Neurosurgery Coding Alert

Use these tips to better translate abbreviations into codes

Do you know your SDH from your SAH? If not, you may need a crash course on neurosurgery acronyms. If you can't differentiate between the abbreviations in your surgeon's chart, you could be applying the wrong codes to your claims.

Because neurosurgery coders encounter various acronyms when reading, coding and evaluating medical charts, you may take for granted that you can decipher most of the abbreviations and acronyms that you come across. But even the most experienced coder can benefit from a primer that outlines the most common abbreviations.

Review the following three examples and see if you can figure out what the surgeon did:

1. PLIF at L5-S1.

2. ICP of 18 mm Hg.

3. HNP at L4-L5.

The solutions: Translated into real-world terminology, the first physician performed a posterior lumbar interbody fusion (PLIF) at lumbar level five (L5) and sacral level one (S1). The second physician noted an intracranial pressure (ICP) of 18 millimeters (mm) of mercury (Hg). And the third physician referred to a herniated nucleus pulposis (HNP) at the space between lumbar levels four and five.

-We see the following acronyms almost constantly,- says Rena G. Hall, CPC, coder and auditor at KC Neurosurgery Group in Kansas City, Mo.: HNP, PLIF, PCDF (posterior cervical discectomy fusion), PCL (posterior cervical laminectomy), CTR (carpal tunnel release), and CTS (carpal tunnel syndrome).

-Some of the more common acronyms in our office are TLIF (transforaminal lumbar interbody fusion), NPH (normal pressure hydrocephalus), SDH (subdural hematoma), SAH (subarachnoid hemorrhage), ICH (intracerebral hemorrhage), and ICP,- says Teresa Thomas, CPC, practice manager at St John's Clinic Neurosurgery in Springfield, Mo.

Understand the Rationale

Medical terminology developed over hundreds of years into an ever-increasing number of words and phrases. With the explosion of technologies over time and with the unfortunate explosion of new diseases, injuries and other types of illnesses came the newer and/or modified terms to deal with the various diagnoses and procedures.

Because of the extended disease and procedure names, physicians generated a system of communication using acronyms and abbreviations to facilitate more efficient communication among other medical professionals.

What is it? An acronym is a word formed from the initial letter (or letters) of words in a phrase or multi-word description. Contractions or abbreviations are shortened forms of a word or phrase, usually used to reduce the amount of time spent writing or dictating.

When in Doubt, Clarify

Unfortunately, despite being more efficient, the onslaught of acronyms has increased the possibility of error because of misunderstandings of the acronym or abbreviation.

Often, the coder can discern the meaning from the usage. For example, if the surgeon noted an -IM spinal cord tumor,- the coder would probably know that the surgeon was referring to an intramedullary tumor, not intramuscular, even though surgeons document -IM- for both of these terms.

However, if the surgeon documented that he performed -SF analysis,- you may wonder whether he analyzed spinal fluid or synovial fluid. If you are ever confused by a medical acronym, ask the physician rather than guessing.

Compile Internal Acronyms

Your physicians may use their own acronyms that you don't know, but don't get discouraged if you don't recognize the phrase immediately. -If we see an acronym that is foreign to us, we research several resources (listservs, coding books, Web sites, etc),- Hall says. -If we are unable to locate a reasonable meaning, we contact the physician directly.-

Physicians usually create internal acronyms for diagnoses more often than for procedures. Hall offers the example of CHIFAH, which stands for -closed head injury, fell at home.-

-Once we determine the meaning, we add it to our -cheat sheet- and file it in a computer folder that can be accessed by the other coders,- Hall says.

Acronyms differ within subspecialties: A surgeon who mainly performs spinal surgery might use completely different acronyms and abbreviations than a surgeon who treats brain trauma. One surgeon told us that he saw a chart in the emergency department with the acronym -HOH-BBB.- He was later told that the term stood for -hit on head, baseball bat.-