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AAPC CPC Prep Course - Chap 2
Summary Notes
CPC Prep course Chapter 2 Notes
Medical Terminology and Anatomy Review
Intro: ● A thorough knowledge of human anatomy is essential to successful coding, as is the ability to understand medical terminology used to describe and document medical procedures and services ● This chapter introduces the basic elements of human anatomy and reviews medical vocabulary and terminology ● Objectives: ○ Understand the language of medicine ○ Review word elements such as combining forms, prefixes, and suffixes ○ Acquire an understanding of procedural and diagnostic terms ○ Understand anatomy as it relates to coding Medical Terminology ● To code medical procedures and diagnoses accurately, you first must learn the language of medicine ○ Many medical terms used today derive from the ancient Greeks and Romans ■ EX: latin phrase - pro re nata, which means when necessary- is the origin of the medical abbreviation PRN ● The best way to learn medical terminology is by understanding word parts and elements of medical language - root words, prefixes, and suffixes - which serve as the foundation of out medical vocabulary ○ When you understand the meanings of each word part, interpretation of tens of thousands of complex medical terms becomes easier Root ● The base of the word is the root ○ Root words are terms standing alone as the main portion of a medical term ○ A prefix, suffix, and combining vowel may accompany it ○ The root word is the word part holding the fundamental meaning of the medical term, and each medical term contains at least on root or base word
○ A word can have more than one root and a root may be used for different meanings based on the body system referred to ● Combining vowels are attached to root words to link the root word with the suffix, or one root word to another root word ○ Combining vowels also make medical terms easier to pronounce ○ The most common vowels are O and I ○ Occasionally, these vowels are dropped altogether, such as when the suffix being with a vowel ■ However the combining vowel is always placed between two root words, even when the second root word begins with a vowel ● Combining forms are root words with a combining vowel ● Common root words and their combining forms associated with the body systems include: ○ Integumentary System Term Definition Derm/o Skin Dermat/o Skin Hidr/o Sweat, perspiration Kerat/o Keratin, horny layer of skin Melan/o Dark, black, melanin Onych/o Nail Seb/o Sebum, sebaceous gland Trich/o Hair ○ Musculoskeletal System Term Definition Arthr/o Joint Burs/o Bursa, sac of fluid near joint Chondr/o Cartilage Erg/o Work Fasci/o Fascia
Arter/o, Arteri/o Artery Arteriol/o Arteriole Atri/o Atrium Cardi/o Heart Phleb/o Vein Valv/o, Valvul/o Valve Vas/o, vascul/o Vessel, duct Ven/o, ven/i Vein Ventricul/o Cavity, ventricle ○ Hemic and Lymphatic Systems
Term Definition Erythr/o, erythrocyt/o Red blood cell Hem/o, hemat/o Blood Immun/o Immunity, immune system Leuk/o, leukocyt/o White Blood Cell Lymph/o Lymph, lymphatic system Lymphaden/o Lymph node Lymphangi/o Lymphatic vessel Splen/o Spleen Thromb/o Blood clot Thymbocyt/o Platelet, thrombocyte Thym/o Thymus gland Tonsil/o Tonsil ○ Digestive System
Term Definition Bucc/o cheek Chol/e, chol/o Bile, gall
Cholangi/o Bile duct Cholecyst/o Gallbladder Choledoch/o Common Bile Duct Enter/o Intestine Gastr/o Stomach Gloss/o Tongue Hepat/o Liver Labi/o Lip Lingu/o Tongue Or/o Mouth Sial/o Saliva, salivary gland, salivary duct Stoma, stomat/o Mouth Proct/o Rectum and Anus Uvul/o Uvula ○ Urinary System
Term Definition Cali/o, calic/o Calyx Cyst/o Urinary bladder Glomerul/o Glomerulus Nephr/o Kidney Pyel/o Renal Pelvis Ren/o Kidney Ur/o Urine, urinary tract Ureter/o Ureter Urethr/o Urethra Urin/o urine
Adren/o, adrenal/o Adrenal gland, epinephrine Adrenocortic/o Adrenal cortex Endocrin/o Endocrine glands or system Hypophys/o Pituitary gland, hypophysis Insul/o Pancreatic islets Parathyr/o, parathyroid/o Parathyroid gland Pituitar/o Pituitary gland, hypophysis Thyr/o, thyroid/o Thyroid gland ○ Nervous System
Term Definition Cerebr/o Cerebrum Cotic/o Cerebral cortex, outer portion Encephal/o Brain Gangli/o, ganglion/o Ganglion Gli/o Neuroglial cells Medull/o Medulla Oblongata, medulla (inner section), middle, soft, Marrow Mening/o, Meninge/o Meninges Myel/o Spinal cord and bone marrow Narc/o Stupor, numbness, sleep Neur/o, neur/i Nervous system, nervous tissue, nerve Psych/o Mind Radicul/o Spinal nerve root Somn/o, somn/i Sleep ○ Special Senses
Term Definition Blephar/o Eyelid
Cochle/o Cochlea of inner ear Corne/o Cornea Dacryocyst/o Lacrimal sac Lacrim/o Tear, lacrimal apparatus Myring/o Tympanic membrane Ot/o Ear Phak/o, phac/o Lens Retin/o Retina Salping/o Tube, Eustachian tube Scler/o Sclera Tympan/o Tympanic cavity (middle ear), tympanic membrane Prefix ● Attach a prefix to the beginning of a word to modify or alter its meaning ● Not all medical terms contain prefix ● Prefixes often indicate location, time, or number ● Some Common Prefixes include: ○ Location Prefix Definition Ec-, ecto- Out; outside End/o In; within Mes/o Middle Dextr/o Right Ab- Away from Ad- Toward; near Dia- Through; complete Per- Through Trans- Through; across
- graph Instrument for recording data
- graphy Act of recording data
- meter Instrument for measuring
- scope Instrument for viewing or examining
- scopy Examination of ○ Suffixes for Surgery
Suffix Definition
- centesis Puncture tap
- desis Binding, fusion
- ectomy Excision, surgical removal
- pexy Surgical fixation
- plasty Plastic repair, plastic surgery, reconstruction
- rraphy Surgical repair, suture
- stomy Surgical creation of an opening
- tome Instrument for incising (cutting)
- tomy Incision, cutting
- tripsy crushing ■ Three commonly confused suffixes are -ectomy, otomy, and -ostomy ■ In most sections of the CPT code book, there are categories for incision and excision ● Incision is a cut ○ This category is where you will find -otomy (incision, cutting) and -ostomy (surgical creation of an opening) suffixes ● Excision is to cut something out ○ This category is where you will find -ectomy suffixes ○ Likewise, the suffix -rraphy (surgical repair, suture) is found in the repair subsections
● Due to Greek and Latin origins of medical terms, the conventions for changing from singular to plural endings are dictated by a specific set of guidelines, shown below ○ Plural Endings Word Ending Plural Ending Singular Example
Plural Example
a ae vertebra vertebrae en ina lumen lumina Ex, ix, yx ices index indices is es prognosis prognoses ma mata stigma stigmata Nx (anx, inx, ynx)
nges phalanx phalanges
on a phenomenon phenomena um a serum sera us i thrombus thrombi ● Using the word parts for translation, you will find the approximate meaning of the complete medical term ○ EX: cardiomyopathy means the patient has a diseased heart muscle ○ The combining form cardio informs the reader that this word element pertains to the heart ○ It can be used in combination with different word elements to relate a plethora of descriptions, illnesses, and conditions Introduction to Anatomy ● The human body contains multiple organ systems ○ An organ system is a collection of body parts depending on one another to achieve a mutual objective ○ The following organ systems will be addressed: ■ Integumentary ■ Musculoskeletal cardiovascular ■ Lymphatic ■ Respiratory ■ Digestive
■ Sagittal - cuts through the body from front to back and divides the body into right and left sections ■ Midsagittal - cuts through the midline of the body from front to back and divides the body into equal right and left sections ■ Frontal (coronal) - cuts at a right angle to the midline, from side to side, and divides the body into front (anterior) and back (posterior) sections ■ Transverse (horizontal) (axial) - cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections Structure of the Human Body ● The structure of the human body is divided into four categories: ○ Cells ○ Tissues ○ Organs ○ Systems ● Each structure is a highly organized unit of smaller structures ● Cells: ○ The cell is the basic unit of all living things ■ Human anatomy is composed of cells varying in size and shape according to function: ● Cell membrane forms the boundary of the cell ● Cytoplasm makes up the body of the cell ● Nucleus is the small, round structure in the center of the cell ● Chromosomes are in the nucleus of the cell; they contain genes that determine hereditary characteristics ● Tissues ○ Tissue is a group of similar cells performing a specific task: ■ Muscle tissue produces movement ■ Nerve tissue conducts impulses to and from the brain ■ Connective tissue connects and supports various body structures: adipose (fat) and osseous (bone) ■ Epithelial tissue is found in the skin and lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems ● Organs
○ Organs are two or more kinds of tissue, together performing special body functions ■ EX: skin is an organ composed of epithelial, connective, and nerve tissue ● Systems ○ Systems are groups of organs working together to perform complex body functions ■ EX: the nervous system is made up of the brain, spinal cord, and nerves ● Its function is to coordinate and control other body parts ● Medical Terms Related to Cells and Tissues ○ Cell membrane - surrounds and protects the individual cell ○ Nucleus - small, round structure within the cell containing chromosomes and nucleoplasm (DNA and RNA) ○ Chromosome - linear strand made of DNA carrying genetic information ○ Cytology - study of cells including the formation, structure, and function of cells ○ RNA - Contained within the nucleus, is transcribed from DNA by enzymes and plays a crucial role in protein synthesis ○ Gene - specific segment of base pairs in chromosomes; functional unit of heredity ○ Mitosis - cells divide and multiply to form two cells Body Cavities ● The body is not a solid structure ○ It has 5 cavities, each of which contains an orderly arrangement of internal organs ● Dorsal cavity includes: ○ Cranial Cavity: the space inside the skull, or cranium, containing the brain ○ Spinal (Vertebral Canal) Cavity: the space inside the spinal column containing the spinal cord ● Ventral Cavity includes ○ Thoracic, or Chest cavity: the space containing the heart, lungs, esophagus, trachea, bronchi, and thymus ○ Abdominal Cavity: the space containing the lower portion of the esophagus, the stomach, intestines (excluding the sigmoid colon and rectum), kidneys, liver, gallbladder, pancreas, spleen, and ureters
● They secrete synovial fluid into the joint cavity; this lubricates the ends of bones, so they can move freely ■ Meninges - meninges are composed of three connective tissue membranes found within the dorsal cavity and serve as a protective covering of the brain and spinal cord ● The meninges from outer layer to inside later are dura mater, arachnoid mater, and pia mater ■ Cutaneous Membrane - this membrane forms the outer covering of the body and consists of a thin layer of stratified squamous epithelium attached to a thicker underlying layer of connective tissue ● The cutaneous membrane is skin ● Connective Tissues support and connect tissues of the body ○ Connective tissue is divided into four general groups: connective tissue proper, cartilage, bone, and blood Integumentary System ● The largest organ system in the body is comprised of three structures: ○ Skin ○ Hair ○ Nails ● These structures work together to provide the following within the body: ○ Protection from injury, fluid loss, and microorganisms (bacteria, virus, fungus, yeast) ○ Temperature regulation ○ Fluid balance (excretion) ○ Sensation Skin ● Two layers make up human skin: dermis and epidermis ○ Each layer and its components are listed below ○ Be familiar with the various layers and be able to apply this knowledge when choosing the appropriate CPT code ● Epidermis ○ The epidermis is composed of four to five layers (depending on location) called stratum
■ The stratum lucidum layer is normally found only on the palms of the hands and the soles of the feet ○ The various strata are: ■ Stratum Corneum - also called the horny layer; outermost layer ■ Stratum Lucidum (Palms and soles) - clear layer ■ Stratum Granulosum -granular layer of cells ● It contains two types of granules: keratohyalin granules, and lamellated granules ■ Stratum Spinosum - composed of prickles cells that are interwoven for protection ■ Stratum Basale (Stratum Germinativum) - deepest of the five layers and made of basal cells ● Dermis ○ The dermis is located deeper, just under the epidermis ■ It has two strata ● Stratum Papillare - thin superficial layer interlocked with the epidermis ● Stratum Reticulare - thick layer of dense, irregular connective tissue ○ The dermis contains many important structures nourishing and innervating the skin: ■ Vessels carrying blood and lymph ■ Nerves and nerve endings ■ Glands ■ Hair follicles ○ The dermis lies on the subcutaneous (beneath the skin) tissue ■ The subcutaneous tissue is known as the hypodermis and is not considered to be a layer of the skin ■ The subcutaneous tissues are mostly composed of fatty or adipose tissue, plus some areolar tissue (loose connective tissue consisting of a meshwork of collagen, elastic tissue, and reticular fibers) ■ he hypodermis serves to protect the underlying structures, prevent loss of body heat, and anchor the skin to the underlying musculature
○ On average, the body has five million follicles, with the greatest concentration (approximately one million) on the head ○ Follicles are never added during lie ○ As the size of the body increases, density of hair follicles on the skin decreases ○ Hair on the scalp grows approximately .3 to .4 mm/day or approximately six per year ● Hair has two separate structures: follicle and shaft ○ The follicle contains several layers ○ At the base is a bulb-like projection, called a papilla ○ Capillaries nourish the bulb ○ Cells in the bulb divide every 23 - 72 hours ○ Inner and outer sheaths protect and mold the growing hair shaft surrounding the follicle ○ The inner sheath ends at the opening of the sebaceous gland, which secretes sebum; it may pocket, causing benign lesions on the scalp (report removal of these benign cysts using CPT codes 11400- ○ Muscles called the arrector pili attach to the outer sheath and cause hair to stand up when the muscles contract ○ The shaft is composed of keratin in three layers: the medulla, cortex, and cuticle ○ Pigment cells in the cortex and medulla give hair its characteristic color Nails ● The fingernail is made of keratin acting as a protective plate and as a counterforce to the fingertip to increase sensory input of touch ○ Nails grow all the time, but growth slows with age and poor circulation ○ Fingernails grow approximately three millimeters per month; toenails grow more slowly, at approximately one millimeter per month ● The nail is divided into six parts: the root, nail bed, nail plate, eponychium (cuticle), perionychium, and hyponychium ○ The root, or the germinal matrix, lies beneath the skin behind the finger nail and extends several millimeters into the finger ○ The root produces most of the volume of the nail and the nail bed: its edge is the white, crescent-shaped structure called the lunula ○ The nail bed, called the sterile matrix, extends from the edge of the lunula to the hyponychium
○ The nail bed contains the blood vessels, nerves, and melanocytes (melanin- producing cells) ○ The nail plate is the actual fingernail, made of translucent keratin ○ Blood vessels underneath give the nail its pink appearance; the grooves along the inner length of the nail plate anchor the nail to the nail bed ○ The cuticle, also called the eponychium, lies between the skin of the finger and the nail plate fusing the skin of the finger to the nail plate ○ The perionychium, also known as the paronychial edge, is the skin overlying the plate on its sides and is the site hangnails, ingrown nails, and an infection of the skin called paronychia ○ The hyponychium is the junction between the free edge of the nail and the skin ● Medical Terms Related to Hair and Nails ○ Alopecia - loss of hair ○ Follicles - specialized structures required for hair growth ○ Hair follicles - sacs holding the root of hair fibers ○ Hair Papilla - knoblike indentation at bottom of hair follicle containing the blood supply to hair root ○ Lunula - little moon area of nail ○ Nail body - visible part of nail ○ Nail Bed - skin below the nail, epidermis, and dermis (sterile matrix) ○ Onychitis - inflammation of nail matrix ● CPT Codes in the 10000 range address procedures and services relative to the integumentary system Musculoskeletal System ● The musculoskeletal System is a system of muscles, joints, tendons, and ligaments providing movement, form, strength, and protection ○ Various muscle and bone types work together in this body system ● Bones ○ Bones are composed of rigid connective tissue and provide the following functions: ■ Form the skeleton ■ Provide the chief means of support for the body ■ Provide the mechanism for motion ■ Protect vital organs
