Introduction to Healthcare Terminology

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Chapter 1

Introduction to Healthcare Terminology

Objectives

State the derivation of most healthcare terms.

Use the rules given to build and spell healthcare terms.

Use the rules given to change singular terms to their plural forms.

Recognize and recall an introductory word bank of prefixes, suffixes, and combining forms and their respective meanings.

ICD-10-CM Example from Tabular

R16 Hepatomegaly and splenomegaly, not elsewhere classified

R16.0. Hepatomegaly, not elsewhere classified

Hepatomegaly, not otherwise specified

R16.1. Splenomegaly, not elsewhere classified

Splenomegaly, not otherwise specified

R16.2. Hepatomegaly with splenomegaly, not elsewhere classified

Hepatosplenomegaly, not otherwise specified

ICD-10-PCS Example from Index

Introduction to ICD-10

Technology is making our world feel smaller—and more complicated. The World Health Organization (WHO) has been publishing a listing of morbidity (disease) and mortality (death) data for more than 100 years. This listing is used to keep track of the rates of disease and death on much of our planet. Periodically, it is updated to reflect advances in medical science and new terminology. The use of the Internet to collect and publish statistics with this listing allows for faster dissemination of the information collected.

As of October 2015, the United States will begin using the International Classification of Diseases, 10^th edition (ICD-10). The American adaptation of ICD-10 is titled ICD-10-CM (clinical modification), the CM representing a substantial expansion of the classification system to give more detailed information about diseases. Accompanying the ICD-10-CM volume, an ICD-10-PCS (Procedure Classification System) has been developed to capture the vastly increased amount of information regarding the diagnostic and therapeutic techniques used to treat disease. In the United States, both volumes of ICD serve to capture encoded disease and procedure information that may be used for billing, research, and public policy.

Students who want to master the intricacies of coding and billing need to begin their study by learning the language of medical professionals and how that specific vocabulary is related to this new coding classification, ICD-10. This text will help you toward your goals by presenting the material in small, manageable segments with a variety of opportunities to test and reinforce the new material and concepts. Guideline Alert! and Special Note boxes will notify you of special concerns for coders, while illustrations and tables will provide additional explanations.

Derivation of Healthcare Terms

Healthcare terminology is a specialized vocabulary derived from Greek and Latin word components. This terminology is used by professionals in the medical field to communicate with each other. By applying the process of “decoding,” or recognizing the word components and their meanings and using these to define the terms, anyone will be able to interpret literally thousands of medical terms.

The English language and healthcare terminology share many common origins. This proves to be an additional bonus for those who put forth the effort to learn hundreds of seemingly new word parts. Two excellent and highly relevant examples are the combining forms (the “subjects” of most terms) gloss/o and lingu/o, which mean “tongue” in Greek and Latin, respectively. Because the tongue is instrumental in articulating spoken language, Greek and Latin equivalents appear, not surprisingly, in familiar English vocabulary. The table on the next page illustrates the intersection of our everyday English language with the ancient languages of Greek and Latin and can help us to clearly see the connections. Suffixes (word parts that appear at the end of some terms) and prefixes (word parts that appear at the beginning of some terms) also are presented in this table.

Ancient Word Origins in Current English and Healthcare Terminology Usage

Term	Word Origins	Definition
glossary	gloss/o tongue (Greek) -ary pertaining to	An English term meaning “an alphabetical list of terms with definitions.”
glossitis	gloss/o tongue (Greek) -itis inflammation	A healthcare term meaning “inflammation of the tongue.”
bilingual	bi- two lingu/o tongue (Latin) -al pertaining to	An English term meaning “pertaining to two languages.”
sublingual	sub- under lingu/o tongue (Latin) -al pertaining to	A healthcare term meaning “pertaining to under the tongue.”

Did you notice that healthcare terms use the word origins literally, whereas English words are related to word origins but are not exactly the same? Fortunately, most healthcare terms may be assigned a simple definition through the use of their word parts.

Types of Healthcare Terms

Decodable Terms

Decodable terms are those terms that can be broken into their Greek and Latin word parts and given a working definition based on the meanings of those word parts. Most medical terms are decodable, so learning word parts is important. The word parts are:

• Combining form: word root with its respective combining vowel.

Word root: word origin.

Combining vowel: a letter sometimes used to join word parts. Usually an “o” but occasionally an “e” or “i.”

• Suffix: word part that appears at the end of a term. Suffixes are used to indicate whether the term is an anatomic, pathologic, or procedural term.

• Prefix: word part that sometimes appears at the beginning of a term. Prefixes are used to further define the absence, location, number, quantity, or state of the term.

In our first examples, gloss/ and lingu/ are word roots with an “o” as their combining vowel. Gloss/o and lingu/o are therefore combining forms; -ary, -al, and –itis are suffixes; and bi- and sub- are prefixes. Figs. 1-1 and 1-2 demonstrate the decoding of the terms glossitis and sublingual.

Fig. 1-1 Decoding of the term **glossitis**.

Fig. 1-2 Decoding of the term **sublingual**.

Nondecodable Terms

Not all terms are composed of word parts that can be used to assemble a definition. These terms are referred to as nondecodable terms, that is, words used in medicine whose definitions must be memorized without the benefit of word parts. These terms will have a blank space in the word origin columns in the tables presented in the text or will include only a partial notation because the word origins either are not helpful or don’t exist. Examples of nondecodable terms include the following:

• Cataract: From the Greek term meaning “waterfall.” In healthcare language, this means “progressive loss of transparency of the lens.”

• Asthma: From the Greek term meaning “panting.” Although this word origin is understandable, the definition is “a respiratory disorder characterized by recurring episodes of paroxysmal dyspnea (difficulty breathing).”

• Diagnosis: The disease or condition that is named after a healthcare professional evaluates a patient’s signs, symptoms, and history. Although the term is built from word parts (dia-, meaning “through,” “complete”; and -gnosis, meaning “state of knowledge”), using these word parts to form the definition of diagnosis, which is “a state of complete knowledge,” really isn’t very helpful.

• Prognosis: Similar to diagnosis, the term prognosis can be broken down into its word parts (pro-, meaning “before” or “in front of”; and -gnosis, meaning “state of knowledge”), but this does not give the true definition of the term, which is “a prediction of the probable outcome of a disease or disorder.”

• Sequela: A condition that results from an injury or disease. Referred to in coding as a “late effect.”

The following is an example of a Guideline Alert from the ICD-10-CM coding manual. CM and PCS Guideline Alerts are scattered throughout the text to help students understand the connection between choosing the most specific correct medical term and accurate, complete coding.

CM Guideline Alert

Late Effects (Sequelae)

A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual effect may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.

An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth, fifth, or sixth character level) to include manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

• Acute: A term that describes an abrupt, severe onset to a disease (acu- means “sharp”).

• Chronic: Developing slowly and lasting for a long time (chron/o means “time”). Diagnoses may be additionally described as being either acute or chronic.

CM Guideline Alert

Acute and Chronic Condition

If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

• Sign: An objective finding of a disease state (e.g., fever, high blood pressure, rash).

• Symptom: A subjective report of a disease (pain, itching).

CM Guideline Alert

Signs and Symptoms

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM—Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0-R99)—contains many, but not all, codes for symptoms.

• Syndrome: A group of signs and symptoms that consistently appear together.

CM Guideline Alert

Syndromes

Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome.

• Etiology: Literally the “study of cause,” although the term is used in coding to simply refer to the cause of a disease.

• Manifestation: An outward demonstration or perception. Signs and symptoms are manifestations of diseases.

CM Guideline Alert

Etiology/Manifestation Convention (“Code First,” “USE Additional Code” and “in Diseases Classified Elsewhere” Notes)¹

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

In most cases the manifestation codes will have in the code title, “in diseases classified elsewhere.” Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition.

¹ For more of this guideline, see ICD-10-CM Official Guidelines for Coding and Reporting.

Other types of terms that are not built from word parts include the following:

• Eponyms: Terms that are named after a person or place associated with the term. Examples include:

Alzheimer’s disease, which is named after Alois Alzheimer, a German neurologist. The disease is a progressive mental deterioration.

Achilles tendon, a body part named after a figure in Greek mythology whose one weak spot was this area of his anatomy. Tendons are bands of tissue that attach muscles to bone. The Achilles tendon is the particular tendon that attaches the calf muscle to the heel bone (calcaneus). Unlike some eponyms, this one does have a medical equivalent, the calcaneal tendon.

Abbreviations and Symbols

Abbreviations are terms that have been shortened to letters and/or numbers for the sake of convenience. Symbols are graphic representations of a term. Abbreviations and symbols are extremely common in written and spoken healthcare terminology but can pose problems for healthcare workers. The Joint Commission has published a “DO NOT USE” list of dangerously confusing abbreviations, symbols, and acronyms that should be avoided (see Appendix D). The Institute of Safe Medical Practice, Inc., has provided a more extensive list. Each healthcare organization should have an official list, which includes the single meaning allowed for each abbreviation or symbol. Examples of acceptable abbreviations and symbols include the following:

• Simple abbreviations: A combination of letters (often, but not always, the first of significant word parts) and sometimes numbers

IHM: abbreviation for “intramuscular” (pertaining to within the muscles)

C2: second cervical vertebra (second bone in neck)

• Acronyms: Abbreviations that are also pronounceable

CABG: coronary artery bypass graft (a detour around a blockage in an artery of the heart)

TURP: transurethral resection of the prostate (a surgical procedure that removes the prostate through the urethra)

• Symbols: Graphic representations of terms

stands for female

stands for male

↑ stands for increased

↓ stands for decreased

+ stands for present

− stands for absent

Match the nondecodable term to its definition.

Decoding Terms

Check, Assign, Reverse, Define (CARD) Method

Using Greek and Latin word components to decipher the meanings of healthcare terms requires a simple four step process. You need to:

• Check for the word parts in a term.

• Assign meanings to the word parts.

• Reverse the meaning of the suffix to the front of your definition.

• Define the term.

Using Fig. 1-3, see how this process is applied to your first patient, Alex.

Fig. 1-3 How to decode a healthcare term using the **CARD** method.

Most of the terms presented in this text appear in standardized tables. The term and its pronunciation appear in the first column, the word origin in the second, and a definition in the third. A table that introduces six healthcare terms that include six different combining forms and suffixes is provided on p. 10. (The use of prefixes will be introduced later.) Success in decoding these terms depends on how well you remember the 12 word parts that are covered in following the table. Once you master these 12 word parts, you will be able to recognize and define many other medical terms that use these same word parts—a perfect illustration of how learning a few word parts helps you learn many healthcare terms.

The “wheels of terminology” included on Fig. 1-4 demonstrate how different suffixes in the table below can be added to a combining form to make a variety of terms.

Fig. 1-4 Body parts and their combining forms. Surrounding the figure are “terminology wheels” that show how different suffixes can be added to a combining form to make a variety of terms.

Common Combining Forms and Suffixes

Combining Forms	Suffixes
arthr/o = joint	-algia = pain
gastr/o = stomach	-tomy = cutting
ophthalm/o = eye	-scope = instrument to view
ot/o = ear	-logy = study of
rhin/o = nose	-plasty = surgically forming
hepat/o = liver	-itis = inflammation

The table below demonstrates how terms are presented in this book. Notice that the first column includes the term. The second column breaks the term down into word parts and their meanings. The third column includes the definition of the term and any synonyms.

Samples of Decodable Terms

Term	Word Origins	Definition
arthralgia	arthr/o joint -algia pain of	Pain of a joint. Also called arthrodynia.
gastrotomy	gastr/o stomach -tomy cutting	Incision of the stomach.
hepatitis	hepat/o liver -itis inflammation	Inflammation of the liver.
ophthalmoscope	ophthalm/o eye -scope instrument to view	Instrument used to view the eye.
otology	ot/o ear -logy study of	Study of the ear.
rhinoplasty	rhin/o nose -plasty surgically forming	Surgical formation of the nose.