and areas

of specialization already.

Respiratory System

The respiratory system is the gas exchange system that provides

oxygen to the body while removing the by-product of oxygen

metabolism, carbon dioxide. The body as a whole cannot do without

oxygen for more than three to five minutes because a lack of oxygen to

the most sensitive parts of the body—the brain and the heart—can

cause permanent, if not fatal, damage.

Circulatory/Cardiovascular System

The cardiovascular system is the supply transportation system for the

body. It brings nutrients like oxygen, glucose, amino acids and

hormones to all the cells in the body and carries off the waste products

of cell metabolism. The cardiovascular system includes the heart, blood

vessels, lymph vessels and the blood or lymph they contain.

The heart is like the dispatcher, sending blood out in regular shipments

through all the organs and cells of the body. The vascular system

includes arteries, veins, capillaries and lymph channels, which are like

highways and city streets. They provide a well-planned flow to and from

delivery and pick up points. The blood and lymph do the actual

transporting of all these materials to and from their destinations. Each

type of cell specializes in the supplies and waste materials it transports.

Nervous System

The nervous or neurological system includes the central nervous system,

which is made up of the brain and spinal cord, and the peripheral nervous

system, which includes the nerves that reach each organ in the body.

Because this system includes the mind, it can also be called the

neuropsychiatric system.

Muscular System

The muscular system consists of organs that produce movement as they

contract and relax. Muscles are not only in the extremities, such as the

biceps muscle that bulges when you flex your elbow, but also in almost

every other organ system in the body except the neurological system. The

muscular system also includes the tendons and aponeuroses, which is

connective tissue that attaches the ends of muscles to bones.

Skeletal System

The skeletal system includes bones, joints, cartilage and spine. Since it is

so difficult to separate the functions of the voluntary muscles and bones,

some people combine the muscular and skeletal organ systems into one

system, the musculoskeletal system. Most people think bones aren’t living

tissue, but rather something hard, like a rock. But each bone in your body is a

living organ, just like your heart.

Integumentary System

The integumentary system includes skin, nails, hair, sweat and sebaceous

glands. Integument means in the covering or in the skin. The skin and the

organs the skin contains are part of this system. The skin is the largest single

organ in the body! This fact explains why a large skin injury, such as a burn,

can be fatal.

Endocrine System

The endocrine system includes the glands that don’t have ducts. These

glands secrete within themselves directly into their blood vessels. Endocrine

glands are made of epithelium tissue. They secrete hormones. Endocrine

glands include the thyroid, parathyroid, pituitary, and adrenal glands as well

as the hypothalmus, pancreas, testes and ovaries. The testes and ovaries are

also part of the reproductive system.

Digestive System

The digestive system is concerned with digestion of food. This system begins

with the mouth and ends at the anus. The stomach, intestines, liver,

pancreas, mouth and esophagus all belong to the digestive system. This

system is also called the gastrointestinal system.

Urinary System

The urinary system filters the blood and produces urine. It includes the

kidneys, ureters, urinary bladder and urethra.

Reproductive System

This organ system involves the organs for reproduction. The reproductive

system includes such organs as the ovaries, uterus, vagina, breasts, testes

and penis.

The Immune System

One system you may not have heard about is the immune or

immunologic system. That is because this system that defends the

body from disease is not clearly understood. The immune system appears

to use parts of the cardiovascular system, the nervous system and the

endocrine system to provide defense against some kinds of disease. The

immune system provides immunity, or resistance, to diseases caused by

stress, viruses and degeneration. This system helps fight cancer and tries

to kill any foreign substance in the body, even a transplanted organ.

Please pause and complete online Practice Exercise 8-3.

Step 11 Lesson Summary

This lesson brings you along in your journey to become an effective and

professional medical coding specialist. Anatomy is an integral part of every aspect

of medicine, so the ability to recognize terms and their medical context makes you

a valuable member of the healthcare team.

This lesson explained the basics of human biology—the study of how the

body is put together and how it works in health and disease. Human biology

in the healthy state includes anatomy and physiology. Human biology in

disease deals with pathology.

You learned that anatomy is the science of the structure of the body,

including the appearance and relationships of body parts. The two kinds of

anatomy are macroscopic anatomy and microscopic anatomy. Physiology is

the study of how the body works; it describes the function of the body and its

organs, tissues, and cells. Physiology also can be divided into macroscopic

physiology, which usually is called gross physiology, and microscopic

physiology, which usually is called cell physiology.

We explained that pathology is the study of human biology when anatomy

and/or physiology are abnormal. Abnormal physiology sometimes is called

pathophysiology. Abnormal anatomy is called pathology or pathologic

anatomy. When doctors describe the location of anatomic parts, they refer to

the anatomic position and the anatomic sections with the corresponding

anatomic planes. There also are specific location terms that doctors use to

describe the relative locations of body parts and organs.

As you continue with the next few lessons, keep in mind that everything you

learn about the human body will help you in your new career as a medical

coding specialist! You are learning terms you will see in your daily work with

physicians and other healthcare professionals.

Please pause and complete an online Quiz. Good luck!

LESSON 9

Anatomy: Landmarks and Divisions

Step 1 Learning Objectives for Lesson 9

When you have completed the instruction in this lesson, you will be trained to do

the following:

Discuss landmarks and divisions as they apply to anatomy.

Talk about the basic body cavities.

Explain how the body is organized.

Step 2 Lesson Preview

In previous lessons you learned some of the language that goes along with the

medical field. In this lesson, we’ll talk about the body—how it works, how it is

organized and how its systems are connected.

In this lesson, we’ll talk about the body.

Don’t worry if you don’t remember everything about this lesson. It is an

introduction designed to give you a knowledge base. This base enables you

to understand what medical providers face every day. As a medical coding

specialist, you need this basic understanding to communicate with doctors

and other healthcare professionals in your work just as you need to

understand the medical terminology we talked about in previous lessons.

Step 3 Gross Anatomy

Contrary to what you might think, gross anatomy does not mean disgusting

anatomy! Instead, as you learned in the previous lesson, it refers to the study of

body parts and systems that can be seen without the aid of a microscope. In this

context, the word gross means large.

Landmarks and Divisions

Location terms have been used for hundreds of years, long before providers could see inside the body with x-ray.

When a doctor examines the surface of the body, he uses several gross

anatomy terms to describe location. The study of the surface of the body

often is called superficial anatomy. These location terms, or landmarks, have

been used for hundreds of years, long before providers could see inside the

body with x-ray or ultrasound machines. These terms are used every day in

physical examinations, medical histories, and surgery reports. As a medical

coding specialist, you’re likely to encounter these terms often.

Surface landmarks, supine

Superficial Landmarks, Face Up

When the body is supine, which means lying flat on the back, the doctor sees

the anterior or ventral side of the body. Let’s look at the terms used for

superficial landmarks on the anterior surface. The following figure shows the

surface landmarks in the supine position. The surface landmarks are

labeled. Can you find these parts on your own body? Check off each landmark

after you find it. If you are not sure what a new term means, consult the list

of meanings that follows the picture.

Surface Landmarks, Supine Meaning

frons forehead

orbit eye

bucca cheek

cervix neck

clavicle collarbone

axilla armpit

thorax chest

costochondral margin rib and cartilage

abdomen trunk

umbilicus navel, bellybutton

pubis front pelvic bone

femur thigh

patella kneecap

talus ankle

brachium upper arm

antecubital fossa front of elbow

antebrachium forearm

carpus wrist

digit finger/toe

flank side from ribs to hip bone

iliac crest top rim of hip bone

inguen groin

tibia shin

digit toe/finger

Superficial Landmarks, Face Down

When the body is lying prone, or face down, the doctor sees the posterior or

dorsal side of the body. The following drawing shows the surface landmarks

in the prone position. The surface landmarks are labeled. Can you find

these parts on your own body? You may not be able to reach all of them.

Check off each landmark after you find it. If you need help, consult the list of

meanings that follows the picture.

Surface landmarks, face down

Surface Landmarks, Prone Meaning

cubitus elbow

occiput back of head

cervix neck

scapula shoulder blade

dorsum upper back

lumbus lower back

sacrum spinal bones located between the buttocks

gluteus buttock

popliteal fossa back of knee

sura calf

calcaneus heel

plantar surface sole of foot

Step 4 Pronounce New Terms

Follow these steps:

a. Take your Quick-Learn Tutor and your Set 10 flashcards out of your Quick-

Learn Kit. Insert the first flashcard for this set into Side A of the Tutor.

b. Access the online portion of your course and go to Lesson 9.

c. Listen to the flashterm. Pause the audio.

d. Practice pronouncing the term out loud. Take your time. Push the flashcard

up and read the meaning of the word part or term.

e. Do this for each term in this set.

f. Put the flashcards in order and play the audio again, pronouncing each

word part or term after you hear it. Don’t forget to listen to your own

pronunciation of each term. If you mispronounce one, put a checkmark next

to that flashterm.

g. Practice the terms you mispronounced by listening again. Be sure you can

pronounce the terms clearly and easily.

Step 5 Write New Terms

Follow these steps:

a. Insert the first flashcard into Side A of your Quick-Learn Tutor.

b. Look at each term as it appears in the window and say it out loud. Write

the flashterm on blank paper. Remember to include the slash if it is a word

part.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the flashterm.

d. Do this for each term in this set.

Step 6 Meanings of New Terms

Follow these steps:

a. Again insert the first flashcard into Side A of your Quick-Learn Tutor.

Pronounce each word part or term and then say the meaning. Check

yourself by pushing the flashcard up until you can see the meaning in the

right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud and then say the term. Again, check yourself

by pushing the flashcard up until you see the term in the left window.

c. Practice with the flashcards several times until you are familiar with the

word parts and terms and their meanings. You may use the flashcards for

your Practice Exercises and Quizzes.

d. When you feel comfortable with the spelling, pronunciation, and meaning

of each flashterm, go on to the next step.

Step 7 Adjective Forms for Landmark Names

Some of the landmark names you just learned probably were unfamiliar to you, but

you may have heard these terms in their adjective form. Read the following chart:

Please pause and complete online Practice Exercise 9-1.

Step 8 Divisions of the Abdomen

When a provider examines the abdomen, she mentally divides the abdomen into

nine areas or regions. When providers, especially surgeons, refer to these areas,

certain organs in the abdominal cavity are assumed to be in each region.

As a medical coder, you will hear these regions used to describe the

location of symptoms, abnormalities, and procedures. Look at these

examples.

An incision was made in the right hypochondriac region.

There are stretch marks in the hypogastric region.

Divisions of the abdomen

These divisions are shown in the drawing that follows. Notice how the names

of some regions describe the superficial landmarks where they are located.

For example, two regions are named for their relationship to the location of

the stomach: the epigastric region and the hypogastric region. As you look at

the drawing, point out each region on your own abdomen.

An Alternative Division of the Abdomen

Some providers use a simpler way to divide the abdomen. The abdomen is

divided into fourths. Each of these areas is called a quadrant, which means

a one-fourth section.

The divisions are made by drawing a line along the midsagittal plane

(dividing left and right) and a line along the transverse plane (dividing

top and bottom) at the level of the umbilicus. This is shown in the

drawing that follows.

The four abdominal quadrants are named using the following words. The

acronym for each quadrant also is listed.

Right upper quadrant: RUQ

Left upper quadrant: LUQ

Right lower quadrant: RLQ

Left lower quadrant: LLQ

Quadrants of the abdomen

These terms are very important in assigning medical codes. Look at the

coding example for abdominal pain in the left upper quadrant:

789.02 Abdominal pain, left upper quadrant

Now look at the coding example for abdominal pain in the right lower

quadrant:

789.03 Abdominal pain, right lower quadrant

The location of the abdominal pain changes the code number! As you can

see, medical coding specialists must be aware of the four abdominal

quadrants to code correctly.

Please pause and complete online Practice Exercise 9-2.

Step 9 Internal Landmarks: The Body Cavities

The spaces within the body that contain the various internal organs are called

body cavities.

Facts About Body Cavities

Body cavities have two functions:

• Body cavities protect the organs they contain.

• Body cavities keep the organs in a fairly constant location.

The two principal body cavities are the dorsal body cavity and the ventral

body cavity. The major body cavities are shown in this drawing.

Body cavities

The dorsal body cavity is subdivided into the cranial cavity and the spinal

canal. The cranial cavity is the space inside the skull that contains the

brain. The spinal canal is the cavity formed by the vertebrae. The spinal

canal contains the spinal cord and the beginning of the spinal nerves. There

is no real boundary between the cranial cavity and the spinal canal. The

foramen magnum is the opening of the occipital bone that interconnects

the two cavities.

The spinal canal is the cavity formed by the vertebrae.

The ventral body cavity also is subdivided into the thoracic cavity and the

abdominopelvic cavity. The thoracic cavity contains smaller cavities and

subdivisions. The mediastinum is a mass of tissue between the lungs

extending from the sternum to the vertebral column. Included in the

mediastinum is the pericardial cavity, which encloses the heart. The two

pleural cavities each contain a lung. The boundary between the thoracic

cavity and the abdominopelvic cavity is the muscular diaphragm, a dome-

shaped muscle.

The abdominopelvic cavity consists of upper and lower portions. The

upper portion is called the abdominal cavity. It contains the gallbladder,

liver, spleen, stomach, small intestine, most of the large intestine, kidneys,

pancreas, and the ureters. The lower portion, called the pelvic cavity,

contains the bladder, colon, rectum, and the internal reproductive organs.

There is no physical boundary between the abdominal cavity and the pelvic

cavity. The imaginary boundary lies at the level of the rim of the pelvic bone.

There is no physical boundary between the abdominal cavity and the pelvic cavity.

Step 10 Membranes That Line the Body Cavities

Membranes are layers of tissue that cover organ surfaces, line body cavities, and

form tubes. Body membranes come from two basic tissue groups:

epithelial tissue

connective tissue

Epithelial Tissue Membranes

Epithelial membranes are classified by where they are located in the body.

Epithelial membranes include cutaneous membrane, mucous membrane,

and serous membrane.

Cutaneous Membrane

The outer layer of the skin is a cutaneous membrane. It is made of

stratified squamous epithelium. The surface of the skin, the outer layer of the

stratified squamous epithelium, dries to a tough, nonliving, keratinized layer

of squamous cells that waterproofs the skin.

Mucous Membrane

Mucous membranes, or mucosa, line every tube or cavity that connects to

the surface of the body. The mucous membranes often secrete mucus, which

prevents body cavities from drying out. The digestive, respiratory,

reproductive, and urinary tracts all are covered with mucous membranes.

Serous Membrane

Serous membranes (serosa) line the major body cavities that do

not connect to the surface of the body. Serous membranes occur in

pairs—the visceral layer lines the organ, and the parietal layer lines

the cavity. The serous membranes secrete serous fluid or serum,

which lubricates the organs and reduces friction as they glide across

each other and the cavity walls.

Serous membranes (serosa) line the major body cavities that do not connect to the surface of the body.

The Thoracic Cavity Membranes

The thoracic cavity is protected by a serous membrane lining called the

pleura. The serous membrane lining the pericardial cavity is the parietal

pericardium. The visceral pericardium is the thin, transparent serous

membrane covering the heart itself. The lungs are protected by two layers of

serous membranes—the parietal pleura lines the pleural cavities, and the

visceral pleura covers the lungs themselves.

The Abdominopelvic Cavity Membrane

The abdominopelvic cavity is protected by the largest serous membrane of

the body, which is called the peritoneum. Unlike other membranes, the

peritoneum contains large folds that bind organs to each other and to the

cavity wall. The parietal peritoneum lines the cavity wall. The visceral

peritoneum covers some of the organs within the cavity.

Connective Tissue Membranes

In this section, let’s review two types of connective tissue membranes.

Synovial Membrane

The synovial membrane is composed of a gel-like material. It usually

contains different types of connective tissue elements. The synovial

membranes line the joints of the shoulders, knees, hips, fingers, and

toes. They secrete a fluid to cushion the motion of these joints so that

the bone surfaces do not rub against each other.

The Cranial and Spinal Canal Membranes

The brain and spinal cord are protected by meninges. The cranial

meninges line the cranial cavity and are continuous with the spinal

meninges that line the spinal canal. The meninges consist of three layers,

each called a meninx. The outer meninx is called the dura mater. The

middle meninx is the arachnoid, and the inner meninx is the pia mater.

Step 11 Retroperitoneal Organs

Sometimes an organ lies outside a cavity. When you look at this type of organ from

inside the cavity, its location is considered to be behind the parietal serosa. For

example, in the following graphic, you can see that the kidney is outside the

abdominal cavity.

Viewed from inside the abdomen, this kidney is behind the peritoneal serosa.

Organs in this location are called retroperitoneal organs.

The kidney is a retroperitoneal organ.

Step 12 Pronounce New Terms

As a medical coding specialist you will need to be able to understand a healthcare

professional’s pronunciation of terms, and you will need to pronounce anatomical

terms yourself. This exercise will help you understand and pronounce the terms

you just learned.

a. Take your Quick-Learn Tutor and your Set 11 flashcards out of your Quick-

Learn Kit.

b. Access the online portion of your course, and go to Lesson 9.

c. Listen to the flashterm as it is pronounced. After you hear a term, pause

the audio.

d. Practice pronouncing the term out loud. Take your time. Push the flashcard

up and read the meaning of the word part or term.

e. Continue this process for each flashcard in this set.

f. Put the flashcards in order and play the audio again, pronouncing each

word part or term after you hear it. Don’t forget to listen to your own

pronunciation of each term. If you mispronounce one, put a check mark

next to that flashterm.

g. Practice the terms you mispronounced by listening again. Be sure you can

pronounce each term clearly and easily.

Step 13 Write New Terms

The next step in your lesson is to practice writing the terms you learned. Follow

the instructions.

a. Insert the first flashcard for this set into Side A of your Quick-Learn Tutor.

b. Look at each term as it appears in the window and say it out loud. Write

the flashterm on blank paper. Remember to include the slash if it is a word

part.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the flashterm.

d. Do this for each flashcard.

Step 14 Meanings of New Terms

Follow these steps to learn the meanings of the terms you have pronounced and

written.

a. Again insert the first flashcard into Side A of your Quick-Learn Tutor.

Pronounce each word part or term out loud and then say the meaning.

Check yourself by pushing the flashcard up until you can see the meaning in

the right window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud. Before you look, see if you can remember the

term that goes with that meaning. Check yourself by pushing the flashcard

up until you can see the term in the left window.

c. Practice with the flashcards several times until you are familiar with the

terms and their meanings. You may use the flashcards for the Practice

Exercises and Quizzes.

d. When you feel comfortable with the spelling, pronunciation and meaning of

each flashterm, go on to the next step.

Step 15 Organization of the Body

So far, you’ve discovered about how the body is organized anatomically. You

learned the locations of different body parts and how the internal parts of the body

are divided into cavities. Now you will study how the body is organized

physiologically, that is, how the body is organized to do its work.

Your body should work like an army.

Your body has many tasks to perform to keep you alive. These tasks often

must be performed simultaneously, and this requires great organization. Your

body has to work efficiently, like an army. In any army, there are many

individual soldiers, and these individuals must be organized so that various

tasks can be completed. Soldiers are grouped into squads, squads are

grouped into platoons, platoons are grouped into regiments, then divisions.

The whole unit is called an army. The army then works with other groups,

just as the U.S. Army works with the Navy, Marines, and Air Force to

accomplish tasks.

The smallest unit in your body is the cell. In fact, your body is composed

of millions of cells. The work of the body, although it appears to be the

work of large parts, is really the combined work of all the different types

of cells in the body.

Similar types of cells group together to form tissues. There are four types of

tissues:

Epithelial tissue covers every body surface, including the outer surface,

body cavities, and organs.

Connective tissue connects other types of tissues, helps support the

body and has its own blood supply.

Muscle tissue can extend and contract, allowing movement.

Nervous tissue transmits electrical impulses and makes up the brain,

spinal cord, and peripheral nerves.

For example, muscle cells group together to form muscle tissue. Liver cells

group together to form liver tissue. Nerve cells form nerve tissue.

Muscle cells group together to form muscle tissue.

Different types of tissue group together to form organs. For example, liver

tissue, blood vessel tissue, nerve tissue, and bile tissue group together to

form the liver. Muscle tissue, connective tissue, nerve tissue, and blood

vessel tissue group together to form a muscle, such as the biceps muscle.

Body organs with similar functions can be grouped into organ systems. For

example, the liver, stomach, intestines, and pancreas are all organs whose

function is digestion. As a group, they form the digestive system.

As you can see, body organization begins with the cell and progresses to

tissues, organs and organ systems.

Please pause and complete online Practice Exercise 9-3.

Step 16 Lesson Summary

This lesson continued your introduction to anatomy—how the body works, how it is

organized, and how its systems are connected. Providers use terms, called

landmarks, to describe locations on the body. These include superficial, or surface,

landmarks for the body in the supine and prone positions. To accurately describe

locations on the abdomen, surgeons divide the abdomen into nine areas that refer

to certain organs in the abdominal cavity in each region. A simpler way to describe

locations on the abdomen is by dividing the abdomen into fourths, or quadrants.

The body is organized into a complex structure that enables it to work

effectively. The smallest unit is the cell. Cells group together to form tissues,

tissues group together to form organs, and organs form organ systems.

These systems function as a whole to operate the amazing mechanism we

call the body.

Everything you learned in this lesson is a base to help you understand the

context of terminology used in medical coding and to help you communicate

effectively with healthcare professionals.You don’t need to memorize the

terms, but being familiar with anatomical terms will help you in your medical

coding career. You’re ready for your next Quiz!

Please pause and complete an online Quiz. Good luck!

Just for Fun

Whew! You need to relax after all this. Relaxation does not come

automatically for many of us—often we are terrible at it. We may not

realize that we are stressed mentally or physically until a problem

develops.

When your body is relaxed, your mind works more efficiently. There are

some very simple physical relaxation exercises you can do as you work.

Give your eyes a rest as you work. Try the 20, 20, 20 method.

Every 20 minutes, let your eyes rest on an object at least 20

feet away, and look at that object for 20 seconds.

Every hour or so, get up out of your chair and walk. Slowly

stretch your arms up over your head. Then let your head and

hands hang toward the ground. Get that blood circulating!

Watch your posture. Are you slumped over? It’s harder for your

body to breathe when in a poor position. Sit up straight and take

a few long, slow breaths.

Let other areas of your body have a chance to move. Tense and

then relax various muscle groups in your body as you sit. For

example, tighten your gluteus maximus, hold for a few seconds

and then relax. Rotate your shoulders and head. If your work

area allows, stretch your legs out. Rotate your feet at the

ankles.

There are many paths to relaxation and reduction of stress. Some are

quite simple, others very sophisticated. A common element to all is that

they be practiced regularly and that work and worries be left behind. Do

any of these ideas appeal to you?

Going for a walk

Meditation

Visualization exercises

Long hot bath

Physical exercise

Massage

Yoga

Guided relaxation using audiotapes or CDs

Friends also can be great stress relievers. Plan fun times. Laugh.

Laughter benefits the heart, lungs, stomach, and other organs. Above all,

make sure you are kind to yourself. Have some fun every day. Give

yourself time off—and don’t feel guilty about it! Work when you work and

then leave it. Give your mind some time off, too.

LESSON 10

Cell and Tissue Anatomy and Pathology

Step 1 Learning Objectives for Lesson 10

When you have completed the instruction in this lesson, you will be trained to do

the following:

Describe the components of a cell.

Understand the primary functions of each cell component.

Determine the different categories of etiologies.

Explain cell damage and how cells respond to injury.

Determine how the body reacts to injury through inflammation, repair,

and damage or death.

Step 2 Lesson Preview

From a previous lesson you already know that the cell is the smallest unit in the

human body; it’s the basic unit of life. Humans started with one cell. That one cell

changed to many different kinds of cells. But what makes up a cell? How does it

function? As a medical coding specialist it’s important you understand this basic

component of the body and that you see how it works to allow the human body to

do all of which it is capable.

The cell is the smallest unit in the human body. It’s the basic unit of life.

In this lesson you’ll also learn about what happens when the body isn’t

operating at peak efficiency. You will study the concepts of pathology

and the disease process. Why is this important? You must understand

how the body defends itself from disease and what mechanisms are at

work in the body to promote health. Knowing why people seek medical

care in the first place also will help you as you assign accurate codes to

those medical records you learned about in earlier lessons.

Step 3 Cell Components and Their Primary Functions

As you know, the human body is composed of an extraordinarily large number of

minute elements known as cells. Cells are the building blocks of the body. Every

structure in the body is made of cells. There are, of course, different types of cells.

But regardless of the type and function, all cells consist of the same basic

components.

In your previous anatomy lessons you learned that a large number of

combined cells with special properties form tissues. For example, certain cells

form muscle tissue, and others with quite different properties form nervous

tissue. These and other tissues, called connective tissues, combine to form

organs, such as the heart and brain.

Cells are the building blocks of the body.

Now you’ll learn about the parts of the cell. All cells contain a nucleus, cell

membrane, cytoplasm, mitochondria, endoplasmic reticulum, lysosomes, and

Golgi apparatus. The following illustration shows some of these parts. Each of

these structures has unique functions that are critical to the life of the cell.

Basic parts of a cell

Cell Membrane

The cell membrane or plasma membrane forms the outer surface of

the cell. This membrane is made up of proteins, lipids, and

carbohydrates that provide energy to the cell, assist other cellular

particles in moving through the cell, and assure balance. The membrane

serves as the site of contact between the cell and its environment. The

cell membrane’s role in the structure and integrity of the cell is

invaluable because this membrane is responsible for the maintenance of

all essential cellular functions. If rupture or major damage to the cell

membrane occurs and cannot be repaired, the cell will die.

Cell surface

Cilia

Cilia are like hairs that wave in the fluid around a cell. They move the

fluid and anything it contains past the cell. Cells that have cilia are called

ciliated cells. For example, ciliated cells lining the trachea move mucus

up and out of the lungs.

Flagella

Flagella are long single projections, like rat tails. They move a cell in the

body fluids. Very few cells have flagella. The sperm cell is one that does. It

has one flagellum, like a tail, to help it move in body fluids.

Flagella are long single projections, like rat tails.

Villi

Villi are short projections of the cell membrane that look like fingers

projecting from the cell membrane. Only some cells have villi. On the other

hand most cells form microvilli, which are very small villi or wrinkles in the

cell membrane. Because microvilli are only wrinkles in the cell membrane,

they are no different than the rest of the cell membrane. Cells form microvilli

when they need them. Microvilli act like the webbing of a sponge to absorb

materials transported across the cell membrane.

Step 4 More Cell Components and Their Functions

Now that you know a little about the features on the outside of the cell, let’s talk

about what goes on inside these little building blocks.

Cytoplasm

The cytoplasm does most of a cell’s everyday work. Cytoplasm surrounds

the nucleus, which we’ll discuss in detail in a bit, and contains other cellular

structures such as mitochondria and the endoplasmic reticulum. These

structures, called organelles, provide energy and nutrients and are

imperative to the life of the cell.

In addition to organelles, the cytoplasm contains supplies of food and water,

called inclusions or inclusion bodies. Inclusions are like little bubbles

floating through the cytoplasm.

The drawing that follows shows the organelles that lie in the cytoplasm. After

you read about each organelle, look at the organelle in the drawing.

Sometimes organelles are named for how they look.

Organelles in the cytoplasm

Ribosomes

The ribosomes are where protein is made. Ribosomes either float freely

in the cytoplasm or attach to the membrane called the endoplasmic

reticulum.

Endoplasmic Reticulum

The endoplasmic reticulum (ER) is a spider web-type membrane inside

the cytoplasm. This structure is a series of little tubes called tubules or canals

that work like a subway to move materials around the cell.

There are two types of ER. Differentiated cells have either one or both types

of ER. Granular ER, also called rough ER, is covered with ribosomes on its

surface. This gives the ER a grainy appearance. The ribosomes use the

granular ER to store and transport protein. The more protein a cell makes,

the more granular ER it has to store and move the protein. Agranular ER,

also called smooth ER, does not have ribosomes on its surface, so it is not

grainy. It transports fatty materials called lipids. The more lipids a cell makes

or handles, the more agranular ER it has to handle this job.

The endoplasmic reticulum is a spider web-type membrane inside the cytoplasm.

Mitochondria

Mitochondria are thread-like bodies within the cytoplasm responsible for

the cell’s use of oxygen, a required element for all cells of the body to

function normally. Mitochondria use oxygen to digest food in the cell. This

process is called oxidation. When food is digested, there are two products:

heat and energy. The energy is stored in molecules called adenosine

triphosphate, or ATP. ATP provides the fuel, the energy, for all of the

activities in the cell.

Mitochondria are regarded as the power plants of the cell because they exist

in large numbers in those human cells that require an enormous amount of

energy to do their work, such as nerve and liver cells.

Mitochondria are regarded as the power plants of the cell.

Lysosomes

Lysosomes are membrane-bound bodies, or sacs of enzymes, in the

digestive part of the cell. These enzymes digest living material like debris and

old organelles and allow them to enter the cytoplasm. If the lysosome sac

breaks, the cell itself can be digested.

Centrioles

Centrioles only are active during reproduction. They become the

mitotic spindles, which pull the nucleus of a dividing cell apart to form

two new cells.

Golgi Apparatus

The Golgi apparatus is an organelle that packages proteins and other

products of a cell for delivery to the rest of the body. Enzymes or other

products of a cell are delivered to the Golgi apparatus. A sac is formed

around the product and sealed off, like a heat-sealed storage bag. This sac is

called a vesicle. The vesicle moves to the surface of the cell membrane,

fuses with it, and bursts. The contents of the vesicle are distributed outside

the cell. A vesicle acts just like a bubble in a pot of boiling water. The bubble

forms, rises to the top and bursts to let the steam out of the water.

A vesicle acts just like a bubble in a pot of boiling water.

Vacuole

A vacuole is any small cavity in the cytoplasm of a cell.

Step 5 The Nucleus

You’ve already learned about the cell membrane, which forms the outside surface

of the cell. Now let’s talk about the nucleus. The nucleus lies inside the cell and is

surrounded by a nuclear membrane.

Both the cell and nuclear membranes are separate compartments filled with

a gelatin-like material called protoplasm. In the cell compartment,

protoplasm is called cytoplasm. Inside the nucleus, protoplasm is called

karyoplasm or nucleoplasm. The suffix /plasm means “growth.”

DNA

The nucleus contains deoxyribonucleic acid, or DNA, which is the material

that directs how the cell will run and how it will reproduce. It is made up of

genes, the code for making proteins. DNA looks like a spiral staircase. Each

gene is a many-stepped segment of the DNA staircase. During reproduction,

the DNA coils tightly and is called a chromosome. Human cells have 23

pairs of chromosomes.

DNA looks like a spiral staircase.

When the cell is not reproducing, the DNA is scattered throughout the

nucleoplasm like pieces of lint. In this form, the DNA is called chromatin.

RNA

Ribonucleic acid, or RNA, is a messenger and helper for the DNA. It

shuttles the instructions for making protein from the nucleus to the

cytoplasm, where the proteins actually are made.

Nucleoli

Nucleoli are small, round bodies that make ribosomes. The ribosomes are

sent out of the nucleus to the cytoplasm.

You now know about the basic components of the cell; however, before you

move on, let’s take a moment to review what you’ve learned so far.

Please pause and complete online Practice Exercise 10-1.

Step 6 Pronounce New Terms

Follow these steps:

a. Take your Quick-Learn Tutor and your Set 12 flashcards out of your Quick-

Learn Kit. Insert the first flashcard for this lesson into Side A of the Tutor.

b. Access the online portion of your course and go to Lesson 10.

c. Listen to the flashterm, and pause the audio.

d. Practice pronouncing the term out loud. Take your time. Push the flashcard

up and read the meaning of the word part or term.

e. Do this for each term in this set.

f. Put the flashcards in order and play the audio again, pronouncing each

word part or term after you hear it. Don’t forget to listen to your own

pronunciation of each term. If you mispronounce one, put a check mark

next to that flashterm.

g. Practice the terms you mispronounced by listening again. Be sure you can

pronounce the terms clearly and easily.

Step 7 Write New Terms

Follow these steps:

a. Insert the first flashcard into Side A of your Quick-Learn Tutor.

b. Look at each term as it appears in the window and say it out loud. Write

the flashterm on blank paper. Remember to include the slash if it is a word

part.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the flashterm.

d. Do this for each term in this set.

Step 8 Meanings of New Terms

Do the following steps:

a. Again insert the first flashcard into Side A of your Quick-Learn Tutor.

Pronounce each word part or term and then say the meaning. Check

yourself by pushing the flashcard up until you see the meaning in the right

window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right window.

Read each meaning out loud and then say the term. Again, check yourself

by pushing the flashcard up until you see the term in the left window.

c. Practice with the flashcards several times, until you are familiar with the

word parts and terms and their meanings. You may use the flashcards for

your Practice Exercises and Quizzes.

d. When you feel comfortable with the spelling, pronunciation and meaning of

each term or word part, go on to the next step.

Step 9 Cell Pathology

Now that you have read about cell anatomy and know how cells function when

they are healthy, let’s talk about pathology. From a previous lesson, you know that

pathology is the study of human biology when anatomy and/or physiology are

abnormal.

Even though pathology means the process of studying disease, disease does

not cause all pathologic processes. Instead, pathology may be a result of an

injury. In some cases, pathology may be due to an abnormality of growth.

The type of abnormality seen in tissues and organs is determined by two

factors.

Pathology is the study of abnormal human anatomy or physiology.

The cause of the abnormality

For example, diseases injure tissue. Trauma can injure tissue. Growth or

development abnormalities don’t injure tissue but can cause a tissue to

look or act differently than normal. The cause of an abnormality or injury

is called the etiology.

How a tissue responds to injury

Each type of tissue only can respond to injury in a few limited ways. For

example, bone can break, but it doesn’t swell. Muscle tissue can’t break,

but it can be torn, and it can swell. Both bone and fat can develop pus in

an infection.

Step 10 Etiologies

Etiologies, the causes of pathology, can be put into categories. Doctors use these

categories to help themselves remember the kinds of etiologies there are for each

abnormality they find. When doctors don’t know the exact cause of an abnormality,

they may use the name of the category.

The basic categories follow.

Developmental Abnormality

This category includes abnormalities in the growth or development of a

particular tissue or organ. Developmental abnormalities have etiologies

that are either hereditary, congenital or acquired.

Hereditary etiologies are genetic. They exist because there is an

abnormality in one of the genes that was passed down from a parent. The

abnormality is inherited. For example, some dwarves have abnormal bone

development caused by an abnormal gene.

Congenital etiologies exist from birth. They are not inherited but

exist because of an abnormality that occurred while the fetus was

developing. An example is hydrocephalus, which means “water on the

brain.”

An abnormal gene can cause abnormal bone development.

An acquired etiology is an abnormality that the person “got” after birth and

did not inherit from a parent. An example of an acquired developmental

abnormality is childhood rickets, which is caused by a diet that does not have

enough vitamin D.

Inflammatory Disease

Inflammation is a common tissue response to any kind of tissue injury:

infection, trauma or disease. However, if the cause or etiology of a

widespread inflammation is not known, the condition is classified as an

inflammatory disease. Rheumatoid arthritis would fall into this category

because it is not caused by infection, trauma or another disease.

Infection is caused by the action of bacteria, viruses, and parasites.

These living organisms and viruses invade the body and cause disease as

long as they are alive and reproducing in the human body. Antibiotics only

work on infectious diseases caused by bacteria. They do not work for viral

infections or parasitic infestations.

Trauma is injury caused by the inappropriate application of force or toxic

agents. An automobile accident can cause traumatic injuries. A chemical

burn is trauma. For example, swallowing lye causes traumatic injury. The

word trauma is used to mean that the tissue or organ injury was not due

to infection or disease.

Hyperplasia and Neoplasia

This category includes conditions that have an abnormal increase in the

number of cells in a tissue or an organ. Hyperplasia means an increase

in the number of normal cells, usually due to a reaction from an outside

irritation. The anatomy and physiology of hyperplastic cells is normal.

Neoplasia is a new growth of cells whose anatomy is very abnormal.

These cells are bizarre versions of normal cells. Neoplastic cell

physiology is abnormal, especially the rate of reproduction. If a neoplasm

grows slowly and does not spread or destroy normal organ function, it is

called a benign neoplasm. If neoplasms grow rapidly, spread quickly, and

destroy normal organ function, they are called malignant neoplasms

or cancers.

As a medical coding specialist you must know if a neoplasm is benign or

malignant to arrive at the correct code. This information will be

documented in the patient’s medical record.

Look at these coding examples of a benign and malignant breast neoplasm

for a woman:

217 Benign neoplasm of breast

174.9 Malignant neoplasm of breast (female) unspecified

Do you see the importance in knowing the difference between a benign

and malignant neoplasm? Good! You are developing the skills needed to

become a successful medical coding specialist.

Metabolic Disease

Abnormalities in the function, or physiology, of cells and tissues cause these

diseases or conditions. They are due to abnormal metabolism of cells or

tissues. Unlike neoplasia, the rate of cell reproduction is normal. Sometimes

metabolic diseases are genetic or congenital. Sometimes they occur later in

life and are called acquired, meaning the body was normal at birth and up to

the time the patient developed the abnormality. Diabetes mellitus is a

disease caused by abnormal sugar metabolism.

Abnormal sugar metabolism caused diabetes mellitus.

Vascular Disease

Conditions that cause bleeding, blood vessel blockage or abnormal blood flow

fall in the category of vascular disease. Atherosclerosis, or hardening of the

arteries, is a good example. Diabetes mellitus, even though it has a

metabolic etiology, causes abnormalities of the blood vessels. It can be

categorized as a vascular disease for this reason.

Immunologic Disease

Immunologic diseases include abnormalities of the immune system. An

allergy is a good example. Allergies like hayfever and drug reactions are

included in this category. Some patients are allergic to their own tissues,

which causes tissue injury. This condition is called an autoimmune disease.

Idiopathic Abnormality

Idiopathic is a term used for any diseases or conditions where the etiology

is unknown. For example, the causes of many cancers or diabetes are

unknown. The idiopathic category is for a pathology that doesn’t have a

known etiology or won’t fit into any other category.

Iatrogenic Abnormality

Iatrogenic pathology is caused by the actions of a doctor, treatment,

procedure or medication. Have you ever had an allergic reaction to

medication prescribed by a doctor? This is an example of iatrogenic

pathology. Every side effect listed for a drug is an iatrogenic abnormality.

In other words, if the patient had not seen a doctor or taken a

medication, he wouldn’t have the iatrogenic abnormality. Iatrogenic

diseases and conditions can be the same conditions found in other

categories. The difference here is that the patient acquired them as a

result of a medical treatment.

Nosocomial Disease

Nosocomial diseases are diseases acquired in a hospital environment. A

number of factors account for this. You can catch a disease from someone

who already has it. Some hospital patients have lowered resistance to

disease and catch things a healthy person wouldn’t normally catch. Bacteria

that grow on the metal instruments in a hospital but rarely grow outside a

hospital can cause unusual infections.

Step 11 Cell Damage

You’ve read about the categories of etiologies or the causes of pathology. Now,

let’s look more closely at five specific ways in which cells can be damaged.

Hypoxia and Anoxia

Hypoxia is the decreased availability of oxygen to the cells. Anoxia is the

complete lack of oxygen. These two conditions are the most common causes

of cell injury.

All humans breathe, and while breathing, oxygen is brought into the body.

Other body functions serve to distribute this vital gas throughout the body,

feeding the cells. When this process is interrupted, either because breathing

has stopped or the body’s oxygen distribution process malfunctions, the cells

immediately suffer.

Hypoxia or anoxia occurs in many circumstances, including obstruction of the

respiratory tubes, such as in suffocation or drowning; reduced intake of

oxygen across the respiratory surfaces of the lung, such as when one has

pneumonia; inadequate transport of oxygen in the blood, such as when one

has anemia; or the inability of the cell to use oxygen for respiration, such as

in cyanide poisoning.

Of course, not all cells respond the same way to injury, and the final outcome

of anoxia will depend on many factors. Brain cells, for example, cannot

survive without oxygen for more than a few minutes, heart cells can survive

one to two hours and kidney cells can survive for several hours.

Obstruction of respiratory tubes can cause hypoxia or anoxia.

Toxic Agents

Toxic agents can damage cells. Poisons are toxic agents. Poisons are

substances that adversely affect the body and its functions. Some poisons act

by directly destroying cells. Others coat the outside of cells and keep them

from interacting in their required manner. If enough poison is ingested, the

cells suffer permanent injury. If enough cells are killed, then the person dies.

Poisons are often compounds and chemicals. Toxic injury is caused by

substances known for their direct toxic effects on cells and by substances that

are not directly toxic but that destroy cells after the body metabolizes the

substances.

For example, a heavy metal, such as mercury, is directly toxic because it

immediately destroys the cytoplasm of the cell. Carbon tetrachloride, a

component of metal cleaning solutions (metal polish), is an indirect toxin

because when digested, this poison changes characteristics and eventually

affects the cell membranes.

Drugs prescribed for medical conditions are not usually considered poisons;

however, it is important to note that drugs can be toxic and can cause cell

injury, especially if they are given in large amounts. Most drugs taken in large

amounts are toxic, and many are even lethal. Suicide by drug overdose is

probably the best example of drug-induced toxicity. However, while medical

treatments for cancer, such as chemotherapy, kill the cancerous cells, they

also might kill healthy cells, and they often cause toxic effects on the body.

Certain drugs have side effects that might cause organ shutdown or other

medical problems.

Microbial Infection

Microbial pathogens or bacteria cause cell injury in several ways. Bacteria

often produce toxins, which interfere with various cell functions such as

respiration or protein synthesis.

Have you ever been instructed not to consume food contained in dented

cans? The reason is that when a can is dented, microscopic breaks in the seal

can occur, allowing bacteria to grow. This bacteria, known as a microbial

pathogen, is harmful to humans.

Bacteria may grow in dented cans.

Food poisoning is one example of how the microbes can infect human cells

and damage them. A familiar scare that has occurred throughout the country

in recent years is the result of E coli bacteria, a form of which can be found in

meat that is not thoroughly cooked.

Another type of microbial pathogen is the virus. Certain viruses invade cells

and destroy them either by disturbing various cellular processes or by

changing the cell’s makeup in the nucleus or plasma membrane.

Allergic/Immune Reactions

When the body produces antigens to fight infections or other invasions, the

body’s own immune system can damage cells. This process often is harmless

because the body regenerates new cells to replace the damaged and dead

cells. However, in some rare disorders, the body’s defense mechanisms try to

kill off its own cells. In such instances, these people become allergic to

themselves, which is called immunopathy.

Metabolic and Genetic Disturbances

Some metabolic disorders damage cells. Metabolic disturbances such as

diabetes mellitus, a disease caused by insulin deficiency, produce changes in

the small blood vessels of the body that cause vessel wall injury. Such injury

often leads to tissue death or pathologic changes in many, if not all, body

organs.

Genetic problems exist, whereby parents pass along defective genes to children.

In addition to metabolic problems, genetic problems exist, whereby

parents pass along defective genes to children. Some genetic problems can

be dramatic and devastating. For example, Tay-Sachs disease, a genetic

deficiency of a certain hormone, causes destruction of the lysosomes of nerve

and eye cells. Severe mental deficiency and blindness develop, and death

usually occurs in early childhood.

Please pause and complete online Practice Exercise 10-2.

Step 12 Cell Response

In this step, you’ll look at how cells adapt to injury and how the cell structure

might change in this healing process. You’ll also learn the natural aging process of

cells that ultimately leads to cell death.

The term for when the body is not injured and cells are balanced with

their environment is homeostasis. However, prolonged exposure of

cells to adverse stimuli causes the cells to change. When the cause of

the injury is removed, the cells often are able to heal and revert to their

normal state. These minor injuries are reversible. On the other hand,

some forms of adaptation, especially those associated with cell loss due

to aging, such as bone loss in osteoporosis, are irreversible. Other forms

of adaptation cause permanent changes in the cell size—changes that

affect organ function after the cell has regenerated. Cell adaptation, a

necessary process the cell undergoes to survive injury, also often causes

secondary medical problems.

Aging is a type of cell adaptation.

Types of cell adaptation include the following:

Atrophy

Hypertrophy

Hyperplasia

Metaplasia

Intracellular Accumulations

Aging

Atrophy

A type of adaptation that causes a decrease in the size of a cell, tissue, organ

or the entire body is called atrophy. There are two types of atrophy:

physiologic and pathologic.

Physiologic atrophy is age related and involves changes in the entire body.

For example, the bones of elderly people are thin and more prone to fracture.

Also, as the body ages, the muscles atrophy and become weak.

Normal cell and one that has undergone atrophy

Another form of cell atrophy, pathologic atrophy, occurs as a result of

inadequate nutrition or stimulation. As nutrients are withheld, the cell

shrinks, and its functions decrease.

Hypertrophy

Hypertrophy is an increase in size of tissues or organs due to an

enlargement of individual cells. An example of hypertrophy is the

enlargement of the heart due to heart disease or an increased workload on

the heart. Hypertrophy of the skeletal muscles is usually caused by exercise

and typically is found in body builders.

Normal cell and one that has undergone hyperplasia

Would you like to see a coding example for hypertrophy of the heart?

429.3 Cardiomegaly

If you think back to your lessons on word parts, you probably can figure

out that cardiomegaly means enlargement of the heart. You know that

hypertrophy increases the size of tissues or organs, so this is an accurate

code.

Hyperplasia

In contrast to hypertrophy, hyperplasia is an increase in the size of the

tissues and organs caused by an increased number of cells, usually brought

about by hormonal stimulation. Examples of hyperplasia are the thickening of

the lining of a woman’s uterus due to an increase in cells (endometrial

hyperplasia) and the enlargement of the prostate in elderly men.

Normal cell and one that has undergone hypertrophy

Hyperplasia also can occur in cases of chronic injury. Sometimes the cause of

hyperplasia is obvious: Chronic irritation of the foot from tight shoes causes

the cells to undergo hyperplasia and form a callous or corn. Other hyperplasic

lesions have no obvious cause, such as polyps or benign growths in the large

intestine.

Now that you understand hyperplasia, let’s look at the diagnosis code for

endometrial hyperplasia.

621.30 Endometrial hyperplasia, unspecified

As a medical coding specialist, your knowledge of cell anatomy and responses

will help you code accurately.

Metaplasia

Another example of cellular adaptation is metaplasia. Metaplasia occurs

when cells change from one type to another. For example cigarette smoke

causes the bronchial tissues to change. Metaplasia often is reversible. For

example, if a person who smokes cigarettes stops smoking, their damaged

lung cells can revert to their original, normal structure.

Smoking causes the bronchial tissues to change.

Intracellular Accumulations

Intracellular accumulations might be the result of an overload of various

metabolites or external materials such as a disease-producing agent, or they

might be the result of metabolic disturbances. Intracellular accumulations

are materials that lie immediately near the cell. These cells are attached to

one another by junctions, and they communicate across these junctions. The

main products of intracellular accumulations are collagen and complex

sugars, which are extremely important in repairing damage to tissue and

maintaining the balance of the inner cell complex.

Aging

The last cell adaptation process we will talk about is the natural process of

aging and death of cells. Cell aging includes many forms of adaptation and,

unfortunately, many cell changes that are irreversible. Aging cannot be

avoided or prevented, and the best you can do is try to lessen aging’s

adverse effects on the body.

Because cells represent the basic living units of all tissues and organs,

scientists know that age-related illness and eventual death are the result of

cells being unable to regenerate and provide the specialized body functions

necessary to sustain life.

Aging cannot be avoided or prevented.

Pathologic changes associated with aging vary from person to person. Most

organs undergo atrophy and have a reduced functional reserve—that is, they

cannot reproduce new cells as needed. Resistance to infection declines with

advancing age, and the incidence of cancer and heart disease increases.

Before you move on, take a few minutes to complete the following Practice

Exercise to review what you’ve learned so far.

Please pause and complete online Practice Exercise 10-3.

Step 13 Tissue Response

You know how cells adapt to injury and how the cell structure might change in this

healing process. But how can you tell when cellular damage has occurred? Well,

let’s get started by discussing the body’s reaction to injury.

Injury to cells, tissues, or organs means that their physiology is interrupted or

they are anatomically changed. When the body is injured, there are three

ways tissues can respond.

Inflammation

Repair

Damage or death

Tissue response

Inflammation

Inflammation is the response of the body to injury in cells, tissues or

organs. The function of the inflamed area decreases while it is inflamed.

Inflammation has four symptoms or signs. A symptom is what a patient feels;

a sign is what a doctor observes.

Rubor

Rubor means redness. Increased blood flow in the area causes this redness.

The medical term for this is hyperemia. The blood flow increases to bring

leukocytes to fight infection. Neutrophils and monocytes are two

leukocytes that eat foreign materials and bacteria. Neutrophils also are called

polymorphonuclear leukocytes. The slang term for neutrophils is polys;

the slang term for monocytes is monos.

Calor

Calor means heat. Hyperemia creates heat. Sometimes heat can kill bacteria

or viruses.

Calor means heat.

Tumor

Tumor means swelling. Increased fluid in the area causes swelling. The

medical term for this swelling is edema, and this can occur when cells are

damaged and lose water abnormally into the space surrounding the tissues. A

swollen area is edematous. Tumor also means a lump. Because cancers

feel like lumps, they are called tumors. But tumor only means a lump. Just

because something feels tumorous, it is not necessarily a cancer.

Dolor

Dolor means pain. Pain is caused when swelling of the tissues pinches nerve

cells. There is no pain if the nerve cells have died from the injury.

Which of the four symptoms of inflammation are present or which are most

noticeable depends on the severity of the injury and when it occurred.

The terms you have learned for injury also apply to the types of inflammatory

response.

Acute Inflammation

Acute inflammation is what most people think of as inflammation. The

changes usually are very dramatic. It is a response to acute injury, pyogenic

infection or severe allergy. The distinguishing feature of acute

inflammation is the fluid that is produced, which is what causes swelling.

Acute inflammation also may have redness, heat, and pain.

Acute inflammation may cause pain.

The fluid of inflammation is called an exudate. An exudate is cloudy and

contains protein, which leaked from damaged cells and bacteria. By

comparison, a transudate is clear fluid that doesn’t contain protein. It is

related to vascular disease, not inflammation.

There are several types of exudate. Serous exudate is the clear yellow fluid

that oozes from burns. It has more fluid than protein.

Fibrinous exudate has a blood clotting material called fibrin, which traps

bacteria in its net. Fibrinous exudate forms scabs.

Purulent exudate is commonly referred to as pus. It gets its appearance

from dead bacteria and neutrophils. Pyogenic means forming pus. A

pyogenic infection is one that forms a purulent exudate in the acute

inflammatory response. When an inflammatory response has a large amount

of pus, it is called a suppurative infection. When a collection of pus is

closed off in a sac by fibrous connective tissue, it is called an abscess. A

small abscess is called a carbuncle.

Ulcerative and pseudomembranous inflammation are two types of acute

inflammation.

Ulcerative inflammation is inflammation of the body surfaces or the

mucosa of hollow organs, such as the stomach or intestines, that

results in ulceration.

Pseudomembranous inflammation is a form of ulcerative

inflammation combined with fibrinopurulent drainage. That is, the fluid

contains fibrin, pus, cellular debris, and mucus. This fluid forms a type

of membrane on the surface of the ulcers.

Chronic Inflammation

Infections that don’t completely heal, slow injury and slow allergic irritation

cause chronic inflammation. The symptoms of chronic inflammation are

not as dramatic as the symptoms of acute inflammation. In chronic

inflammation, there is less exudate or fluid and more fibrous tissue repair.

Pain is more prominent than redness or heat. Arthritis is a good example of a

disease with chronic inflammation as the body’s response to disease.

Subacute Inflammation

Subacute inflammation is a “flare-up” of a chronic inflammation. The pain,

redness, heat, and/or edema are suddenly more noticeable than in the

chronic state.

Granulomatous Inflammation

Granulomatous inflammation forms tumors rather than heat, redness or

pain. The tumor that is formed is more like a lump than swelling. The tumor

is called a granuloma. In this type of inflammation, the cells that come to

clear out the infection are called macrophages.

Granulomatous inflammation has special causes. It is seen with fungus

infections, tuberculosis and foreign bodies, like popcorn in the trachea. Any

disease that causes a granulomatous inflammatory response is called a

granulomatous disease.

Repair

There are two ways tissues can repair damage: regeneration and repair.

Regeneration

Normally, tissue replaces itself as old cells degenerate and die. For example,

the lining of the stomach replaces itself every three days or so. Red blood

cells are replaced every 120 days. When your skin flakes, you can see the

dead cells that are removed. They are replaced by new young cells.

Your skin flakes much more after the trauma of sunburn.

Regeneration is a normal process. However, in disease, this process is sped

up to replace damaged cells. Your skin flakes much more after the trauma of

sunburn, for example.

Repair

Repair is the response to injury when regeneration won’t repair the damage

that disease caused. Here the damaged tissues cannot regenerate, so they

are replaced by fibrous connective tissue. This is called fibrous connective

tissue repair. This also is called scarring or fibrosis.

Fibrous tissue doesn’t have the function of the tissue it replaced and usually

is firmer. A wound will heal with fibrous tissue repair whether it is secondary

to trauma or to surgery. The body doesn’t know the difference.

A wound that is sewn shut by surgery will heal with a smaller scar than one

that is not sewn shut. When the wound is sewn shut, there is less damaged

tissue to replace with fibrous tissue. That is why large cuts are closed with

“stitches.” This is called healing by primary intention or primary union.

When a wound heals with the borders separated, there is more inflammatory

response, and the tissue that forms during healing is called granulation

tissue. The tissue is friable, meaning it breaks easily. It takes longer for the

fibrous tissue to repair the wound. The scar is larger. This is called healing by

secondary intention or secondary union.

Damage or Death

When cells, tissues or organs are injured, there is damage. When cells

are damaged, there is degeneration, and the function decreases. The

body can do one of the following: repair the damage, not repair the

damage or allow the tissue to die. If there is no repair, the following

things can happen.

Morbidity

Morbidity means damage to a whole organism, like the human body. This

damage usually is not a desired outcome of treatment. For example, after a

stroke the human body doesn’t die, but it may not return to normal function.

This loss of function is a morbid change.

Atrophy and Hypertrophy

Remember these terms from earlier in the lesson? You know that atrophy

means cells slowly have decreased in size and/or number over a long time.

Atrophic changes are caused by chronic injury.

Hypertrophy means that cells enlarge or swell but don’t increase in number.

Chronic injury can do this. In hypertrophic change, the swelling is in the cells.

In inflammation, the swelling is in the fluid surrounding the cells. Hypertrophy

is one of two ways that tissues or organs become bigger. The other way

tissues enlarge is hyperplasia, an increase in the number of cells, although

the cells are not larger in size.

Accumulated Compounds

Chronic injury usually leads to increased collections of abnormal, unwanted or

waste materials in cells. This will increase the size of cells and organs and

change their color and texture as well.

For example, when the liver is damaged, it can accumulate fat. This is called

fatty metamorphosis. The liver is becoming larger and more yellow in color

because it contains more fat than normal; it is changing from a

morphologically normal liver to a morphologically abnormal liver.

Death

Necrosis is death of cells, tissues or organs in a living body. The change is

not reversible. That is, death cannot be reversed to life. Death occurs when

cells are so damaged that they cannot repair or regenerate; the tissues are

necrotic. Necrosis often results from an acute injury.

Mortality means death of an organism, like the human body. Anything that

kills is called lethal. For example, if a gene causes a genetic or congenital

abnormality that kills the body, the gene is called a lethal gene.

Mortality means death of an organism.

Different types of necrosis are seen microscopically. They include coagulation

necrosis, liquefaction necrosis, and caseous necrosis. The type of necrosis

tells you its cause. Interruption of the blood supply causes coagulation

necrosis. Liquefaction necrosis is the result of infection. The liquid pus

you see is the debris left by the inflammatory response, including dead tissue

cells and white blood cells. Caseous necrosis, which is seen in

granulomatous inflammation, looks like cheese and contains dead tissue with

tuberculosis bacteria in it.

Step 14 Pronounce New Terms

Follow these steps:

a. Take your Quick-Learn Tutor and the flashcards labeled Set 13

out of your Quick-Learn Kit. Insert the first flashcard into Side A

of the Tutor.

b. Access the online portion of your course, and go to Lesson 10.

c. Listen to the term, and pause the audio.

d. Practice pronouncing each term out loud. Take your time. Push

the flashcard up and read the meaning of the term.

e. Do this for each term in this set.

f. Put the flashcards in order and play the audio again,

pronouncing each word part or term after you hear it.

g. Don’t forget to listen to your own pronunciation of each term. If

you mispronounce one, put a check mark next to that flashterm.

h. Practice the terms you mispronounced by listening again. Be

sure you can pronounce the terms clearly and easily.

Step 15 Write New Terms

Follow these steps:

a. Insert the first flashcard into Side A of your Quick-Learn Tutor.

b. Look at each term as it appears in the window and say it out loud. Write

the term on blank paper.

c. Push the card up until the meaning appears in the right window and read

the meaning out loud. Write the meaning beside the term.

d. Do this for each flashcard.

Step 16 Meanings of New Terms

Follow these steps:

a. Again insert the first flashcard into Side A of your Quick-Learn Tutor.

Pronounce each term out loud and then say the meaning. Check yourself

by pushing the flashcard up until you can see the meaning in the right

window.

b. Now insert the flashcard into Side B of your Quick-Learn Tutor. Push the

card up until you see the meaning of the first flashterm in the right

window. Read each meaning out loud. Before you look, see if you can

remember the term that goes with that meaning. Check yourself by

pushing the flashcard up until you can see the term in the left window.

c. Practice with the flashcards several times until you are familiar with the

terms and their meanings. You may use the flashcards for the Progress

Checks and the Mail-In Quizzes.

Please pause and complete online Practice Exercise 10-4.

Step 17 Lesson Summary

Wow! We’ve covered a lot of information here! If you’re feeling a little

overwhelmed, just relax. It’s not necessary that you memorize all the new terms

you’ve just learned. As a medical coding specialist, you won’t be asked to describe

ribosomes or give an example of chronic inflammation. However, it’s important that

you have an understanding of cells, how they work properly, and what happens

when they aren’t operating at their peak.

Let’s do a quick review before you move on to your Quiz. This lesson taught

you the basic components of a cell and each component’s function. You

learned about everything from cytoplasm to the nucleus. You studied

etiologies, or the cause of abnormalities and injuries. You also looked at how

cells adapt to injury and how the cell structure might change in the healing

process. Lastly, you learned the body reacts to injury through inflammation,

repair, and damage or death.

Hopefully, you found parts of this lesson fascinating. Learning about

how the human body responds to damage can be an interesting read.

Perhaps you’ve experienced your own body healing in a way we’ve

discussed here. If there were parts of this lesson that you found

particularly confusing, go back and reread those sections before

moving on. A little extra studying will pay off!

Please pause and complete an online Quiz. Good luck!

LESSON 11

Diagnostic Coding 101

Step 1 Learning Objectives for Lesson 11

When you have completed the instruction in this lesson, you will be trained to do

the following:

Describe the history and development of the diagnostic coding system.

Explain the role of medical coding and its uses.

Compare and contrast the ICD-9-CM and the ICD-10-CM coding systems.

Step 2 Lesson Preview

So far in this course, you’ve learned about everything from medical facilities and

healthcare professionals to how insurance works. You’ve also gained a strong

foundation in medical records, ethics, terminology and anatomy. You’re probably

wondering when you’ll get to code. Well, here you go! This lesson will introduce

you to diagnostic coding.

When a provider makes a diagnosis, it is you, the medical coding specialist, who codes it.

Whenever a patient sees a provider for a health-related problem, the

patient is asking for a diagnosis. We’ve talked quite a bit about diagnoses

in previous lessons, and you already know a bit about diagnosis codes.

You also know that when a provider makes a diagnosis, it is you, the

medical coding specialist, who codes it. The diagnosis codes that you

assign are then used to determine the medical necessity. This helps the

payer, such as the insurance companies, to determine reimbursement for

the provider’s services.

This lesson will discuss the history and development of the ICD coding

system and explain the future of diagnostic coding. So, let’s get started!

Step 3 History of the International Classification of

Diseases

We spoke briefly of the International Classification of Diseases in a previous

lesson. The history of the ICD dates back to the 1600s in England! The system

came to the United States in the mid-1700s. This classification of diseases

originally was used to track mortality statistics to determine how many people died

of different diseases.

London Bills of Mortality.

In the seventeenth century, the statistical study of diseases began with the

work of John Graunt on the London Bills of Mortality. The Bills was initially a

list of only the number of burials. Graunt had added to the Bills, which now

included the cause of deaths. He tabulated and studied the data from the

annual bills from 1629 through 1660 and published Natural and Political

Observations Made upon the Bills of Mortality in 1662. This publication is

considered one of the forerunners of today’s international mortality

classifications.

In 1837, the General Register Office of England and Wales found its first

medical statistician, William Farr. Farr labored to secure an improved

classification, as well as international uniformity. In 1853, the first

International Statistical Congress (ISC) asked Farr to prepare an

internationally applicable, uniform classification of causes of death.

Although this classification was never universally accepted, the general

arrangement survived as the basis of the International List of Causes of

Death.

The International Statistical Institute created a committee, chaired by Dr.

Jacques Bertillon, to prepare a classification of causes of death. The report

was presented in 1893, and the Bertillon Classification of Causes of Death,

as it was first called, received general approval. Several countries adopted

it at that point. Jesus E. Monjaras first used the classification in the

Americas for the statistics of San Luis de Potosi, Mexico.

In 1900, the first international conference for the revision of the Bertillon or

International List of Causes of Death convened. Representatives from 26

countries attended and adopted the first of the ICDs or International

Classification of Diseases. It was determined that the classifications should

be revised every 10 years; therefore, the succeeding conferences were

held in 1909, 1920, 1929 and 1938, and a new version of the ICD was

adopted at each.

The WHO

The World Health Organization (WHO) is the directing and coordinating

authority for health within the United Nations system. It is responsible for

providing leadership on global health matters, shaping the health research

agenda, setting norms and standards, articulating evidence-based policy

options, providing technical support to countries and monitoring and

assessing health trends.

In 1946, the United Nations gave the responsibility

of the ICD to the WHO, which issued the sixth and subsequent revisions in

1948, 1958 and 1967.

The ICD is the international standard diagnostic classification. It classifies

diseases and other health problems recorded on many types of health and

vital records, including death certificates and health records.

ICD-9-CM

The World Health Organization published the 9

Revision, International

Classification of Diseases (ICD-9) in 1977. In 1979, the United States

adopted the International Classification of Diseases, 9

Revision,

Clinical Modification (ICD-9-CM) based on the ICD-9. The Clinical

Modification expanded the number of diagnosis codes and developed

a procedural coding system.

ICD-9-CM manual

The ICD-9-CM consists of:

Tabular List

Alphabetical Index

Procedure Index and Tabular List

Please pause and complete online Practice Exercise 11-1.

Step 4 Why Code?

Through the years, the number of people who go to the doctor has increased. This

increase has occurred for several reasons:

People live longer and require more health care.

Technological advances offer more options for better health care.

People have better access to health care than ever before.

Your role as the medical coding specialist is to translate the provider’s written

diagnoses for all of these patients into numeric, or number codes, and

alphanumeric, or combined letter and number, codes. The provider’s office

uses this coded information for a number of purposes. A primary use of

medical codes is to communicate to the insured the reason for a patient’s

medical visit. Thus, the diagnosis code communicates to the insurance payer

the reason the provider required medical services.

Coded information is used for numerous purposes.

Another use for medical coding is as a statistics-gathering tool for research,

grants and financial analysis. Hospitals use coding to index hospital records

according to diseases and operations. By indexing—or organizing—records

this way, they consistently can store and retrieve data. Coding is useful for

reporting medical diagnostic trends to agencies that track this information.

For instance, the American Cancer Society can access accurate cancer

statistics thanks to coding.

As you can see, the coding system is a common language that the medical

community uses as a standard communications device. Using this coding

system correctly is important. You know by now that if a code is used that

does not match the services performed, the claim will be rejected. In

addition, for government claims, such as to Medicaid or Medicare, the correct

code is required by law.

Originally, medical coding was used to allow access to medical records for

easy retrieval of information for medical research, education and

administration. Today, coding is used to:

Facilitate payment of medical services.

Study patients’ use of healthcare facilities.

Study the cost of health care.

Research the quality of health care.

Determine healthcare trends.

Plan for future healthcare needs.

Step 5 ICD-10

After 30 years, the ICD-9 needs to be replaced. The terminology and classification

of some conditions are outdated and/or obsolete. These outdated codes produce

inaccurate and limited data. And, the limits of the categories result in increasing

lack of specificity. Finally, the ICD-9-CM hinders comparisons with international

data. It’s clear that the ICD must be flexible enough to adjust for emerging

diagnoses and procedures and exact enough to identify precise diagnoses and

procedures.

In 1989, the WHO prepared the International Statistical Classification of

Diseases and Related Health Problems, 10

Revision (ICD-10), which was

released in 1994. The United Kingdom adopted it in 1995, followed by the

Nordic countries of Denmark, Finland, Iceland, Norway and Sweden from

1994 through 1997. Each year, another country adopted the ICD-10: France

(1997), Australia (1998), Belgium (1999), Germany (2000) and Canada

(2001). On January 15, 2009, the Department of Health and Human Services

(HHS) released the final rule for the implementation of the International

Classification of Diseases, 10

Revision, Clinical Modification (ICD-10-CM)

and the International Classification of Diseases, 10

Revision, Procedural

Classification System (ICD-10-PCS). The final rule pushed the ICD-10 (both

ICD-10-CM and ICD-10-PCS) implementation date to October 1, 2013.

To read about the ICD-10 Final Rule, visit: http:edocket.access.gpo.gov/2009/pdf/E9-

743.pdf

On April 17, 2012, a proposed rule was released that would delay, for one

year, implementation of the ICD-10 data sets until October 1, 2014.

Impact for Coders

How does this affect you as a medical coder? Is it a waste of time to learn

coding from the ICD-9-CM? Absolutely not! Per U.S. government mandate,

the ICD

9 CM will be used by all medical service providers up until midnight

on September 30, 2014. The ICD-10-CM will be implemented on October 1,

2014. To make sure you have the information about the current industry

standard, we will focus on discussing the ICD-9-CM in your course for the

immediate future. Once you are familiar with the coding process with the

ICD-9 CM, it’ll be a smooth transition to the ICD-10-CM. You can get

reference material, in the format of an ICD-10-CM supplement, available for

purchase online through our bookstore. This supplement is optional and is not

a required part of your course.

Step 6 ICD-9-CM vs. ICD-10-CM

Let’s briefly review the two different code sets and compare them. The format and

structure will be examined in detail in later lessons. For now, just compare and

contrast the diagnosis code sets.

Now you understand the need for the ICD-9-CM update and when that will

happen.

Please pause and complete online Practice Exercise 11-2.

Step 7 Lesson Summary

Congratulations! You’ve made it through diagnostic coding 101. You have a

good understanding of the history behind the development of the ICD-9-CM

coding system. You can explain your role as a medical coding specialist, as

well as other uses for coding today. Finally, you know why the transition to

the ICD-10 is necessary and when to expect the implementation of this new

coding system. A background in the similarities and differences between the

coding systems will result in a smooth transition.

Please pause and complete an online Quiz. Good luck!

Endnotes

World Health Organization. The WHO Family of International Classifications. 2010.

http://www.who.int/classifications/icd/en/HistoryOfICD.pdf. Accessed 1 February 2010.

Bertillon J. Classification of the causes of death (abstract). In: Transactions of the 15th International

Congress on Hygiene Demography. Washington, 1912.

World Health Organization. The WHO Family of International Classifications. 2010.

http://www.who.int/classifications/icd/en/HistoryOfICD.pdf. Accessed 1 February 2010.

World Health Organization. About WHO. 2010. http://www.who.int/about/en/. Accessed 1 February 2010.

World Health Organization. International Classification of Diseases. 2010.

http://www.who.int/classifications/icd/en/. Accessed 1 February 2010.

Table of Contents

Title Page 2

Table of Contents 5

Acknowledgments 4

Lesson 1—The World of Health Care 12

Step 1 Learning Objectives for Lesson 1 12

Step 2 Lesson Preview 12

Step 3 Daily Activities in the Medical Office 13

A Day in the Life of the Medical Office Manager 13

The Doctor’s Point of View 15

Step 4 A Little Teamwork Goes a Long Way 16

Physicians 17

Nurses 17

Nurse’s and Physician Assistants 18

Support Staff 18

Emergency Personnel 21

Office Professionals 22

Step 5 Welcome to Your Career as a Medical Coding Specialist! 22

But Where Will I Work? 23

Step 6 Personal Qualities of a Medical Coder 26

Professionalism 26

Presentation 28

Adaptability 28

Step 7 Medical Records 28

Parts of a Medical Record 29

The Flow of Medical Information 35

Step 8 Lesson Summary 37

Lesson 2—Medical Insurance 38

Step 1 Learning Objectives for Lesson 2 38

Step 2 Lesson Preview 38

Step 3 The Life Cycle of a Medical Bill 39

Processing the Bill 40

Step 4 Insurance 41

Step 5 Common Insurance Terms 42

Provider 43

Claim Form 43

Deductible 43

Copayment 43

Reasonable and Customary 44

Explanation of Benefits 44

Electronic Claims 45

Step 6 Types of Health Insurance 46

Government Insurance 47

Private, Traditional Insurance 49

Managed Care 49

Blue Cross/Blue Shield 50

Step 7 Diagnostic Codes—A Piece of the Insurance Puzzle 50

How Important Is Diagnostic Coding? 51

Step 8 Procedure Coding—Another Piece of the Puzzle 52

Step 9 Looking Ahead 53

Step 10 Lesson Summary 54

Lesson 3—Introduction to Medical Terminology: Word Parts 56

Step 1 Learning Objectives for Lesson 3 56

Step 2 Lesson Preview 56

Step 3 Word Parts 57

Step 4 Root Words 59

Step 5 Medical Terms 61

The Combining Vowel 61

Step 6 Root Words 63

The Functions of Root Words 64

Step 7 Pronounce Root Words 65

Step 8 Write Root Words 66

Step 9 Meanings of Root Words 67

Step 10 Prefixes 68

Step 11 Pronounce Prefixes 70

Step 12 Write Prefixes 71

Step 13 Meanings of Prefixes 72

Step 14 Suffixes 72

Step 15 Pronounce Suffixes 75

Step 16 Write Suffixes 76

Step 17 Meanings of Suffixes 77

Step 18 Lesson Summary 77

Just for Fun 78

Lesson 4—Medical Terminology: Dividing and Combining Terms 81

Step 1 Learning Objectives for Lesson 4 81

Step 2 Lesson Preview 81

Step 3 Dividing Medical Terms 82

Consonants, Vowels and the Role They Play 83

A Little Practice 84

Word Meanings 86

Step 4 Pronounce Word Parts 88

Step 5 Write Word Parts 89

Step 6 Meanings of Word Parts 89

Step 7 Combining Medical Terms 90

Consonants, Vowels and the Role They Play 91

Step 8 Pronounce Word Parts 92

Step 9 Write Word Parts 93

Step 10 Meanings of Word Parts 93

Step 11 Lesson Summary 94

Lesson 5—Medical Terminology: Abbreviations, Symbols and Special Terms 96

Step 1 Learning Objectives for Lesson 5 96

Step 2 Lesson Preview 96

Step 3 Abbreviations 97

Abbreviations in Hospitals 97

Office Records 98

Doctors 98

Pharmacies 98

Step 4 Learn Abbreviations 98

Step 5 Meanings of Abbreviations 99

Step 6 Slang 99

Medical Slang 100

English Slang 100

Step 7 Slang Terms 101

Step 8 Meanings of Slang Terms 102

Step 9 Symbols 102

Step 10 Special Terms 103

Eponyms 104

Brand Names 105

Acronyms 106

Step 11 Pronounce Acronyms 107

Step 12 Sound-Alikes and Opposites 108

Homophones (Sound-Alikes) 108

Antonyms (Opposites) 109

Step 13 Medical Plurals 110

Medical Rules for Plurals 110

Step 14 Lesson Summary 110

Lesson 6—Documenting Medical Records 112

Step 1 Learning Objectives for Lesson 6 112

Step 2 Lesson Preview 112

Step 3 Documentation—The Key Component of Medical Records 113

Types of Documentation 114

Commonly Used Narrative Formats 116

Step 4 The Business of Managing Medical Records 118

Good Recording Practices 118

Step 5 Lesson Summary 120

Lesson 7—Ethics and Legal Issues 122

Step 1 Learning Objectives for Lesson 7 122

Step 2 Lesson Preview 122

Step 3 Confidentiality 122

Guidelines for Confidentiality of Medical Records 123

Guidelines for Faxing Medical Records 124

Step 4 Medical Ethics 125

Step 5 Health Insurance Portability and Accountability Act 127

Step 6 Fraud and Abuse 139

Preventing Fraud and Abuse 140

Consequences of Committing Fraud 141

Step 7 Liability Insurance 142

Insurance Audits 143

Step 8 Recovery Audit Contractors 144

Step 9 Legal Concerns 144

Subpoenas 145

Arbitration 145

Medical Testimony 146

Step 10 Lesson Summary 146

Endnotes 147

Lesson 8—Introduction to Anatomy 149

Step 1 Learning Objectives for Lesson 8 149

Step 2 Lesson Preview 149

Step 3 Human Biology 150

What Is Human Biology? 150

Anatomy 151

Physiology 153

Step 4 Pathology 153

How Do Anatomy, Physiology and Pathology Relate to One Another? 154

Step 5 Beginning Anatomy and Physiology Concepts 156

The Anatomic Position 156

Planes and Sections of the Human Body 157

Transverse Planes and Sections 158

Sagittal Planes and Sections 158

Coronal Planes and Sections 159

Planes and Sections 160

Step 6 Location Terms 161

Step 7 Pronounce New Terms 167

Step 8 Write New Terms 168

Step 9 Meanings of New Terms 169

Step 10 Organ and Organ Systems 169

Respiratory System 170

Circulatory/Cardiovascular System 170

Nervous System 171

Muscular System 171

Skeletal System 171

Integumentary System 171

Endocrine System 172

Digestive System 172

Urinary System 172

Reproductive System 172

The Immune System 172

Step 11 Lesson Summary 173

Lesson 9—Anatomy: Landmarks and Divisions 174

Step 1 Learning Objectives for Lesson 9 174

Step 2 Lesson Preview 174

Step 3 Gross Anatomy 174

Landmarks and Divisions 175

Step 4 Pronounce New Terms 177

Step 5 Write New Terms 178

Step 6 Meanings of New Terms 178

Step 7 Adjective Forms for Landmark Names 179

Step 8 Divisions of the Abdomen 180

An Alternative Division of the Abdomen 181

Step 9 Internal Landmarks: The Body Cavities 182

Step 10 Membranes That Line the Body Cavities 184

Epithelial Tissue Membranes 184

Connective Tissue Membranes 185

Step 11 Retroperitoneal Organs 186

Step 12 Pronounce New Terms 186

Step 13 Write New Terms 187

Step 14 Meanings of New Terms 188

Step 15 Organization of the Body 188

Step 16 Lesson Summary 190

Just for Fun 191

Lesson 10—Cell and Tissue Anatomy and Pathology 193

Step 1 Learning Objectives for Lesson 10 193

Step 2 Lesson Preview 193

Step 3 Cell Components and Their Primary Functions 194

Cell Membrane 195

Cilia 195

Flagella 195

Villi 196

Step 4 More Cell Components and Their Functions 196

Cytoplasm 196

Step 5 The Nucleus 199

DNA 199

RNA 200

Nucleoli 200

Step 6 Pronounce New Terms 200

Step 7 Write New Terms 201

Step 8 Meanings of New Terms 201

Step 9 Cell Pathology 202

Step 10 Etiologies 203

Developmental Abnormality 203

Inflammatory Disease 203

Hyperplasia and Neoplasia 204

Metabolic Disease 205

Vascular Disease 205

Immunologic Disease 205

Idiopathic Abnormality 205

Iatrogenic Abnormality 206

Nosocomial Disease 206

Step 11 Cell Damage 206

Hypoxia and Anoxia 206

Toxic Agents 207

Microbial Infection 208

Allergic/Immune Reactions 208

Metabolic and Genetic Disturbances 208

Step 12 Cell Response 209

Atrophy 210

Hypertrophy 211

Hyperplasia 211

Metaplasia 212

Intracellular Accumulations 213

Aging 213

Step 13 Tissue Response 214

Inflammation 215

Repair 218

Damage or Death 219

Step 14 Pronounce New Terms 220

Step 15 Write New Terms 221

Step 16 Meanings of New Terms 221

Step 17 Lesson Summary 221

Lesson 11—Diagnostic Coding 223

Step 1 Learning Objectives for Lesson 11 223

Step 2 Lesson Preview 223

Step 3 History of the International Classification of Diseases 223

The WHO 225

ICD-9-CM 225

Step 4 Why Code? 226

Step 5 ICD-10 227

Impact for Coders 228

Step 6 ICD-9-CM vs. ICD-10-CM 228

Step 7 Lesson Summary 229

Endnotes 229