Transcript ANATOMY & MEDICAL TERMINOLOGY – ICD

Presented by:
MAXINE I COLLINS MBA, CPA, CMC, CMIS, CMOM
M COLLINS & CO PLLC
940-692-2733
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Anatomical terms come from Greek,
Latin and sometimes Arabic origin
Word origins often come from
descriptive images
Example: muscle – from Latin word
“mus”, which is mouse.
– Describes the movement of the muscle under the
skin, much like a mouse under a carpet
Source: Medical Billing Basics, Ingenix Coding Lab, Chapter 1, p. 1.
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Converting Greek to Latin introduced
new terms
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Medical terms broken into basic word parts
– Root term – the basic building block
• Basic meaning of the term
• Often the body part
– Prefix – Appears before the root term
• Further describes root term
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Location
Number
Color
Status
– Suffix – Appears after the root term
• Usually, but not always denotes condition
– Can also describe procedure, disorder or disease
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Common “root” terms
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Card/i
Nephr/o
My/o
Myel/o
Heart
Kidney
Muscle
Spinal cord; bone marrow
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Peri
Poly
Dys
Ante
surrounding/around
many
difficult
before
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itis
osis
algia
centesis
inflammation
abnormal condition
pain
surgical puncture
Common “prefixes”
Common “suffixes”
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Combining vowel is always used to form compound
words when two are more root terms are combined
– Cardio/o/pulmonary
– Gastr/o/enteritis
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Combining vowel not used when suffix begins with a
vowel (a,e,i,o,u)
Neur/itis
Gastr/it is
Combining vowel is used when suffix begins with a
consonant
Neur/o/plasty
Cardi/o/megaly
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Anatomy - Study of human body structures
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Physiology – Study of the functions of the
structures
– Greek – “Ana”, up; process of cutting
– Morphologic structure of an organism
– Foundation of medicine
– Greek – “physi” – nature; (normal vital processes of
living organisms and their functions)
– Greek – “logos” – study; -ology – science/study of
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Cells – smallest unit of living structure
capable of independent existence; basic units
of life
– Composed of membrane-enclosed mass of
protoplasm and containing a nucleus or nucleoid
– Highly variable and specialized in both structure
and function
– All must at some stage replicate (to produce )
proteins and nucleic acids, utilize energy, and
reproduce themselves
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Blood Cells (2011, August jj), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Basophil – a white blood cell, granular with pale-staining nucleus;
hormone producing
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Eosinophil – white blood cell, coarse, granular of uniform size, part of
the immune system process
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Erythrocyte – red blood cell, contains hemoglobin, carries oxygen; one of
the most common types of blood cells
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Lymphocyte – white blood cell, B & T cells; of importance in the immune
system; produce antibody
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Monocyte – a single nucleus white blood cell; helps other white blood
cells remove dead or dangerous tissues (e.g. cancer)
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Neutrophil – extracellular white blood cell; fights infections
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Platelet – irregular shaped, colorless body in blood, formed in bone
marrow; helps blood to clot
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Thrombocytes – anucleated cell fragments that play a key role in blood
clotting; platelets
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Blood Cells (2011, August jj), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Blood Cells (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Blood Cells (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Tissues – groups of similar cells and the
intercellular substances surrounding them
◦ Latin – “texo” – to weave
◦ Work together to perform similar tasks
◦ 4 basic types:
 epithelium
 connective tissues (including blood, bone, and
cartilage)
 muscle tissue
 nerve tissue
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Organ – two or more tissues
◦ Latin – “organum”; Greek – “organon”, a tool,
instrument
◦ Any part of the body exercising a specific function as
in respiration, secretion, or digestion
◦ Together perform special body functions
◦ Example: olfactory – the olfactory region is in the
superior portion of the nasal cavity; organum olfactus
– of smell
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Tissues, (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Systems – A consistent and complex whole
made up of correlated and semiindependent parts
– Greek – “systema” – an organized whole
– Usually Organs
– Work together to perform complex body
functions
– Example: alimentary – the digestive tract from
the mouth of the anus with all of its associated
glands and organs; digestorium; systema
alimentarium
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Alimentary System,(2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Integumentary
– Integument – the enveloping membrane of the body; includes, in addition
to the epidermis and dermis, all of the derivatives of the epidermis such
as skin, sweat glands, sebaceous (oil) glands, hair and nails
– Example: “Derma” – root word – skin; Dermatology – study of skin
– CPT code range – Surgery/Integumentary – 10040-19499; reports
procedures performed on the skin, subcutaneous tissue and accessory
organs, nails, pilonidal cysts, and breasts, including repair of
lacerations, repair, closure, removal of lesions, and reconstruction
– ICD-9-CM code range – Codes appear throughout ICD-9-CM as this
system includes the outer covering of the body as well as the covering for
internal organs. However, for infection, inflammation and other diseases
of the skin and subcutaneous tissues of the outer layer of the body, codes
will be found at code range 680-709.
– ICD-10-CM code range- Corresponding code range in ICD-10-CM is
L00-L99
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HORNY LAYER
Integumentary System(2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.org
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Stratum – layers of differentiated tissue, the aggregate of which forms any
given stucture
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Corneum – the outer layer of the epidermis composed of several layers of
flat keratinized non-nucleated cells – horny layer of epidermis
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Basale the deepest layer of the epidermis, composed of dividing
stem cells and anchoring cells, basale cell layer – growing layer
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Sudoriferous – Latin – “sudor” – sweat + “fero” – to bear; sweat glands
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Adipose – Latin – “adipis” – fatty tissue; akin to Greek – “lipo”
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Subucanteous – Latin – “sub” – below + “cutis” – skin
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Sebaceous – Latin – “sebaceus” – relating to the sebum; oily, fatty; “sebum”
– secretion of sebaceous glands; Latin – “tallow”- the rendered fat from
mutton suet –(kidneys of cattle and sheep)
Gland – Latin – “glans”, acorn – an organized aggregation of cells
functioning as a secretory or excretory organ
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L08.1
L10.0
L11.9
L21.0
L30.1
L57.1
L60.2
L70.2
L81.1
L90.6
L98.5
Erythrasma
Pemphigus vulgaris
Acantholytic disorder, unspecified
Seborrhoea capitis
Dyshidrosis {pompholyx}
Actinic reticuloid
Onychogryposis
Acne varioliformis
Chloasma
Striae atrophicae
Mucinosis of skin
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L08.1 – Erythrasma – a skin disease that causes brown, scaly
skin patches caused by the gram positive bacterium
Corynebacterium minutissimum. It is a chronic superficial
infection of the intertriginous areas of skin. Usually presents in
the axillae and groin area.
The bacteria invades the upper third of the stratum corneum
under favorable conditions such as heat and humidity.
Organisms proliferate and the stratum corneum becomes
thickened.
The organisms dissolve the keratin fibrils. Coral-red
fluorescence of the scales seen under the Wood lights is
secondary to production of porphyrin by diptheroids.
Erythromycin is the drug of choice. Therapy must be
comprehensive and cover all likely pathogens.
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Erythraino – Greek – to redden
Gram positive – Latin – “granum”-grain; refers to the ability of a bacterium to
resist decolorization with alcohol after being treated with Gram crystal violet
stain
Keratin fibrils – keratin – Greek – “keras” – horn; collective name for group of
proteins that form the intermediate filaments in epithelial cells. fibril – Latin –
“fibrilla” – a minute fiber or component of a fiber
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Porphyrin –pigments widely distributed
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Immuno-compromised – “immune” – Latin – free from service;
immunocomprised – denoting an individual that is deficient in immunity
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Intertriginous – inter – between + Latin – “tero” – to rub; a scaling of the skin;
irritant dermatitis appearing between the folds of skin
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Diptheroids- dipthera – Greek – leather + “eidos” – Greek – resemblance; One
of a group of local infections suggesting diptheria, but caused by
microorganisms other than Corynebacterium diphtheria.
Pathogens - path – Greek – feeling + “gen” – Greek – to produce – any virus,
micro-organism or other substance causing disease
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Pemphigus Vulgaris
◦ Pemphigus- Greek- “Pemphix”; blister, (Autoimmune bullous
diseases with acantholysis)
◦ “Vulgus”- Latin; a crowd (A serious form of Pemphigus)
 Bullous- “bull”, “bullae”- Latin; boiling ( A fluid filled blister
greater than 100cm appearing in a circumscribed area of
separation from the epidermis)
 Acantholysis- Greek- “Acantho”; a thorn: “lysis”- Greek- a
loosening (Separation of individual epepidermal kerainocytes
from their neighbor, such as Pemphigus Vulgaris and Darier
Disease)
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Musculoskeletal System, (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia
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Includes soft tissue (deep fascia, muscles, tendons, and
ligaments), joints, bursa, cartilage and bones
– Tendons are fibrous cords that vary in length and are found at the
ends of muscles and connect muscles to bones
– Ligaments are bands of fibrous tissue that connect two or more
bones or cartilage
– Joints – area of contact between two bones, holding the bones together
and allowing articulation (movement) between cartilage and bones
– Bursa – consist of a sac that contains synovial fluid within a synovial
membrane lining. Found at friction points between tendons and
muscles.
– Cartilage – a type of connective tissue (hyaline, elastic, and fibrocartilage)
that is found in joints.
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Three types of muscle tissue: skeletal, cardiac, and visceral
− Muscles consist of specialized cells that allow contraction to produce
voluntary or involuntary movement of body parts.
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Bones – classified by either shape; long,
short, flat, and irregular, or by location:
sutural, and sesamoid bones:
– Long bones: humerus, tibia, and femur
– Short bones: wrist and ankle
– Flat bones: sternum, scapula, and ribs
– Irregular bones: vertebra column and some facial
bones
– Sutural bones: specific cranial bones
– Sesamoid bones: patella and in tendons where
there is pressure ( e.g. wrist)
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M02.1 Postdysenteric arthropathy
M05.9 Seropositive rheumatoid arthritis,
unspecified
M10.0 Idiopathic gout
M12.2 Villonodular synovitis
M16.1 Other primary coxarthrosis
M16.3 Other dysplastic coxarthrosis
M17.4 Other secondary gonarthrosis, bilateral
M24.6 Ankylosis of joint
M62.0 Diastasis of muscle
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Arthropathy – “arthron”-Greek – a joint; pathy – Greek, “pathos” –
feeling, suffering, disease
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Idiopathic – “idio”- Greek –private, peculiar; pathos – disease
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Villonodular –nodular projections
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Coxarthrosis – “coxa” – Latin –hip; arthr – joint; osis – abnormal
condition
– Denoting a disease of unknown origin
– Abnormal condition of the hip joint
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Gonarthrosis – “gony” – Greek – knee
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Ankylosis – “anklyos” – Greek – bent
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Diastasis – “dia” – Greek – through; Any simple separation of
normally jointed parts
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The nose, pharynx, larynx, trachea, bronchus
(bronchial tubes) and lungs.
Pulmonology – the science or study of the
pulmonary system
Brings oxygen-rich air into the body for
delivery to the blood cells
Expels waste products (carbon dioxide and
water ) that have been returned to the lungs
by the blood
Produces the air flow through the larynx that
makes speech possible
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Respiratory System, (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.
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Heart, blood vessels, lymphatic (immune system) and
blood (hematology)
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Cardiovascular – pertaining to the heart and blood
vessels
– Heart – a muscular organ located between the lungs and above
the diaphragm
– Pericardium – double-walled membraneous sac – encloses the
heart
– Coronary arteries and veins supply blood to the myocardium.
– Atria – two upper chambers – receive blood; separated by the
interatrial septum or wall
– Ventricle – lower two chambers of the heart on the right and
left – separated by the interventricular septum; the pumping
chambers
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Right atrium receives oxygen-poor blood from all tissues, except lungs through
the superior and inferior venae cavae. Blood flows out of the RA through
tricuspid valve (controls the opening between right atrium and right ventricle)
into right ventricle.
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RV pumps the oxygen-poor blood through the pulmonary valve into pulmonary
artery, which carries it to the lungs.
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Pulmonary semilunar valve – located between the right ventricle and pulmonary
artery.
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LA receives oxygen-rich blood from lungs the four pulmonary veins. Blood
flows out of the LA through the mitral valve (bicuspid valve – located between
the left atrium and left ventricle) and into left ventricle.
LV receives oxygen-rich blood from left atrium. Blood flows out of the LV
through aortic valve and into aorta which carries it to all parts of the body,
except the lungs
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Aortic semilunar valve – located between the left ventricle and the aorta.
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Oxygen-poor blood is returned by the venae cavae to the right atrium and the
cycle continues
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Electrical impulses from nerves stimulate the myocardium of the chambers of
the heart. The conduction system or electrical impulses are controlled by the
sinoatrial (S-A) node, atrioventricular (A-V) node and bundle of HIS.
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RED –
BUNDLE
OF HIS
Cardiovascular System, (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wikipedia.
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Question: The spinal cord ends in a
tuft of spinal nerves. What
imaginative name was given to this
tangle of branches?
Sacral Dendron
 Spinal Candelabrum
 Neuroalluvium
 Cauda Equina
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Source: FunTrivia.com: Anatomy and Physiology
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 Cauda
Equina
 “Cauda Equina” means horse tail
◦ Do you know any “horse’s tails”?
Source: FunTrivia.com: Body Parts with Silly Names
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What is the function of the “amygdala”?
 Secretion of steroid hormones
 Memory and emotion
 Concentrating bile
 Production of seminal fluid
Source: FunTrivia.com: Anatomy & Physiology
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Memory and emotion
◦ Part of the limbic system, (“limbic” comes from Latin, limbus– “border” or
“edge”) the amygdala is important in Pavlovian classical conditioning.
◦ A set of brain structures including the hippocampus, amygdala, anterior
thalamic nuclei, spetum, limbic cortext and formic, which reportedly support a
variety of functions including emotion, behavior, long term memory, and
olfaction.
 Ivan Pavlov (1927) researched respondent conditioning to measure the
behavioral response to stimuli.
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Source: FunTrivia.com: Anatomy & Physiology
Amygdala, , (2011, August 11), In Wikipedia, The Free Enclycopedia. From Wikipedia contributors, http://en.wiki
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What is another name for hypoperfusion?
 Cardiac Arrest
 Hyperventilation
 Shock
 Myocardial Infarction
Source: FunTrivia.com: Anatomy & Physiology
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Shock
◦ Treatment for shock includes:
 Depends on the type of shock
 Hypovolemic – most common-insufficient
circulating volume
 Cardiogenic
 Septic
 Anaphylactic
 Neurogenic
 Other
 Trandelenberg position (legs elevated), oxygen
therapy, keeping warm and intravenous fluids.
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What is
arm?
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the name of the bone in the upper
Brachial
Femur
Humerus
Forearm
Source: FunTrivia.com: Anatomy & Physiology
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 Humerus
◦ And, of course, your “funny bone” is
at the end of the humerus. That is
kind of humerous, don’t you think?
Source: FunTrivia.Com; Body Parts with Silly Names
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 By
what name is the “axilla” more
commonly known?
Windpipe
 Jawbone
 Belly button
 Armpit
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Source: FunTrivia.Com: Anatomy & Physiology
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 Armpit
◦ Comes from the Greek. Probably
relates to the word “axis” since it
occurs at the joining of the arm and
torso.
◦ Don’t confuse “axilla “with “maxilla”
which is the upper bone of the jaw.
Source: FunTrivia.com; Body Parts with Silly Names
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 What
is the popular name of the
tendon that connects the calf to
the heel?
Source: FunTrivia.com: Anatomy Alphabet
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 Achilles
& Achilles tendon
◦ Named after a hero from the Trojan
War whose only place of weakness
was his heel.
Source: FunTrivia.com: Anatomy Alphabet
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 Which
wrist?
is one of the bones of the
Cochlea
 Coccyx
 Capitate
 Cranium
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Source: FunTrivia.com: Alphabet Anatomy
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 Capitate
◦ There are 8 bones in the wrist.
◦ The cranium is part of the skull
◦ The cochlea is a spiral shaped
chamber in the inner ear.
◦ The coccyx is the tailbone
Source: FunTrivia.com: Alphabet Anatomy
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The diagnosis classification system developed
by the Centers for Disease Control and
Prevention for use in all U.S. health care
treatment settings.
Diagnosis coding under this system uses 3 -7
alpha and numeric digits and full code titles, but
the format is much the same as ICD-9-CM
ICD-10 medical terms are more specific and
clinical in nature
The medical coder will have to continue to
increase their knowledge of anatomy/physiology
and medical terminology!
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DATE
COMPLIANCE STEP
January 1, 2010
Payers and Providers should begin internal testing of Version 5010
standards for electronic claims
December 31, 2010
Internal testing of Version 5010 must be complete to achieve Level I
Version 5010 compliance
January 1, 2011
• Payers and Providers should begin external testing of Version 5010
for electronic claims
• CMS begins accepting Version 5010 claims
• Version 4010 claims continue to be accepted
December 31, 2011
• External testing of Version 5010 for electronic claims must be
complete to achieve Level II Version 5010 compliance
January 1, 2012
• All electronic claims must use Version 5010
• Version 4010 claims are no longer accepted
October 1, 2014
• Claims for services provided on or after this date must use ICD-10
codes for medical diagnosis and inpatient procedures
• CPT codes will continue to be used for outpatient services
Source:
Website: http://www.cms.gov?ICD10/03_ICD-10andVersion5010ComplianceTimeles.asp
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While ICD-10 has organizational changes and
new features, its format and conventions
remain much the same as ICD-9.
ICD-10 consists of 21 chapters
“V” and “E” codes as used in ICD-9 are no
longer supplementary classifications and
become other codes
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A78
Q fever
A69.32 – Meningitis due to Lyme
disease
S52.131A – Displaced fracture of neck of
right radius, initial encounter for closed
fracture
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Become - ICD-10-CMs “Z” Codes
◦ Used in all healthcare settings
Factors influencing health status and contact with health
services:
Z00-Z99
Examples:
Contact/Exposure
Inoculations/vaccinations
Status codes
History of
Screening
Observation
Aftercare
Follow-up
Others…….
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Become - ICD-10-CMs “V” – “Y” Codes
External Causes of Morbidity
◦ V01-Y99
◦ Use full range of External Cause codes to :
 Completely describe the cause, the intent, the place of
occurrence and, if applicable, the activity at the time of
the event, and the patient’s status, for all injuries, and
other health conditions due to an external cause.
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Preparations are being done now to transition from
“9” to “10”
Over 100 new “Activity” codes were added to “E”
codes in 2010
Changes are also seen in the ICD-9-CM codes
effective 10/01/2010.
◦ New codes for foreign bodies and complications
of medical care
Continual increase in acceptance of “V” and “E”
codes by carriers
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ICD-10 distinguishes between burns and
corrosions:
◦ Burn codes are for thermal burns, except sunburns, that
come from a heat source, such as fire or hot appliance.
Also for burns resulting from electricity and radiation
◦ Corrosions are burns due to chemicals
◦ Encounters for treatment of late effects of burns or
corrosions should be coded with a burn or corrosion code
with the 7th character of “S” – sequlae
◦ An external cause code should be used with burns and
corrosions to identify the source and intent of the burn, as
well as the place where it occurred.
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Codes in categories T36-T65:
◦ Are combination codes that include the substances
related to adverse effects, poisoning, toxic effects and
underdosing, as well as the external cause.
◦ Sequence the T36-T65 codes first, followed by the
code(s) that specify the nature of the adverse effect,
poisoning, or toxic effect.
◦ Do not code directly from the Table of Drugs – always
refer back to the Tabular List.
◦ Use as many codes as necessary to describe completely
all drugs, medicinal or biological substances
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ICD-10-CM CHAPTERSPECIFIC GUIDELINES
CHAPTER 1:
CERTAIN INFECTIONS
AND PARASITIC
DISEASES
CODE RANGE:
A00-B99
CHAPTER 1-SPECIFIC
GUIDELINES
• HIV
• Infectious agents as
cause of diseases
classified to other
chapters
• Infections resistant to
antibiotics
• Sepsis, Severe Sepsis
and Septic Shock
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CMS
◦ General ICD-10 Information
 http://www,cms.hhs.gov/ICD10
◦ ICD-10 Notice of Proposed Rulemaking
 http://www.cms.hhs.gov/TransactionCodeSetsStands/
01_TransactionsandCodeSetsRegulations.asp
◦ ICD-10-CM Coding System
 http://www.cms.hhs.gov/ICD10/03 ICD 10 CM.asp#
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Q&A?
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