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 [...]