Medical Terminology and Anatomy for ICD-10 Coding

790 Pages·2011·56.6 MB·English

ICD-10
for Coding
Contents
CHAPTER 1 Introduction to Healthcare Terminology, xxiv
CHAPTER 2 Body Structure and Directional Terminology, 26
CHAPTER 3 Musculoskeletal System and Connective Tissue, 56
CHAPTER 4 Skin and Subcutaneous Tissue, 132
CHAPTER 5 Digestive System, 174
CHAPTER 6 Genitourinary System, 222
CHAPTER 7 Pregnancy, Childbirth, and the Puerperium, 284
CHAPTER 8 Blood, Blood-Forming Organs, and the Immune Mechanism, 308
CHAPTER 9 Circulatory System, 346
CHAPTER 10 Respiratory System, 414
CHAPTER 11 Nervous System, 454
CHAPTER 12 Mental and Behavioral Disorders, 498
CHAPTER 13 Eye and Adnexa, 522
CHAPTER 14 Ear and Mastoid Process, 554
CHAPTER 15 Endocrine System and Nutritional and Metabolic Diseases, 574
Illustration Credits, 604
APPENDIX A Word Parts and Definitions, 605
APPENDIX B Definitions and Word Parts, 618
APPENDIX C Abbreviations, 630
APPENDIX D Pharmacology Terminology, 636
APPENDIX E Body Part Key, 640
Answers to Exercises and Review Questions, 677
Index, 707
ICD-10
for Coding

Betsy J. Shiland
MS, RHIA, CCS, CPC, CPHQ, CTR
AHIMA Approved ICD-10-CM/PCS Trainer
Assistant Professor
Allied Health Department
Community College of Philadelphia
Philadelphia, Pennsylvania
With 400 illustrations
3251 Riverport Lane
St. Louis, Missouri 63043
MEDICAL TERMINOLOGY AND ANATOMY FOR ICD-10 CODING ISBN: 978-1-4557-0774-4
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Library of Congress Cataloging-in-Publication Data
Shiland, Betsy J.
Medical terminology & anatomy for ICD-10 coding / Betsy J. Shiland.
p. ; cm
Medical terminology and anatomy for ICD-10 coding
Includes index.
ISBN 978-1-4557-0774-4 (pbk. : alk. paper)
I. Title. II. Title: Medical terminology and anatomy for ICD-10 coding.
[DNLM: 1. International statistical classification of diseases and related health problems.
10th revision. 2. Anatomy—Terminology—English. 3. Clinical Coding—methods—
Terminology—English. 4. International Classification of Diseases—Terminology—English.
QS 15]
610.1′4—dc23
2011036486
Publisher: Jeanne Olson
Managing Editor: Linda Woodard
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Working together to grow
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Designer: Jessica Williams libraries in developing countries
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors
Erinn Kao PharmD RPh
Pharmacist
GE Healthcare
St. Louis, Missouri
Preface
In 2013, the United States will begin classifying diseases, disorders and proce-
dures with a revised coding system: ICD-10-CM/PCS. Literally overnight the
number of possible codes will jump from approximately 18,000 in ICD-9 to over
155,000 in ICD-10.
100,000
90,000
80,000
S 70,000
E
D
O 60,000
C
OF 50,000 ICD-9
R
E 40,000
B ICD-10
M
U 30,000
N
20,000
10,000
0
Diagnoses Procedures
Because of this dramatic increase, coders will need to learn new medical
terms and new ways of using familiar terms. They will also need to learn an
astonishing amount of anatomy in order to assign these new codes correctly.
In the not-so-distant future, coders will be expected to know the locations of
most arteries, veins, bones, muscles, sinuses, nerves, tendons, ligaments, and
lymphatic vessels. Detailed anatomy of the heart will include locations and
names of the great vessels (and which vessels are classified as great vessels in
ICD-10 as opposed to most anatomy texts), the chambers, septa, papillary
muscles, chordae tendinae, valves, and valvular structures—all in the terminol-
ogy used by ICD-10. Students must be able to not only recognize synonyms
for this terminology, but also know how it is used within this new classifica-
tion system.
As someone who has been engaged in extensive training, workshops, and
seminars in ICD-10, I thoroughly understand the concerns about the depth of
the anatomy necessary for ICD-10. Personally, with my own anatomy and
physiology courses recalled only as a distant memory, I wondered how I would
refresh my own knowledge. I realized that simply reviewing an anatomy and
physiology text was not enough: I needed to know what this new classification
system required and what terms it used to describe the anatomy.
Preface vii
Using both volumes of ICD-10, I spent many weeks sorting and categorizing
the indices and tabular sections to find out just what terminology was needed
(and how it was presented). I discovered that “standard” anatomy and physiol-
ogy often did not translate directly to ICD-10 terminology and that flexibility
in the use of terms was necessary, because not every clinician will be using the
terminology that a particular anatomy and physiology text employs.
Additionally, the change from ICD-9 to ICD-10 involves more than a simple
increase in the volume of codes due to attention to anatomical detail. The dif-
ferences that call for greatly increased clinical documentation requirements also
include:
• Laterality of a condition or injury
• Increase in the number of digits and characters, including the use of
extensions to provide additional information (for example, the timing of
an injury)
• Inclusion of combination codes that include both etiology and
manifestation
• The inclusion of information regarding trimester in pregnancy, delivery,
and the puerperium
• Postprocedural codes
• Updated terminology and new procedures
I realized that of all the resources available to help coders manage the
requirements of ICD-10, none addressed its specific needs. What was needed
was a text that was designed around ICD-10 terminology and anatomy, not
terminology and anatomy in general. Medical Terminology and Anatomy for
ICD-10 is the result. This terminology textbook, unlike any other medical ter-
minology textbook on the market, provides an accessible, carefully sequenced
means of learning the medical terminology and anatomy specifically required
to understand and apply subsequent ICD-10 coding instruction. Medical Ter-
minology and Anatomy for ICD-10 prepares students for a coding career with a
focused delivery of content that allows them to recognize, recall, and apply
their knowledge.
viii Preface
ORGANIZATION OF THE BOOK
Medical Terminology and Anatomy for ICD-10 Coding uses a scaffolding approach
to carefully sequence learning from simple to complex. Students begin with an
introduction to Greek and Latin word parts and rules for building terms. Next,
they learn directional terminology, surface anatomy, and terms that are used to
describe anatomical structures. The first body system discussed is the musculo-
skeletal system, which is key to understanding an enormous number of terms
used in other body systems. A careful and thorough understanding of these first
chapters is an investment that pays a substantial return on investment for the
rest of the text. Students will find examples of word parts and terms covered in
these first chapters that are used over and over again in the following chapters.
A solid knowledge of word parts leads to an easier understanding of the loca-
tion and function of anatomical terms. Word parts continue to play an
important role in grasping the details of the pathologic terms for a particular
body system and the procedural terms that diagnose and treat those diseases.
Word parts are the basis for the assigning of codes, as the figure below
demonstrates.
codes
procedural
terms
pathologic
terms
anatomical
terms
word
parts
The internal structure of each chapter consists of small learning segments or
“chunks.” Concepts, terms, illustrations, and abbreviations for the anatomy and
physiology, pathology, and procedures for a body system are covered and are
then immediately followed by exercises that reinforce and assess your under-
standing and retention of the material. Special boxes alert you to terminology
and coding pitfalls, and electronic healthcare records provide practice of newly
learned terminology.