Medical Terminology and Medical Billing
Professional medical billers have mastered the specialized language of medical code, and this code is based on the language of medicine. Medical billers and medical coders need to comfortable using and understanding medical terms in order to apply the correct codes to describe services delivered to patients.
Medical language is precise. Each of the specialized words has a specific meaning so that health care providers can communicate their exact observations and prescriptions. The definitions of each code are written for trained professionals rather than for laypeople. It is expected that the people who use medical code fully understand the foundation on which the codes are based.
Both the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM) and the Healthcare Common Procedural Coding System (HCPCS) specify that the code used must match its definition, based on the documentation in the medical record.
Medical coding is the art of translating the information contained in the medical record into a sequence of abstract numbers and letters, each sequence carrying a specific meaning. With proper training, professional medical billers and certified medical coders perform this translation accurately and efficiently.
Basics of Medical Terminology
Many of the words used by physicians, surgeons, and other healthcare providers consist of Greek and Latin root words that are combined to create a multi-syllabic term that carries a precise meaning.
“Hepato-” is the Greek for the liver. “Megaly” is based on the Latin word for greatly enlarged. A patient diagnosed with hepatomegaly is someone who has been found to have an abnormally large liver.
In medical terms, a heart attack is a myocardial infarction. Myocardium means “heart muscle”, and the word infarction comes from the Latin “infacire” which means to clog. A myocardial infarction means that the artery supplying the heart muscle is clogged, preventing oxygen from reaching it. This is contrast to angina, which is heart pain in which the muscle is not totally deprived of oxygenated blood. It is also different from ventricular fibrillation, which is a condition caused by the heart’s electrical conduction.
While a medical biller or coder knows what a layperson means when they say that someone has suffered a heart attack, this term means nothing for coding or billing purposes. Medical terminology precisely defines a condition. Professional medical billers are able to understand the specifics of this terminology in order to communicate it to third-party payers for accurate reimbursement.
Every part of the human anatomy has been named. Healthcare providers memorize the various arcane terms to know exactly what part of the body is being discussed. The malleolus is the bony part on the side of the ankle. The radius and the ulna are the two long bones in the lower arm. The Islets of Langerhans are specialized structures located in the kidneys. The spine is divided into four parts: cervical spine, thoracic spine, dorsal lumbar spine, sacral spine. The sacral spine is made up of the sacrum and the coccyx.
To say that someone had a spinal injury does not provide enough information for a medical biller to assign codes for reporting purposes. Nor does it tell a healthcare provider enough to formulate a treatment plan or communicate a meaningful diagnosis to another provider. A more accurate description, in medical terminology would be to say, “idiopathic fraction L4-L5 with nerve impingement.” This is the kind of terminology medical billers and medical coders encounter in their daily work day.
The HCPCS system makes a point to state that the codes provided must meet the the definition specified in the code book. Not all procedures are alike. For instance, a transurethral resection of the prostate (TURP) is different from a transurethral needle ablation of the prostate (TUNA), and both are different from transurethral microwave thermotherapy (TUMT), or robotic prostate resection. A professional medical biller recognizes the difference between these procedures and assigns the appropriate HCPCS code when they are performed.
A hematoxylin and eosin stain does not carry its own code, it is considered an integral part of a surgical pathology examination, and for this reason it is included in the codes for those procedures. Special stains, such as a gram-stain to identify bacteria, or a immunohistochemistry stain to identify antigens, are not routinely performed unless a pathologist needs additional information to provide a complete diagnosis. Medical billers in the pathology field understand the difference between all the different services this specialized branch of medicine provides, and which codes to use to describe them.
Bilateral means something occurs on both sides of the body, while unilateral means that it occurs only on one side. The inferior aspect of the foot is the sole, while the superior aspect of the head is the top. The ascending colon is on the right side of a patient’s body, while the descending colon is on the patient’s left. They are connected by the transverse colon.
Specialized adjectives are used to paint an accurate picture of where and the patient’s condition is located, as well as how it is treated. Medications can be delivered topically, orally, rectally, vaginally, subcutaneously, intramuscularly, or intravenously. Each of these routes carry their own codes, as do the medications themselves.
A benign neoplasm is a self-contained tumor, while a malignant neoplasm is a tumor that is likely to spread to other parts of the body. Both of them are cancers, but medical billers need to know the difference between a benign tumor and a malignant one, as well as the definition of a metastatic tumor. This additional information affects the diagnostic coding, and it effects the procedural coding. Skin biopsies of benign, malignant, and uncertain lesions all carry their own codes.
BPH is medical shorthand for benign prostatic hypertrophy. A myocardial infarction that happened this morning is documented in the medical record as an acute MI. Not all medical abbreviations are so straightforward. NPO means “nothing by mouth,” which is a literal translation from the Latin, “nil per os.” With so many long words, and obscure words, to document in a patient’s medical record, standardized abbreviations have been developed so that healthcare providers can document the patient’s condition efficiently.
Medical billers who review medical records need to be familiar with the meanings of the abbreviations and terms used regularly in patient care. An order for NPO does not affect coding. Certified medical coders and professional medical billers recognize this, and they do not waste time figuring out which information is important to assemble a medical bill, and which information is important for nursing care. This is not to say that professional medical billers and certified medical coders have memorized every word and abbreviation used in every medical specialty. They use references effectively to accurately translate the patient’s medical record into code, and they are able to converse with healthcare providers in the language of medicine.
Uses of Medical Terminology
Medical billers and medical coders rely on their codebooks, medical dictionaries, and medical policy determinations to assign codes appropriately. These books are written in the specialized terminology of medicine with the understanding that the people who use them will be familiar with the terms and concepts. Without appropriate training, it is impossible for a layperson to make much sense of the coding system. This does not mean that medical coding and billing are complicated, only that it assumes a familiarity with the terminology used to describe medical procedures and conditions.
Without a grounding in medical terminology, professional medical billers and certified medical coders cannot perform their jobs well. That is why graduating from a formal program of study is important to employers. Being able to understand the language of medicine ensures that medical bills are accurate, reducing legal exposure to charges of fraud and abuse of the healthcare reimbursement system. Being able to speak the language of medicine with licensed healthcare providers helps to ensure that medical services, and the reasons for which they are performed, are accurate, and that they satisfy the burden of medical necessity to justify prompt payment at reasonable and customary rates.