Chapter 2
Medical Terminology and Anatomy Review
Introduction
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 proce- dures and services. This chapter introduces the basic elements of human anatomy and reviews medical vocabulary and terminology.
Objectives
l Understand the language of medicine
l Review word elements such as combining forms, prefixes, and suffixes
l Acquire an understanding of procedural and diagnostic terms
l Understand anatomy as it relates to coding
Medical Terminology
Every profession has its own language, and medicine is no exception. The language of medicine is more than 2,000 years old. Many medical terms used today derive from the ancient Greeks and Romans. For example, the Latin phrase pro re nata, which means when necessary, is the origin of the medical abbreviation PRN. To code medical procedures and diagnoses accurately, you first must learn the language of medicine.
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 our medical vocabulary. When you understand the meanings of each word part, interpretation of tens of thousands of complex medical terms becomes easier.
Word Elements
The base of the word is considered the “root.” Root words are terms standing alone as the main portion of a medical term. A prefix, suffix, and/or 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 one root or base word. A word can have more than one root.
Common root words consistently associated with the major 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
CPT® Example: 15780 Dermabrasion; total face
ICD-9-CM Example: 110.1 Onychomycosis
ICD-10-CM Example: L30.1 Dyshidrosis [pompholyx]
Musculoskeletal System
Term Definition
Arthr/o joint
Burs/o bursa, sac of fluid near joint
Chondr/o cartilage
Erg/o work
Fasci/o fascia
Kin/o, kinesi/o movement
Muscul/o muscle
My/o muscle
Myel/o bone marrow, spinal cord
Oste/o bone
Synov/i synovial fluid, joint, or membrane
Ten/o, tendin/o tendon
Ton/o tone; pressure
CPT® Example: 23800 Arthrodesis, glenohumeral joint (-desis means binding or fusion; arthrodesis is binding or fusion of the joint)
ICD-9-CM Example: 729.4 Fasciitis, unspecified
ICD-10-CM Example: M46.27 Osteomyelitis of vertebra, lumbosacral region
Respiratory System Hemic and Lymphatic Systems
CPT® Example: 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate
measurement(s), with or without maximal voluntary ventilation.
ICD-9-CM Example: 486 Pneumonia, organism unspecified
ICD-10-CM Example: J00 Acute nasopharyngitis [common cold]
Cardiovascular System
CPT® Example: 38308 Lymphangiotomy or other operations on lymphatic channels
ICD-9-CM Example: 453.81 Acute venous embolism and thrombosis of superficial veins of upper extremity
ICD-10-CM: D69.3 Immune thrombocytopenic purpura
Digestive System
Term Definition
Angi/o vessel
Aort/o aorta
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
CPT® Example: 33010 Pericardiocentesis; initial
ICD-9-CM Example: 451.84 Phlebitis and thrombophlebitis of upper extremities, unspecified
ICD-10-CM Example: I44.0 Atrioventricular block, first degree
CPT® Example: 47715 Excision of choledochal cyst
ICD-9-CM Example: 527.2 Sialoadenitis
ICD-10-CM: K14.0 Glossitis
Urinary System
Female Reproductive System
CPT® Example: 50120 Pyelotomy; with exploration
ICD-9-CM Example: 583.9 Nephritis and nephropathy not specified as acute or chronic with unspecified pathological lesion in kidney
ICD-10-CM Example: N13.71 Vesicoureteral-reflux without reflux nephropathy
Male Reproductive System
CPT® Example: 58940 Oophorectomy, partial or total, unilateral or bilateral
ICD-9-CM Example: 611.0 Inflammatory disease of breast (Mastitis)
ICD-10-CM Example: O23.521 Salpingo-oophoritis in pregnancy, first trimester
Endocrine System
CPT® Example: 54522 Orchiectomy, partial
ICD-9-CM Example: 601.0 Acute prostatitis
ICD-10-CM Example: N43.42 Spermatocele of epididymis, multiple
CPT® Example: 60240 Thyroidectomy, total or complete
ICD-9-CM Example: 253.6 Other disorders of neurohypophysis
ICD-10-CM Example: E27.1 Primary adrenocortical insufficiency
Nervous System
a prefix. Prefixes often (not always) indicate location, time, or number.
Some common prefixes include:
Location
CPT® Example: 72240 Myelography, cervical, radiological supervision and interpretation
ICD-9-CM Example: 348.30 Encephalopathy, unspecified
ICD-10-CM Example: G13.0 Paraneoplastic neuromyopathy and neuropathy
Special Senses
Time
Number
Prefix Definition
Mon/o one; single
Bi- two, twice
Tri- three
Quadri- four
Poly- many, much
CPT® Example: 15820 Blepharoplasty, lower eyelid
ICD-9-CM Example: 381.50 Eustachian salpingitis, unspecified
ICD-10-CM Example: H73.011 Bullous myringitis, right ear A prefix typically is attached to the beginning of a word to
modify or alter its meaning. Not all medical terms will contain
The term “suffix” comes from the Latin word subfigure, meaning “to fasten underneath.” A suffix traditionally is attached to the end of a word to modify its meaning. Not all medical terms have a suffix. In medical terms, suffixes frequently indicate the procedure, condition, disorder,
or disease. Some common suffixes meaning “condition of” include -ia, -ism, -sis, and -y. Suffixes used to show medical specialties include -ian, -iatrics, -iatry, -ics, -ist,
and -logy. Some common suffixes for diseases include -itis (inflammation), -oma (tumor), and -pathy (disease of).
Throughout procedural coding, you will see common suffixes used for diagnostic procedures and surgical procedures. To code appropriately, you need to memorize these suffixes:
Suffixes for Diagnostic Procedures
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 as in the table below.
Plural Endings
CPT® Example: 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.
Suffixes for Surgery
Using the word parts for translation, you will find the approximate meaning of the complete medical term. For example, the word “cardiomyopathy” tells a provider
the patient has a diseased heart muscle. When one sees the combining form “cardio,” it is apparent this word element pertains to the heart. It can be used in a variety of
combinations with different word elements to relate a plethora of descriptions, illnesses, and conditions to the heart. As such, the word “cardiomyopathy” paints a detailed clinical picture using a single word.
CPT® Example: 58275 Vaginal hysterectomy, with total or
partial vaginectomy
Three commonly confused suffixes are -ectomy, -otomy, and
-ostomy. Understanding the differences between these will help locate codes within the CPT® codebook.
In most sections of the CPT® codebook, there are subsections for incision and excision. Incision is a cut. This subsection is where you will find -otomy (incision, cutting) and -ostomy (surgical creation of an opening) suffixes. Excision is to cut something out. This subsection is where you will find -ectomy
Section Review 2.1
1. Which part is considered the foundation of a word?
A. Prefix
B. Combining vowel
C. Root word
D. Suffix
2. Blepharoplasty is performed on which part of the body?
A. Lip
B. Eyelid
C. Stomach
D. Leg
3. Based on word parts, what is the definition of a salpingo-oophorectomy?
A. Creating a hole in the ovary.
B. Surgical removal of the ovary.
C. Surgical repair of the ovary and tube.
D. Surgical removal of an ovary and tube.
4. Based on word parts, what structure does paronychia refer to?
A. Hair
B. Nail
C. Sweat glands
D. Parathyroid gland
5. The prefix sub- means beneath. Based on word parts, what is the definition of subfascial?
A. Beneath the face
B. Beneath the fascia
C. Beneath the skin
D. Beneath the nail
6. Based on word parts, what is the definition of a tracheostomy?
A. Surgical removal of a portion of the trachea
B. Creation of a hole in the trachea
C. Surgical repair of the trachea
D. Revision of the trachea
7. Leukocytosis refers to an increase in:
A. White blood cells
B. Red blood cells
C. Blood platelets
D. Blood flow
8. Based on word parts, what is the definition of a glossectomy?
A. Creating a hole in the glossy part of the eye
B. Surgical removal of the tongue
C. Surgical repair of the tongue
D. Surgical removal of the tear duct in the eye
9. A choledochal cyst is a cyst originating from which structure?
A. Gallbladder
B. Liver
C. Common bile duct
D. Intestine
10. A cystourethroscopy is examination of what structures?
A. Bladder and urethra
B. Gallbladder and urethra
C. Bladder and ureters
D. Kidneys and urethra
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 briefly here, and in greater depth in subsequent coding chapters as relevant:
Integumentary Musculoskeletal Cardiovascular Lymphatic Respiratory Digestive Urinary Reproductive Nervous
Organs of sense
l Eye
l Ear
Endocrine Hematologic Immune
Anatomical Positions and Planes
For physicians, nurses, and other healthcare personnel to communicate accurately, they must use a standard form for body directions and orientations. This is done by the use of anatomical directions and planes. The standard body position is considered the anatomical position. The anatomical position is an upright, face-forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart.
Based on the anatomical position, the following directional
Body Directions
terms are pertinent to understanding medical documentation:
Anterior (ventral)—toward the front of the body. Posterior (dorsal)—toward the back of the body. Medial—toward the midline of the body.
Lateral—toward the side of the body.
Proximal—nearer to the point of attachment or to a given reference point.
Distal—farther from the point of attachment or from a given reference point.
Superior (cranial)—above; toward the head.
Inferior (caudal)—below; toward the lower end of the spine.
Superficial (external)—closer to the surface of the body.
Deep (internal)—closer to the center of the body.
Midsagittal plane (midline)
Proximal end of humerus
Distal end of humerus
Lateral ligaments of knee
Medial ligaments of knee
Source: Ehrlich, Medical Terminology for Health Professionals, 6e, ISBN #978-1-4180-7252-0
For radiological studies on the body, the body is often virtually cut along a flat surface called a plane. The most frequently used planes include:
Sagittal—cuts through the midline of the body from front to back and divides the body into right and left sections.
Frontal (coronal)—cuts at a right angle to the midline cut, 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.
Superior portion
Inferior portion
Body Planes
Midsagittal plane
Right Left
Transverse plane
Frontal plane
l Systems
Each structure is a highly organized unit of smaller structures.
The cell is the basic unit of all living things. Human anatomy is composed of cells varying in size and shape according to function:
l Cell membrane forms the boundary of the cell
l Cytoplasm makes up the body of the cell
l Nucleus is the small, round structure in the center of the cell
l Chromosomes are located in the nucleus of the cell; they contain genes determining hereditary characteristics
Tissue is a group of similar cells performing a specific task:
l Muscle tissue produces movement
l Nerve tissue conducts impulses to and from the brain
l Connective tissue connects and supports various body structures: adipose (fat) and osseous (bone)
l Epithelial tissue is found in the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems
Organs are two or more kinds of tissue together performing special body functions. As an example, skin is an organ composed of epithelial, connective, and nerve tissue.
Systems are groups of organs working together to perform
Source: Ehrlich, Medical Terminology for Health Professionals, 6e, ISBN #978-1-4180-7252-0
Application to Documentation
INDICATION: Left vocal cord paralysis CT NECK WITH CONTRAST
TECHNIQUE: Axial CT cuts were obtained from the top of the orbits down to the thoracic inlet using 100 cc of Isovue 300. 13 mm axial CT cuts were also obtained through the larynx. Sagittal and coronal computer reconstruction images were also obtained.
Use of anatomical planes — axial, sagittal and coronal — explain what types of images were obtained.
Structure of the Human Body
The structure of the human body falls into four categories:
l Cells
l Tissues
l Organs
complex body functions. For example, 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 [deoxyribonucleic acid] and RNA [ribonucleic acid]).
Chromosome—Linear strand made of DNA carrying genetic information.
Cytology—Study of cells including the formation, structure, and function of cells.
RNA (Ribonucleic acid)—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; func- tional unit of heredity.
Mitosis—Cells divide and multiply to form two cells.
Body Cavities
The body is not a solid structure as it appears on the outside. It has five cavities, each of which contains an orderly arrange- ment of internal organs.
1. Cranial Cavity – The space inside the skull, or cranium, containing the brain.
2. Spinal (Vertebral Canal) Cavity – The space inside the spinal column containing the spinal cord. The
combined cranial cavity and spinal cavity is known as the dorsal cavity.
3. Thoracic, or Chest, Cavity – The space containing the heart, lungs, esophagus, trachea, bronchi, and thymus.
4. 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.
5. Pelvic Cavity – The space containing the urinary bladder, certain reproductive organs, part of the large intestine, and the rectum.
Membranes
Membranes line the internal spaces of organs and tubes opening to the outside and line body cavities. There are five types of membranes: mucous membranes, serous membranes, synovial membranes, meninges, and the cutaneous membrane.
Mucous Membranes—Line the interior walls of the organs and tubes opening to the outside of the body, such as those of the digestive, respiratory, urinary, and reproductive systems. These membranes are lined with epithelium, and are involved in absorption and secretion. The mucous membrane is composed of epithelium overlaying a layer of connective tissue called lamina propria. In some instances, the lamina propria rests
on a third layer of smooth muscle cells. Not every mucous membrane secretes mucous.
Serous Membranes—Line cavities, including the thoracic cavity and internal organs (eg, heart). They consist of a layer of simple squamous epithelium overlaying a layer of loose connective tissue. Serous membranes support internal organs and compartmentalize the large cavities to hinder spread of
infection. The serous membranes are named according to their organ associations. The lungs are covered by pleura and the heart is covered by pericardium. The serous layer also lines the abdominal cavity and is called the peritoneum.
Synovial Membranes—Line joint cavities and are composed of connective tissue. They secrete synovial fluid into the joint cavity; this lubricates the ends of bones so they can move freely.
Meninges—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 layer are dura mater, arachnoid, and pia mater.
Cutaneous Membrane—Forms the outer covering of the body and consists of a thin outer layer of stratified squamous
epithelium attached to a thicker underlying layer of connective tissue. The cutaneous membrane is skin.
The term “connective tissue” includes a number of different tissues with a common feature. They 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 the following structures:
l Skin l Hair l Nails
These structures work together to provide the following functions within the body:
l Protection from injury, fluid loss, and microorganisms (eg, bacteria, virus, fungus, yeast)
l Temperature regulation l Fluid balance—excretion l Sensation
Skin
Two layers make up human skin: dermis and epidermis. Each layer and its components are listed below. The coder should 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 called stratum. The number of stratum varies based on where the epidermis is located. 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. They accumu- late two types of granules; keratohyaline granules and lamel- lated granules.
Stratum Spinosum—Composed of prickle cells.
Stratum Basale (Stratum Germinativum)—Deepest of the five layers, made of basal cells.
Dermis
The dermis is located just under the epidermis. It has two layers of 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:
l Vessels carrying blood and lymph
l Nerves and nerve endings
l Glands
l Hair follicles
The dermis lies on the subcutaneous (beneath the skin) tissue. The subcutaneous tissue is known as the hypodermis, but is not considered 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). The hypodermis serves to protect the underlying structures, prevent loss of body heat, and anchor the skin to the underlying musculature. The fibrous connective tissue, referred to as superficial fascia, is included in this layer.
It is imperative to understand the stratification of the tissue layers and the structures lying within when coding for surgical procedures throughout the body—and most particularly those procedures performed on the integument. When applying CPT® codes found in the 10000 section, the coder needs to know in which layer the provider worked.
Application to Documentation
portion of the muscle fascia. An oblique drain was positioned through an inferior stab wound and secured with Ethilon. All bleeding was controlled with cautery. The subcutaneous tissue was approximated with Vicryl, and the skin was approximated with intracuticular 4-0 Vicryl suture. Steri-Strips and dressings were applied. The patient was awakened and moved to the recovery room in satisfactory condition. There were no complica- tions. Blood loss was minimal.
In the above documentation, understanding the depth of the procedure (eg, which skin tissue layer is involved) is necessary to select the appropriate procedure code.
Medical Terms Relating to Skin
Cutaneous—Pertaining to the skin.
Dermatology—The study of skin.
Dermatologist—Physician specializing in diseases of the skin and subcutaneous tissue.
Decubitus—Pressure ulcer/bedsore.
Ecchymosis—Condition in which blood seeps into the skin causing discoloration.
Hypodermic—Pertaining to under the skin. Intradermal—Pertaining to within the skin. Jaundice—Yellowness of skin.
Melanin—Pigment giving color to the skin. Melanoma—Pigmented tumor of the skin. Pediculosis—Infestation with lice.
Subcutaneous—Pertaining to below the skin.
Tinea—Ringworm (a fungal infection of the skin).
Hair
By 22 weeks, a developing fetus has its lifetime supply of hair follicles. On average, the body has five million follicles, with the greatest concentration (approximately one million) on
the head. Follicles are never added during life, and as the
size of the body increases, density of hair follicles on the skin
NARRATIVE: After prone positioning and IV sedation, the left upper back was prepped and draped in a sterile manner. Local anesthesia 1% lidocaine and bicarbonate was used. A vertical incision was made over the mass and extended. Deep in the subcutaneous tissue over muscle fascia was an 8 cm lipoma with a lot of lobulations between skin ligaments, and these were all progressively divided to excise the entire mass including a
decreases. Hair on the scalp grows approximately .3 to .4 mm/ day or about six inches 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. There are capillaries nourishing the bulb. Cells in the bulb divide every 23 to 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 (removal of these benign cysts are reported using CPT® codes 11400-11471 range). A muscle called the erector pili, attaches to the outer sheath and causes hair to stand up when it contracts. 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 their rate of growth slows down with age and poor circulation. Fingernails grow at an approximate rate of 3 mm per month; toenails grow more slowly, at approximately 1 mm per month.
The nail is divided into six specific parts: the root, nail bed, nail plate, eponychium (cuticle), perionychium, and hyponychium. The root, also known as the germinal matrix, lies beneath the skin behind the fingernail and extends several millimeters into the finger. The root produces most of the volume of the nail and the nail bed and its edge is the white, crescent-shaped struc- ture 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, is 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 nail plate on its sides and is the site of 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.
Section Review 2.2
1. Squamous cell carcinoma and basal cell carcinoma are both cancers of cell tissue of the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems. What type of tissue are these carcinomas found in?
A. Muscle tissue
B. Nerve tissue
C. Connective tissue
D. Epithelial tissue
2. The bronchi are found in what body cavity?
A. Cranial cavity
B. Spinal cavity
C. Thoracic cavity
D. Abdominal cavity
3. Which type of membrane is found lining the interior walls of the digestive system?
A. Mucous membrane
B. Serous membrane
C. Synovial membrane
D. Cutaneous membrane
4. Which layer of the epidermis is normally found on the palms of the hands and the soles of the feet?
A. Stratum Corneum
B. Stratum Lucidum
C. Stratum Papillare
D. Stratum Reticulare
5. A procedure requiring the physician to cut down to the superficial fascia is documented as cutting down into the:
A. Epidermis
B. Dermis
C. Hypodermis
D. Cutaneous tissue
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:
l Form the skeleton
l Provide the chief means of support for the body
l Provide the mechanism for motion
l Protect vital organs
l Serve as a production factory for blood cells (eg, marrow)
l Store calcium, phosphorus, and magnesium salts
Bones, classified according to shape are:
Long—Bones longer than they are wide and found in the limbs (eg, femur and humerus). These bones are named for their elongated shape, not their size.
Tubular—Also referred to as long bones.
Short—Roughly cube-shaped bones such as carpal bones of the wrist and tarsal bones of the ankle.
Sesamoid (“shaped like a sesame seed”)—A short bone formed within tendons; cartilaginous in early life and osseous (bony) in the adult. The patella is the largest sesamoid bone in the body.
Cuboidal—Also referred to as short bones.
Flat—Consist of a layer of spongy bone between two thin layers of compact bone; cross-section is flat, not rounded. Flat bones have marrow, but lack a bone marrow cavity. Skull and ribs are examples.
Irregular—Bones in the body not fitting into the above categories mentioned; several are found in the face, such as the zygoma. Vertebrae are also considered irregular bones.
Cartilage and Joints
Cartilage is a type of flexible connective tissue, it is nonvas- cular (has no blood vessels). Cartilage is a matrix made of chondrocytes, collagen, and glycosylated protein called proteo- glycans, depending on the type of cartilage.
Joints and articulating surfaces are synonymous and provide a connection between two or more parts of the skeleton.
Joints are classified according to the type of connective tissue at the articulating surfaces. There are three types: fibrous,
cartilaginous, and synovial. Most joints are synovial and have the following characteristics:
l Articular cartilage that covers the bone ends
l Joint cavity lined with a synovial membrane, which secretes a thick, viscid, slippery mucous that cushions the joint and allow smooth motion
l Joint capsule of fibrous connective tissue that surrounds and provides stability of the joint
l Accessory ligaments that give reinforcement
Human Skeleton
The human skeleton is divided into two parts — the axial and appendicular skeleton:
Axial Skeleton
l Skull
l Hyoid and cervical spine (neck)
l Ribs
l Sternum l Vertebrae l Sacrum
Appendicular Skeleton l Shoulder girdle l Pelvic girdle
l Extremities
Common Bone Fractures
Closed Fracture—Does not involve a break in the skin.
Compound Fracture—Projects through the skin with a possibility of infection.
Comminuted Fracture—More than two separate bone compo- nents—Segmental fracture, bony fragments.
Transverse Fracture—Breaks shaft of a bone across the longitu- dinal axis.
Greenstick Fracture—Only one side of shaft is broken, and other is bent; common in children.
Spiral Fracture—Spread along length of bone and produced by twisting stress.
Colles’ Fracture—Occurs in wrist and affects the distal radius bone.
Compression Fracture—Vertebrae collapse due to trauma, tumor, or osteoporosis.
Epiphyseal Fracture—Occurs when matrix is calcifying and chondrocytes are dying; usually seen in children.
Understanding the type of fracture is essential to proper diagnosis coding. An example of this can be seen when coding a compound fracture. A compound fracture is coded as an open fracture.
Muscles
Muscles have the property of contractility. They also provide form and produce heat for the body. There are three types of muscles found in the body:
Skeletal Muscle—Also called striated muscle, is attached to the skeleton by tendons; contraction of skeletal muscle is under voluntary control.
Cardiac Muscle—Also called heart muscle, contains inter- locking involuntary striated muscle as well as smooth muscle, which allow the electrical impulses to pass quickly across the muscle fibers.
Smooth Muscle—Found in the walls of all the hollow organs of the body (except the heart). Its contraction reduces the size of these structures; movement generally is considered involuntary (not under voluntary control).
Medical Terms Related to Musculoskeletal System
Ankylosis—Condition of stiffening of a joint.
Arthralgia—Pain in joint. Arthritis—Inflammation of a joint. Arthrodesis—Surgical fixation of a joint. Arthropathy—Joint disease.
Bursitis—Inflammation of a bursa. Carpal—Pertaining to the wrist bones. Chondral—Pertaining to cartilage.
Chondralgia—Pain around and in the cartilage.
Coccygeal—Pertaining to the coccyx. Connective—Tissue connecting or binding together. Dactylic—Pertaining to finger or toe.
Femoral—Pertaining to femur and thigh bone.
Iliac—Pertaining to the ilium.
Kyphosis—Abnormal curvature of thoracic spine (humpback).
Lordosis—Abnormal anterior curvature of spine, usually lumbar.
Metacarpal—Long bones of the hand that form the skeletal structure of the palm.
Osteoblast—Bone-forming cell. Osteocarcinoma—Cancerous tumor of bone. Osteochondritis—Inflammation of bone and cartilage.
Osteopenia—Lower than average bone density, can be a precursor to osteoporosis.
Osteoporosis—Condition resulting in reduction of bone mass.
Osteorrhaphy—Suture of bone. Patellar—Pertaining to patella. Phalangeal—Bones of the fingers and toes. Scoliosis—Lateral curvature of spine.
Sternotomy—Surgical incision of sternum.
Tendonitis—Inflammation of tendon.
In CPT®, the section containing the 20000 code series pertains primarily to the musculoskeletal system, and is arranged by anatomical regions and structures.
Section Review 2.3
1. What type of fracture is an incomplete fracture commonly found in children?
A. Compound fracture
B. Colles’ fracture
C. Spiral fracture
D. Greenstick fracture
2. Which of the following belongs to the appendicular skeleton as opposed to the axial skeleton?
A. Ribs
B. Pelvic Girdle
C. Sacrum
D. Hyoid
3. What is an example of a long bone?
A. Metacarpals
B. Ribs
C. Carpals
D. Patella
4. What type of joint is most common in the human body?
A. Fibrous
B. Cartilaginous
C. Synovial
D. Stiff
5. What is the root word meaning joint?
A. Arthr/o
B. Chondr/o
C. Synov/i
D. Oste/o
Cardiovascular System
This system is comprised of the heart and the blood vessels working together to move blood throughout the body. Blood provides nutrients and oxygen to all organs within the body.
Blood Vessels
The human body contains three types of blood vessels: arteries, veins, and capillaries.
Arteries carry blood away from the heart. They often are colored red in anatomical drawings to depict the red color of oxygenated blood. All arteries leaving the heart carry oxygen- ated blood except the pulmonary arteries. The pulmonary arteries carry deoxygenated blood from the right side of the heart to the lungs. These vessels get smaller as the arteries go out into the extremities, turning into arterioles, and eventually they comprise the arterial side of the capillary bed.
The venous side of the circulation begins in the venous side
the left atrium of the heart through the right and left pulmo- nary veins. Oxygenated blood is pumped from the left side of the heart to the systemic circulation via the left ventricle to the aorta. Because the left side of the heart is responsible for pumping blood throughout the entire body, the muscle surrounding the left ventricle is stronger and larger than the right ventricle.
The heart is composed of three layers (epicardium, myocar- dium, and endocardium) and is enclosed in a double-wall lining called the pericardial sac. The pericardial sac prevents the heart from rubbing against other organs or body structures as it beats. The epicardium is the outer layer of the heart. The main muscle of the heart is the myocardium (myo=muscle, cardi=heart). Myocardial tissues allow electrical impulses to pass quickly across muscle fibers as part of the heart’s unique electrical conduction system. The inner lining of the heart is the endocardium.
Interior of the Heart
of the capillary bed, enlarging to form venules and eventually forming veins. Most veins bring deoxygenated blood, which
is dark reddish brown in color, back to the heart. Veins often are depicted in illustrations as blue (not a true physiological depiction). Veins take deoxygenated blood to the heart except
for pulmonary veins which carry oxygenated blood from the pulmonary veins to the left side of the heart.
Capillaries are tiny vessels, usually a single-cell-layer thick. They are semi permeable and facilitate the exchange of fluids, oxygen, nutrients, and waste between local tissues and the blood stream.
Heart
The adult heart is compared to the size of the human fist, and usually weighs less than one pound. The heart pumps blood to two distinct systems for circulation. The first system is the pulmonary circulation, receiving deoxygenated blood into the right atrium from the superior and inferior vena cava. The blood then flows into the right ventricle and is pushed into
pulmonary circulation via the pulmonary trunk, which divides
Aorta
Superior vena cava
Right pulmonary veins
Right atrium
Right atrio- ventricular (tricuspid) valve
Chordae tendineae
Inferior vena cava
Papillary muscles
(A)
Left
pulmonary
artery
Left pulmonary veins
Left atrium
Left atrio- ventricular (bicuspid) valve
Semilunar valves
Left ventricle
Right ventricle Septum (interventricular)
into the right and left pulmonary arteries. Blood is circulated
through the pulmonary vascular tree in the lungs and sent into
Source: Rizzo, Fundamentals of Anatomy and Physiology, 3e, ISBN #978-1-4354-3871-2
Medical Terms Related to the Cardiovascular System Anginal—Relating to spasmodic attacks of suffocating pain as related to an inflammatory condition of the throat or mouth or
angina pectoris marked by chest pain due to deficient oxygen- ation of the heart muscle.
Angiocarditis—Inflammation of heart and vessels.
Angioplasty—Surgical repair of vessels. Arteriosclerosis—Hardening of an artery. Arteriotomy—Incision into an artery.
Atherosclerosis—A type of arteriosclerosis characterized by lipid deposits causing fibrosis and calcification.
Bradycardia—Slow heartbeat.
Cardiocentesis—Surgical puncture of the heart. Cardiologist—A physician specializing in diseases of the heart. Cardiomegaly—Enlargement of the heart.
Cardiopulmonary—Pertaining to heart and lungs.
Carditis—Inflammation of the heart.
Cyanosis—Bluing of skin and mucous membranes caused by oxygen deficiency.
Electrocardiogram—Electrical tracing of the heart and heart muscle activity.
Embolism—Blood clot traveling through a blood vessel to another part of the body.
Hemangioma—Benign tumor of a blood vessel.
Hypertension—Persistent excessive pressure in the arteries.
Pericarditis—Inflammation of the pericardium.
Thrombus—Blood clot formed within a blood vessel.
You need to understand standard medical abbreviations used in medical records documentation. In the cardiovascular section, physicians often dictate using medical abbreviations to indicate the artery or vein involved.
Application to Documentation
The LAD was then dissected out. Arteriotomy was performed and the IMA was anastomosed in an end-to-side fashion to the LAD using running 7-0 Prolene around the heel of the anasto- mosis. The toe of the anastomosis was closed using interrupted 7-0 Prolene. Rewarming was begun during this anastomosis.
The IMA pedicle clamp was released. Rapid resuscitation of the heart was seen as well as rapid distal filling of the LAD. The IMA pedicle was affixed to the epicardium using 5-0 silk suture. The aortic cross-clamp was removed. A partial occlusion clamp was placed on the aorta and three punch arteriotomies were made on the aorta. The vein grafts were measured to length, cut, and spatulated and anastomosed in an end-to-side fashion to the aorta using running 6-0 Prolene. All three proximal vein graft anastomoses were marked with titanium clips. The most distal graft on the aorta is to the posterolateral branch of the circum- flex, more proximal is to the ramus, and the vein graft to the PDA was brought to the right side of the aorta. Partial occlusion clamp was removed.
In the documentation above, “IMA” indicates the internal mammary artery, “LAD” indicates the left anterior descending artery, and “PDA” indicates the posterior descending artery.
CPT® codes 33010–37799 address surgical procedures to the cardiovascular system. CPT® codes 92950–93998 address therapeutic and diagnostic procedures and services to the cardiovascular system.
Section Review 2.4
1. The heart receives de-oxygenated blood in the right atrium via which vessel?
A. Right pulmonary artery
B. Left pulmonary veins
C. Inferior and Superior Vena Cava
D. Aorta
2. The heart circulates blood through the lungs and is sent back into the left atrium of the heart via which vessel?
A. Left pulmonary artery
B. Left and right pulmonary veins
C. Vena cava
D. Aorta
3. What is the term for inflammation of the heart and vessels?
A. Carditis
B. Pericarditis
C. Angiocarditis
D. Angina
4. What is the inner layer of the heart?
A. Pericardium
B. Epicardium
C. Myocardium
D. Endocardium
5. What is cyanosis caused by?
A. Oxygen overload
B. Oxygen deficiency
C. Liver excretion
D. Drinking blue liquids
Lymphatic System
The lymphatic system is comprised of lymph vessels and lymph nodes. This system collects excess fluid from the interstitial spaces (potential spaces between tissues) and returns it to
the heart. The venous end of the capillaries reabsorbs fluid pushed from arterial capillaries into the interstitial space; the lymph picks up excess fluid. The lymphatic system operates without a pump using a series of valves to ensure fluid travels in one direction, back to the heart. Lymphoid organs scattered throughout the body house phagocytic cells and lymphocytes essential to the body’s defense system and its resistance to disease. Lymphoid organs include the spleen, thymus, tonsils, and Peyer’s patches of the intestine.
Lymphatic Vessels
Lymphatic vessels are similar in structure to blood vessels. Lymphatic capillaries are closed off at one end. After lymph fluid is picked up, it is circulated to increasingly larger lymph vessels called lymphatics. Lymphatics empty their contents into either the right lymphatic duct or the thoracic duct. Both of these ducts are situated in the thoracic cavity.
The right lymphatic duct collects lymph fluid from the right arm, right side of the head, and right side of the thorax. The thoracic duct collects lymph from the rest of the body. For the body to maintain an appropriate volume of circulating blood, it is necessary to put fluid back into the main system of circulation. Both lymphatic ducts empty their contents into
the subclavian veins. The right lymphatic duct empties into the right subclavian vein and the thoracic duct empties into the left subclavian vein.
Spleen
The spleen is an organ of the lymphatic system in the left upper abdomen filtering and destroying red blood cells that are no longer efficient. It serves as a blood-forming organ early in life, and later as a storage unit for extra red blood cells (RBCs) and platelets.
Thymus
The thymus is an organ consisting of two lobes. It is located in the thoracic region in front of the heart and behind the
sternum. The thymus is prominent in newborns, and continues to increase in size during the first year of life. After puberty, the thymus starts to atrophy gradually. The thymus is respon- sible for the T lymphocyte maturation, enabling these cells to function against specific pathogens in the immune response.
Tonsils
The tonsils are partially encapsulated lymphoid tissue located in the throat. They are the simplest lymphoid organs. Tonsils are named according to their location: palatine tonsils, lingual
tonsils, and pharyngeal tonsils (referred to as adenoids if enlarged).
Peyer’s Patches & Appendix
Peyer’s patches are found in the lining of the intestine and help to protect against invading microorganisms.The appendix is
a “finger-like” projection of tissue attached to the cecum, the first part of the large intestine.
Medical Terms Related to the Lymphatic System Lymphadenitis—Inflammation and enlargement of lymph nodes, usually as a result of infection.
Lymphangitis—Inflammation of lymphatic vessels as a result of bacterial infection.
Lymphedema—Swelling of tissues with lymph caused by obstruction or excision of lymphatic vessels.
Lymphoma—Any neoplastic disease of lymphoid tissue.
Thymitis—Thymus gland inflammation.
Section Review 2.5
1. How does the lymphatic system work to ensure lymph fluid travels one way to the heart?
A. Travels through blood
B. Using a pumping system
C. With a system of one-way valves
D. Gravity
2. What type of cell is housed by the lymphatic system to help the body’s defense system?
A. Erythrocytes
B. Phagocytes
C. Endothelial
D. Epithelial
3. What procedure is performed when the spleen is removed?
A. Splenoplasty
B. Splenorrhaphy
C. Splenoportography
D. Splenectomy
4. The lymphatic ducts empty their contents into what structure?
A. Aorta
B. Subclavian veins
C. Pulmonary veins
D. Femoral artery
5. What is the medical term for inflammation of lymphatic vessels due to bacterial infection?
A. Lymphadenitis
B. Lymphangitis
C. Lymphedema
D. Lymphoma
Respiratory System (Pulmonary System)
The respiratory system includes the nose, nasal cavity, pharynx, larynx, trachea, bronchi, and their smaller branches, lungs, and alveoli. It functions to exchange carbon dioxide for oxygen. Air inspired through the nose and mouth passes to the lungs through a series of branching airways known as the bronchial tree. This series of structures connects the lungs to outside air containing oxygen.
The nose is responsible for providing an airway to breathe (moistening, warming, and filtering inspired air), serving as a resonating chamber for speech, and housing smell receptors.
The pharynx is divided into three regions; nasopharynx (air passageway), oropharynx (air and food passageway), and laryn- gopharynx (air and food passageway).
The larynx is the voice box. In addition to voice production, it helps provide an open (patent) airway and acts as a switching mechanism to route air and food into proper channels.
The trachea is in the mediastinal region and splits into two bronchi (at the carina) that enter the lungs. There are three lobes in the right lung and two lobes in the left lung.
At the smallest branch of the bronchial tree, airways are called bronchioles. Each of these bronchioles narrow further until they end in a tiny pouch called an alveolar sac. Gases are exchanged across the single-cell layer of tissue comprising the alveolar sac into the pulmonary circulation. Capillaries from the pulmonary circulation are also a single-cell-layer thick. They form a bed around each alveoli; gas is exchanged between the alveoli and the capillaries via the principles of diffusion (molecules flow from levels of higher concentration to lower concentration).
Medical Terms Related to the Respiratory System
Bronchiolitis—Inflammation of the bronchioles.
Bronchoscope—Instrument used to examine the bronchi.
Carina—A projection of the lowest tracheal cartilage where the trachea separates into two bronchi. Used as a landmark for endoscopy (bronchoscopy). The carina is the most sensitive area of the trachea and larynx for triggering a cough reflex.
COPD (Chronic obstructive pulmonary disease)—Any group of chronic, progressive, and debilitative respiratory diseases (emphysema, asthma, bronchitis, etc).
Dyspnea—Difficulty breathing. Hemothorax—Presence of blood in the pleural space. Hyperpnea—Rapid or excessive breathing.
Lobectomy—Surgical excision of a lobe of the lung.
Orthopnea—Difficulty breathing unless upright or in a straight position.
Pneumothorax—Collection of air in the chest or pleural cavity.
Rales (crackles)—Abnormal chest sounds heard when air enters small airways or alveoli containing fluid typically during inspiration.
Rhinorrhea—Discharge from the nose.
Rhonchus—Rale or rattling sound in throat or bronchial tube caused by obstructed or inflamed bronchi.
Tachypnea—Fast or rapid breathing.
Thoracotomy—Incision into the chest wall.
Thoracentesis—Removal of fluid from the pleural cavity via surgical puncture; pleural tap.
Wheeze—Whistling sound usually caused by air passageway obstruction, common in asthmatics.
Application to Documentation
TECHNIQUE: After induction of satisfactory general anesthesia, flexible fiberoptic bronchoscopy was performed. Airways were essentially normal with minimal secretions. No endobronchial lesions. The patient was kept supine and his neck was prepared with DuraPrep and draped in sterile fashion. A transverse incision was used and deepened with cautery. The pretracheal fascial
plane was entered and the mediastinoscope easily passed. Samples of lymph nodes were taken from the subcarinal area, the right tracheobronchial angle area, and the low pretracheal area. All were negative for neoplasm. The wound was irrigated, checked for hemostasis, and closed with absorbable sutures and a dry sterile dressing was placed. A double-lumen tube was placed and its proper position confirmed bronchoscopically.
In the sample documentation above, it is important to under- stand anatomy to determine where the biopsies were taken.
The CPT® 30000–32999 code series addresses surgical procedures of the respiratory system.
Section Review 2.6
1. Subcarinal means beneath the carina. Where is the carina located?
A. At the connection of the larynx and trachea
B. At the entrance of the bronchi into the lungs
C. Where the bronchi split into bronchioles
D. At the bifurcation of the trachea into two bronchi
2. Which structure is responsible for moistening, warming, and filtering inspired air?
A. Esophagus
B. Nose
C. Lungs
D. Alveoli
3. What is a thoracotomy?
A. Removal of a lobe of the lung
B. Incision into the chest wall
C. Inserting a tube into the chest
D. Removing the chest wall
4. Where is gas exchanged and moved from the respiratory system into the circulatory system?
A. Veins and arteries
B. Lungs and bronchi
C. Alveoli and capillaries
D. Pharynx and larynx
5. Which suffix means breathing?
A. -capnia
B. -pnea
C. -oxea
D. -phonia
Digestive System
The feeding tube begins in the mouth and ends at the anus. This continuous structure winds through several body cavities and encompasses a multitude of structures and organs. The system mechanically and chemically breaks down food into minuscule or molecular size for absorption into the blood stream and use at the cellular level.
Food enters the digestive system via the mouth. The teeth and tongue mechanically break food into small particles to provide greater exposure/surface area for the chemical
processes that follow. Chewing is called mastication. Salivary glands surround the mouth and secrete saliva, which is comprised primarily of water, mucus, electrolytes, and salivary amylase. Saliva aids in early phases of chemical digestion and liquefaction of food. Food is swallowed and peristalsis in the
esophagus moves food through the upper thoracic cavity into the stomach.
Stomach and Small Intestine
The opening to the stomach is referred to as the cardiac orifice. The fundus of the stomach is the rounded upper portion, above the body of the stomach. The body of the stomach is the main portion, and the lower portion is referred to as the pyloric antrum. The pyloric sphincter leads to the duodenum. Food moves through the stomach into the small intestine, which
is divided into three sections. The first section of the small intestine is the duodenum, the second is the jejunum, and the distal portion is the ileum (not to be confused with the ilium, a bone in the pelvis).
Structures of the Stomach
Esophagus Fundus
Lower esophageal sphincter
Pylorus
Antrum
Duodenum of small intestine
Pyloric sphincter
Rugae
Body
Source: Ehrlich, Medical Terminology for Health Professionals, 6e, ISBN #978-1-4180-7252-0
Practical Coding Note
The name ileum for the distal portion of the small intestine can be remembered and separated from the ilium of the pelvis bone by the “e.” Each of the names of the small intestine (duodenum, jejunum, and ileum) have an “e” and no “i.”
Large Intestine
The large intestine begins just after the ileocecal valve at the cecum, with the appendix attached at the bottom. There are four portions to the colon: ascending, transverse, descending, and sigmoid or pelvic colon. The ascending colon proceeds from the ileocecal valve upward to the hepatic flexure on the right side of the abdomen. It becomes the transverse colon, and turns downward to become the descending colon at the splenic flexure on the left side of the abdomen. The descending colon gives way to the sigmoid colon and ends at the rectum.
The internal and external anal sphincters at the terminus of the rectum control the flow of fecal material leaving the body.
Ancillary Organs
Ancillary organs such as the pancreas, liver, and gallbladder also are considered part of the digestive system because the chemicals they produce are necessary for chemical breakdown of food. The digestive (or exocrine) pancreas is responsible for making digestive enzymes that are secreted into the intestines to help digest food. The gallbladder stores bile produced in
the liver. Bile secreted into the intestines from the gallbladder helps digest fats.
Medical Terms Related to the Digestive System
Aphagia—Inability to swallow.
Biliary—Pertaining to bile.
Buccal—Pertaining to the cheek. Cholecystectomy—Surgical excision of the gallbladder. Cholecystitis—Inflammation of the gallbladder.
Colectomy—Excision of part of the colon.
Colonoscopy—Examination of the colon and the distal small bowel with an endoscope.
Diverticula of Colon—Herniations of mucosa and submu- cosa of the colon, which can cause episodes of bleeding and inflammation.
Diverticulitis—Inflammation of the diverticula in the colon.
Diverticulosis—Presence of a number of diverticula of the intestine.
Dysphagia—Difficulty in swallowing. Epigastric—Region above the stomach. Esophageal—Pertaining to the esophagus. Gastralgia—Pain in the stomach.
Gastroenterologist—Physician specializing in the gastrointes- tinal system.
Hematemesis—Vomiting blood.
Herniotomy—Incision into a hernia.
Ileostomy—Creating an opening through the abdominal wall into the ileum.
Laparotomy—Surgical incision into the abdomen.
Pancreatitis—Inflammation of the pancreas.
Pharyngeal—Pertaining to the pharynx. Rectocele—Herniation of the rectum into the vagina. Sigmoidoscope—Instrument used to view the sigmoid. Splenomegaly—Enlarged spleen.
Stomatitis—Inflammation of the mucous membrane of the mouth.
Sublingual—Below or beneath the tongue. Synonym—subglossal.
The CPT® 40490–49999 codes series address surgical proce- dures of the digestive system.
Application to Documentation
The patient first was placed into occlusion using Karlis bolts of 8 mm in length. The jaws were put in proper occlusion using 24-gauge stainless steel wires. A buccal incision was made just above the sulcus, carried down through the subcutaneous
tissues with the electrocautery. Xylocaine 0.5 % with epinephrine had been injected for hemostasis. The periosteum was elevated, and the patient was noted to have a comminuted fracture of the maxilla creating a Le Fort I fracture. Placement into occlusion had placed the patient in good reduction.
In the documentation above, understanding “buccal” refers to the cheek provides an understanding of where the incision was made.
Section Review 2.7
1. What is the term for the first portion of the small intestine?
A. Duodenum
B. Jejunum
C. Ileum
D. Cecum
2. Where is bile produced?
A. Gallbladder
B. Kidney
C. Liver
D. Urinary bladder
3. Which part of the large intestine is between the hepatic flexure and the splenic flexure?
A. Ascending colon
B. Transverse colon
C. Descending colon
D. Sigmoid colon
4. Which medical term refers to the cheek?
A. Buccal
B. Sublingual
C. Uvula
D. Palate
5. Food moves through the digestive tract by what means?
A. Mastication
B. Gravity
C. Uvuloptosis
D. Peristalsis
Urinary System
Production of urine for excretion of metabolic wastes, along with fluid and electrolyte balance, is the main function of the urinary system. This system also provides transportation and temporary storage of urine prior to the intermittent process of urination. Key structures of this system include kidneys,
ureters, urinary bladder, and urethra. The kidney also secretes hormones, giving it endocrine function, as well.
Male and female urethras are quite different anatomically in position and length; however, they perform similar functions and are treated similarly for many surgical procedures.
Medical Terms Related to the Urinary System
Albuminuria—Presence of serum protein in the urine.
Bacteriuria—Bacteria in the urine.
Cystectomy—Excision of the bladder or part of the bladder; removal of a cyst.
Cystitis—Inflammation of bladder.
Cystocele—Hernia of the bladder protruding into the vagina.
Cystolithectomy—Excision of a stone from the bladder.
Cystopexy—Surgical fixation of the bladder to the abdominal wall.
Cystoplasty—Surgical repair of the bladder.
Cystorrhagia—Blood bursting forth from the bladder.
Dialysis—Separation of waste material from blood to maintain fluid, electrolyte, and acid-base balance in impaired kidney function or in the absence of a kidney.
Dysuria—Difficult or painful urination.
Hematuria—Blood in urine.
Hydronephrosis—Condition in which urine collects in the renal pelvis due to obstructed outflow, results in dilation of the renal pelvis and calices.
Incontinence—Inability to hold urine. Nephrectomy—Excision of a kidney. Nephritis—Inflammation of a kidney.
Nephrologist—A physician treating diseases of the kidney.
Nephropathy—Disease of the kidney. Nephrosclerosis—Hardening or sclerosis of the kidney. Polyuria—Excessive urination, profuse micturition Pyelocystitis—Inflammation of the bladder and renal pelvis. Pyelonephritis—Inflammation of the kidney and renal pelvis. Pyuria—Pus in urine.
Uremia—Excess urea and other nitrogenous waste in blood.
Ureteroplasty—Surgical repair of the ureter.
Urethalgia—Pain in the urethra. Syn. – urethrodynia.
Urinalysis—Examination of the urine to detect abnormalities by various diagnostic methods.
Urologist—A physician treating diseases of the urinary system.
CPT® codes dealing with the urinary system are found primarily in the 50010-53899 range.
Reproductive Systems
The organs of the reproductive system differ greatly between male and female; however, functions are similar. Reproduc- tion is achieved through male production of a 23-chromo- some gamete called a sperm, and a 23-chromosome gamete called an ovum, or egg, produced by the female. The female also houses, feeds, and protects the growing fetus through the gestational period.
Male and female reproductive organs include external and internal genitalia.
Male Genitalia
External male genitalia include the testes, epididymis, scrotum, and penis. Internal organs of the male genital system include the prostate gland, seminal vesicles, and Cowper’s glands. There is also a system of tubes and ducts sperm travel through to leave the body. It is comprised of the vas deferens, ejaculatory duct, and urethra.
Female Genitalia
External female genitalia include the vulva, labia majora and minora, clitoris, external opening of the vagina (also called the introitus), opening of the urethra or urinary meatus, Skene’s glands (found on either side of the urinary meatus), and Bartholin’s glands (found on either side of the introitus). Internal female genital system organs include the vagina, uterus, two fallopian tubes, and two ovaries.
Medical Terms Related to the Male/Female Reproductive System
Amenorrhea—Absence of menstruation.
Amniocentesis—Surgical puncture of the amniotic sac to obtain a sample of amniotic fluid.
Antepartum—Time period during pregnancy before onset of labor.
Colporrhaphy—Suture or repair of the vaginal wall.
Dysmenorrhea—Painful or difficult menstruation.
Endometriosis—Condition in which the endometrial tissue is found outside of the uterus such as in the abdominal or pelvic cavity.
Epispadias—Congenital defect in which the urethra opens on the upper aspect (dorsum) of the penis.
Fibroma—Fibrous tumor, also called a myoma, fibroid, or leiomyoma.
Genitalia—Male or female reproductive organs, internal and external.
Gynecologist—A physician specializing in the study of the female reproductive system.
Hysterotomy—Surgical incision into the uterus.
Hypospadias—Congenital defect in which the urethra opens on the underside of the penis or on the perineum.
Mammography—A graphic recording of the breast using X-ray technology.
Mastectomy—Surgical excision of the breast.
Menorrhagia—Excessive blood flow during menstruation.
Menorrhea—Normal menstruation.
Myometritis—Inflammation of the muscular wall (myome- trium) of the uterus.
Orchiectomy—Surgical excision of a testicle.
Postpartum—Period after childbirth. Salpingectomy—Surgical excision of fallopian tube(s). Prostatalgia—Pain in the prostate.
Trimester—Period of three months; in pregnancy—first, second, and third trimesters.
Vaginitis—Inflammation of the vagina.
Vasectomy—Excision of the vas deferens surgically.
CPT® codes for the male and female genitourinary systems can be found in the 54000–58999 range. Maternity care and delivery is found in the 59000–59899 range.
Section Review 2.8
1. Which anatomical structure in the urinary system differs in position and length between male and female, but serves the same function with regards to urine, and is often treated the same?
A. Ureter
B. Urethra
C. Bladder
D. Kidneys
2. What is the primary function of the urinary system?
A. Excretion of metabolic wastes, and fluid and electrolyte balance
B. Produce bile to aid in digestion of fats
C. Produce bile via emulsification of lipids
D. Excretion of enzymes and hormones
3. Which structure is an internal organ of the male genital system?
A. Epididymis
B. Testes
C. Cowper’s glands
D. Skene’s glands
4. What is the medical term for a congenital defect in which the urethra opens on the dorsum of the penis?
A. Orchitis
B. Epispadias
C. Cryptorchidism
D. Hypospadias
5. Where are the Bartholin’s glands found?
A. In the pubic symphysis
B. Below the prostate
C. In the peritoneal cavity
D. Either side of the introitus in the female
Nervous System
The nervous system is an enormous network of nerve fibers traversing the human body. The nervous system is composed of central and peripheral portions. The brain and spinal cord are the components of the central nervous system (CNS). The peripheral nervous system (PNS) includes the cranial and spinal nerves. The CNS is the command center and the PNS serves as the communication lines linking all parts of the body to the CNS.
The nervous system functions as both the central operator and central intelligence for the body. It regulates body functions and provides an internal method of communication between the brain and other organs, and between the organism and the environment (for instance, it sends signals from the finger to the brain when a hot, cold, or sharp object is encountered). The brain regulates subconscious body functions such as respiratory rate, body temperature, and peristalsis of the intestines.
Medical Terms Related to the Nervous System
Amnesia—Loss of memory.
Ataxia—Loss of muscular coordination. Bradykinesia—Abnormal or slowness of motion. Cephalgia/Cephalagia—Headache.
Cerebrospinal—Pertaining to the brain and spinal cord.
Craniotomy—Surgical incision into the skull.
Discectomy—Surgical excision of an intervertebral disc.
Dysphasia—Impairment of speech. (Syn.- aphasia.)
Encephalomalacia—Softening of the brain often due to isch- emia or infarction.
Epidural—Pertaining to above or outside the dura mater.
Hemiparesis—Paralysis on one side of the body.
Intracranial—Within the skull.
Laminectomy—Excision of the vertebral posterior arch or spinal process.
Meningitis—Inflammation of the meninges or the membranes covering the spinal cord or brain.
Myelitis—Inflammation of spinal cord.
Neuralgia—Severe or stabbing pain in the course or distribu- tion of a nerve.
Neuritis—Inflammation of a nerve.
Neurologist—Physician who specializes in diagnosis and treat- ment of disorders of the nervous system.
Neurolysis—Destruction of nerve tissue or lysis (breaking up) perineural adhesions.
Neurorrhaphy—Repair of severed nerve by suture, graft or with synthetic conduit.
Neurosis—Emotional condition or disorder; anxiety is a primary characteristic.
Paranoia—A mental disorder, often includes delusions involving persecution.
Poliomyelitis—Inflammation of gray matter of the spinal cord.
Psychosis—An Abnormal condition of the mind, gross disor- ganization, or distortion of mental capacity.
Quadriplegia—Paralysis of all four extremities. Radiculitis—Inflammation of the spinal nerve roots. Subdural—Below the dura mater.
Vagotomy—Surgical incision of the vagus nerve.
Procedures of the nervous system are found primarily in the 60000 range of CPT® codes (61000–64999).
Application to Documentation
With a marker, a line was drawn on the skin in the midsagittal plane from the external occipital protuberance to the level of C2. The skin was infiltrated with Marcaine and opened with a scalpel. The midline fascia between the suboccipital muscles was used as a plane of dissection. The dorsal arch of C1 was exposed, and the muscle was dissected off the suboccipital bone bilaterally.
The term “suboccipital” assists in selecting the correct CPT® code for this craniectomy. Another location for this craniectomy could have been “subtemporal.”
Organs of Sense — Eye
Organs of sense are classified as a subsection in the nervous system because they ultimately coalesce in nerve endings called sensory receptors. Sensory organs receive and filter sensory input interpreted in the central nervous system.
The eye, the sense organ of sight, is a complex structure situated in the bony orbit or socket formed by seven bones: frontal, maxillary, sphenoid, lacrimal, malar, ethmoid, and palatine bones. The eyeball has three layers: the retina (innermost), choroid (middle), and sclera (outermost). It is
separated into an anterior segment filled with aqueous humor and a posterior segment filled with vitreous humor. The crystalline lens separates the two segments.
The anterior segment has two chambers, referred to as an anterior chamber and a posterior chamber. The aqueous humor is a watery substance filling the anterior and posterior chambers of the anterior segment of the eye. It is responsible for intraocular pressure.
A clear gel-like substance filling the posterior segment of the eye is called vitreous, which also is responsible for intraocular pressure and prevents the eyeball from collapsing. The retina is the portion of the posterior segment serving as a light receptor.
The optic nerve (sensory receptor for the eye) emerges in the posterior segment in the posterior-most regions and is known as the optic disk or blind spot.
There are many adnexal or accessory structures to the eye, such as the eyelids, eyelashes, and the lacrimal system. There are six ocular muscles working in opposition to move the eye in multiple directions to facilitate a wide field of vision.
Common Medical Terms for the Eye
Amblyopia—Lazy eye causing dullness of vision. Ametropia—Defect in the refractive power of the eye. Aphakia—Absence of lens of the eye.
Astigmatism—Due to an abnormal curve of the cornea, rays of light do not focus on the retina, but are spread over area causing out-of-focus vision.
Blepharitis—An inflammation of the edges of the eyelids.
Corneal—Pertaining to the cornea. Cycloplegia—Ciliary muscle paralysis. Diplopia—Double vision.
Ectropion—Turning outward (eyelid).
Entropion—Turning inward (eyelid).
Glaucoma—Disease of the eye characterized by increased intraocular pressure.
Intraocular—Within the eye. Keratitis—Inflammation of the cornea. Lacrimal—Tears.
Ocular—Pertaining to the eye.
Ophthalmologist—A physician specializing in diagnosis and treatment of diseases of the eye.
Ophthalmoscope—An instrument used to examine the inte- rior portion of the eye.
Presbyopia—Farsightedness associated with aging and progressive disease.
Retinopathy—Non-inflammatory degenerative disease of the retina.
Tonometer—Instrument to measure intraocular pressure.
Trichiasis—Ingrown eyelashes, can rub against the cornea irritating the eye.
Ophthalmology has its own vocabulary and is a very special- ized field of medicine and coding. There are two types of services pertaining to the eye: vision services and surgical services. Vision services can be found in the 92002–92499 range of CPT® codes. Surgical services on the eye can be found in the 65091–68899 range of CPT® codes.
Organs of Sense — Ear
The ear works in tandem with the auditory nerves sending auditory impulses to the temporal lobes of the cerebrum. These structures, working together, form the auditory apparatus.
The ear has three distinct and separate anatomical divisions: the outer ear (external ear), middle ear (tympanic cavity), and inner ear (labyrinth). The auditory apparatus uses the ear to capture sound waves and transmits or conducts them into the tiny hair cells in the organ of Corti. Dendrites (nerve endings) of the sensory neurons for hearing are found in the bottom of those tiny hair cells.
Otology (study of the ear) is a very specialized field of medicine and coding. There are two types of services pertaining to the ear: audiometry services (hearing testing) and surgical services.
Surgical services on the ear are found in the 69000-69979 range of CPT® codes. Special otorhinolaryngologic services
are found in the 92502-92700 range. The range 92601-92604 is used to report diagnostic analysis of cochlear implants.
Medical Terms for the Ear
Audiology—Study of hearing disorders.
Auricle—External ear.
Labyrinthitis—Inflammation of the labyrinth.
Myringoplasty—Repair of the tympanic membrane.
Otolaryngologist—Physician specializing in diagnosis and treatment of diseases of the ear and larynx.
Otologist—Physician specializing in diagnosis and treatment of diseases of the ear.
Otopyorrhea—Pus draining from the ear. Otoscope—Instrument used to examine the ear and ear drum. Tinnitus—Ringing in the ear.
Vertigo—Feeling you or your environment is moving or spinning, caused by a disturbance of equilibrium in the labyrinth.
Section Review 2.9
1. The brain and spinal cord are part of which system?
A. Somatic Nervous System
B. Autonomic Nervous System
C. Central Nervous System
D. Peripheral Nervous System
2. Which layer is the middle layer of the eyeball?
A. Iris
B. Choroid
C. Retina
D. Sclera
3. What prevents the eyeball from collapsing?
A. Crystalline lens
B. Aqueous humor
C. Optic nerve
D. Vitreous humor
4. Which structure of the ear is considered the inner ear?
A. Tympanic cavity
B. Labyrinth
C. Dendrites
D. Cerebrum
5. What term is used for pus draining from the ear?
A. Labyrinthitis
B. Otopyorrhea
C. Tiniitus
D. Vertigo
Endocrine System
The endocrine system is comprised of glands. A gland is a group of cells secreting or excreting chemicals called hormones. Endocrine glands are ductless glands secreting their hormones directly into the blood stream. Exocrine glands have ducts. Glands secrete hormones eliciting an effect on tissues other than themselves. Glands are found throughout the body. Each gland and its associated hormone have a unique cause and effect.
Exocrine and Endocrine Glands
Body surface
Gland cell
Hormone
Bloodstream
Exocrine gland (has duct)
Endocrine gland (ductless)
Source: Ehrlich, Medical Terminology for Health Professionals, 6e, ISBN #978-1-4180-7252-0
The following glands are found in the human endocrine system:
Adrenal Glands—Ductless, pyramid-shaped glands are situated on the top of the superior end of each kidney. There are two structural parts of each adrenal gland. The inner portion is called the medulla and the outer portion is the cortex. Each structure performs a separate function. The medulla secretes epinephrine and norepinephrine. The cortex secretes several steroids (eg, glucocorticoids, mineral corticoids, and adrenal estrogens and androgens).
Carotid Body—A structure made of epithelial-like cells located on each side of the body at the bifurcation (division) of the common carotid artery. This has a vascular/ sinusoidal bed and a large network of nerve fibers from the glossopharyngeal nerve. This configuration works together to measure concentration of oxygen, carbon dioxide, and free hydrogen atoms in blood. This chemoreceptor organ regulates respiration and pH balance. Although not a
true endocrine structure, it is made of both glandular and nonglandular cells. Procedures on this structure are included in the endocrine family of CPT® codes.
Parathyroid Gland—Small round bodies located on the posterior side of the thyroid gland and imbedded in the connective tissue surrounding it. The number of these bodies varies, but usually there are four. These glands regulate calcium and phosphorus metabolism.
Pituitary Gland—Also called the hypophysis cerebri, this single (unpaired) gland has two separate parts located in an area of the brain just under the hypothalamus. One
portion is called the posterior pituitary or neurohypophysis. The posterior pituitary secretes oxytocin, a hormone responsible for uterine contractions and “let down” reflex
of milk in response to a baby’s suckling; and Vasopressin, an antidiuretic. The anterior pituitary manufactures
adrenocorticotrophic hormone (ACTH), thyroid stimulating hormone (TSH), follicle stimulating hormone (FSH), luteinizing hormone (LH), growth hormone (somatotrophin or GH), melanocyte stimulating hormone (MSH), and prolactin (PRL).
Thymus Gland—Composed of lymphoid tissue and located in the mediastinum of the chest. The precise functions of this gland are not known entirely. This gland helps regu- late humoral (circulating defenses versus cellular defenses) immune functions. The gland does much of its work in early childhood, and is largest shortly after birth. By puberty, it is small and may be replaced by fat.
Thyroid Gland—Regulates metabolism and serum calcium levels through the secretion of thyroid hormone and calci- tonin, respectively. This bilobed, ductless gland is located in the neck just below the thyroid cartilage of the trachea. The two lobes sit on either side of the trachea and are joined by a small band of tissue called the isthmus.
When the endocrine system and the nervous system work together, they form a system of internal communication for the human body.
Common Terms in the Endocrine System Endocrinologist—Physician specializing in diagnosis and treatment of diseases of the endocrine system.
Euthyroid—Normal thyroid gland activity.
Glandular—Pertaining to a gland.
Hyperkalemia—Excessive amounts of potassium in the blood. Hyperthyroidism—Excessive secretion of thyroid hormone. Hypothyroidism—Deficient secretion of the thyroid hormone.
Insulin—Hormone secreted by the beta cells in the islets of Langerhans of the pancreas which regulates energy and
glucose metabolism. Also used in management of diabetes.
Parathyroid—Glands located behind the thyroid gland.
Thymitis—Inflammation of the thymus gland.
Thyroiditis—Inflammation of the thyroid gland
Thyrotoxicosis—Condition caused by excess thyroid hormone, often due to hyperactivity of the thyroid gland.
The CPT® 60000–60699 codes address surgical procedures of the endocrine system.
Section Review 2.10
1. Which gland secretes thyroid hormone and calcitonin?
A. Adrenal glands
B. Parathyroid gland
C. Pituitary gland
D. Thyroid gland
2. Which structure is not a true endocrine structure?
A. Adrenal glands
B. Carotid body
C. Pituitary gland
D. Thyroid gland
3. Which gland is larger in early life than in puberty?
A. Adrenal glands
B. Parathyroid glands
C. Thymus gland
D. Thyroid gland
4. Which gland is also known as the hypophysis cerebri?
A. Adrenal glands
B. Pituitary gland
C. Parathyroid glands
D. Thymus gland
5. Which gland has two separate structures called the medulla and the cortex?
A. Adrenal glands
B. Pituitary gland
C. Carotid body
D. Parotid gland
Hematologic (Hemic) System
The hemic system involves the blood. Red cells, white cells, and platelets are produced in the marrow of bones, especially the vertebrae, ribs, hips, skull, and sternum. These essential blood cells fight infection, carry oxygen, and help control bleeding. Plasma is a pale yellow mixture of water, protein, and salt,
and acts as a carrier for blood cells, nutrients, enzymes, and hormones.
Red Blood Cells (RBCs or erythrocytes)—Disk-shaped cells containing hemoglobin enabling cells to pick up and deliver oxygen to all parts of the body. Erythropoietin (EPO) is a glycoprotein hormone providing a direct stimulus for eryth- rocyte formation. Some erythrocyte disorders include anemia and polycythemia.
Hemoglobin transports oxygen and carbon dioxide in the blood. It is composed of globin, a group of amino acids forming a protein, and heme, which contains iron atoms and imparts the red color to hemoglobin. Hemoglobin is an important determinant of anemia (decreased), dehydration
(increased), polycythemia (increased), poor diet/nutrition, or a malabsorption problem. Most tests of the hematologic system are performed in the clinical laboratory.
White Blood Cells (WBCs or leukocytes)—The body’s primary defense against infection and only account for less than 1
percent of total blood volume. Types of leukocytes include neutrophils, lymphocytes, monocytes, eosinophils, and basophils, each having their own function in defense. Leuko- cyte disorders include leukopenia, leukemias, and infectious mononucleosis.
Platelets (thrombocytes)—Form clusters to plug small holes in blood vessels and assist in the clotting process.
Some bleeding disorders include thrombocytopenia, impaired liver function, and hemophilia.
Procedures on blood and its components are covered in the 80000 range of CPT® codes.
Immune System
The immune system is classified as a separate system from the hematologic system; however, most immune cells originate in the hematologic system. In medicine, the study of the immune system (immunology) and the study of allergies often go hand in hand because an allergic response is, in fact, an immune response. The human immune system is the body’s final line of defense against invading microorganisms, harmful chemicals, and foreign bodies.
There are two kinds of immune cells: B-cells and T-cells. Several types of cells protect the body from infection (eg,
neutrophils, lymphocytes, monocytes, eosinophils, and basophils). Neutrophils are the body’s main defense against infection and antigens. High levels of neutrophils may indicate an active infection; a low count may indicate a compromised immune system or depressed bone marrow (low neutrophil production).
Lymphocytes are involved in protection of the body from viral infections such as measles, rubella, chicken pox, or infectious mononucleosis. Elevated levels may indicate an active viral infection and a depressed level may indicate an exhausted immune system.
Monocytes fight severe infections and are considered the body’s second line of defense against infection. Elevated levels are seen in tissue breakdown, chronic infections, carcinomas, leukemia (monocytic), or lymphomas. Low levels of monocytes indicate a good state of health.
The body uses eosinophils to protect against allergic reac- tions and parasites; elevated levels may indicate an allergic response. A low count of eosinophils is normal. Basophilic activity is not understood fully, but it is known to carry histamine, heparin, and serotonin. High levels are found in allergic reactions; low levels are normal.
Antigens elicit an immune response in the body. Antigens entering the body from the environment can include:
l Inhaled macromolecules (eg, proteins on cat hairs triggering an asthma attack)
l Ingested macromolecules (eg, shellfish proteins triggering an allergic response)
l Molecules introduced beneath the skin (eg, on a splinter or in an injected vaccine)
Antibodies are immune system related proteins called immu- noglobulins. Some antibodies destroy antigens directly; others indirectly by making it easier for white blood cells to destroy the antigen.
Clinical lab tests performed on the function and health of the immune system are found in the 86000–86849 range of CPT® codes and performed in the clinical laboratory.
Medical Terms Related to
the Hematologic System and Immune System
Erythropathy—Disease of red blood cells.
Hematocrit—Blood test that measures the red blood cell volume by centrifuge, a technique which separates the plasma and the blood cells.
Hematologist—Physician specializing in the study of blood disorders.
Hemoglobin—The red respiratory protein of RBCs, transports oxygen to the tissues.
Hemolysis—Destruction of red blood cells.
Hemostasis—Control of bleeding. Hypercalcemia—Excessive amounts of calcium in the blood. Hyperglycemia—Excessive amounts of sugar in the blood. Hyperlipemia—Excessive amount of fat in the blood.
Hypoglycemia—Deficient amount of sugar in the blood.
Leukemia—Overproduction of leukocytes resulting in a malig- nant, acute, or chronic disease.
Mononucleosis—Disease of excessive mononuclear leukocytes in the blood due to infection with the Epstein-Barr virus.
Polycythemia—Abnormal increase in red blood cells.
Septicemia—Pathogenic bacteria present in the blood.
Section Review 2.11
1. Anemia and polycythemia are disorders related to which blood cell?
A. Erythrocytes
B. Leukocytes
C. Lymphocytes
D. Monocytes
2. Which leukocyte protects the body from viral infections?
A. Neutrophils
B. Lymphocytes
C. Monocytes
D. Eosinophils
3. Which leukocyte is the body’s second line of defense against infection?
A. Neutrophils
B. Lymphocytes
C. Monocytes
D. Eosinophils
4. Which leukocyte does the body use to protect against allergic reactions and parasites?
A. Neutrophils
B. Lymphocytes
C. Monocytes
D. Eosinophils
5. What is the disease of excessive mononuclear leukocytes in the blood?
A. Leukopoiesis
B. Leukopenia
C. Mononucleosis
D. Myelocytic leukemia
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