Introduction to Healthcare Terminology

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Introduction to Healthcare Terminology

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, 10th 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:

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.

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.

• 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.

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

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

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

• 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.

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

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:

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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:

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

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.

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.

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Building Terms

Now that you’ve seen how terms are decoded, we will discuss how they are built. First, a few rules on how to spell healthcare terms correctly.

Spelling Rules

With a few exceptions, decodable healthcare terms follow five simple rules.

1. If the suffix starts with a vowel, a combining vowel is not needed to join the parts. For example, it is simple to combine the combining form arthr/o and suffix -itis to build the term arthritis, which means “an inflammation of the joints.” The combining vowel “o” is not needed because the suffix starts with the vowel “i.”

2. If the suffix starts with a consonant, a combining vowel is needed to join the two word parts. For example, when building a term using arthr/o and -plasty, the combining vowel is retained and the resulting term is spelled arthroplasty, which refers to surgically forming a joint.

3. If a combining form ends with the same vowel that begins a suffix, one of the vowels is dropped. The term that means “inflammation of the inside of the heart” is built from the suffix -itis (inflammation), the prefix endo- (inside), and the combining form cardi/o. Endo– + cardi/o + -itis would result in endocardiitis. Instead, one of the i’s is dropped, and the term is spelled endocarditis.

4. If two or more combining forms are used in a term, the combining vowel is retained between the two, regardless of whether the second combining form begins with a vowel or a consonant. For example, joining gastr/o and enter/o (small intestine) with the suffix -itis, results in the term gastroenteritis. Notice that the combining vowel is kept between the two combining forms (even though enter/o begins with the vowel “e”), and the combining vowel is dropped before the suffix -itis.

5. Sometimes when two or more combining forms are used to make a medical term, special notice must be paid to the order in which the combining forms are joined. For example, joining esophag/o (which means esophagus), gastr/o (which means stomach), and duoden/o (which means duodenum, the first part of the small intestines) with the suffix -scopy (viewing), produces the term esophagogastroduodenoscopy. An esophagogastroduodenoscopy is a viewing of the esophagus, stomach, and duodenum. In this procedure, the examination takes place in a specific sequence, that is, esophagus first, stomach second, then the duodenum. Thus the term reflects the direction in which the scope travels through the body (Fig. 1-5).

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