Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 26, 2010 PDF

Hint: When in doubt, check with the practitioners rather than guessing.

For most coders, not a day passes when you don't encounter at least one or two acronyms in medical charts. Whether or not you know what they mean could be the difference between coding accurately and getting the codes way off-base.

While there are quite a few acronyms that all coders should know, there are also some that practices should never use. The Joint Commission includes an official "Do Not Use" list on its Web site (www.jointcommission.org).

Among the abbreviations you should not use are "U" when referring to the word "unit" -- instead, you should write out the word "unit."

Good practice: If you see an acronym that you don't recognize, ask the practitioner to decipher it for you rather than attempting to guess at its answer.

If the patient is sent to your practice from another office, you may have to follow up with the original office to determine the acronym's definition.

"I handle compliance in a hospital laboratory," says Carolyn J. Kent, MBA, MT (ASCP) with Compliance/PLIS in Jackson, Miss. "When unknown acronyms are presented to us via requisitions, we follow up with the clinic."

Test yourself: Check out how you fared in the acronym quiz that we challenged you to on page 114 with the following expert answers.

Acronym 1 -- PLIF at L5-S1.In this example, the physician performed a posterior lumbar interbody fusion (PLIF) at lumbar level five (L5) and sacral level one (S1).

Acronym 2 -- Repaired EPB, APL, BR, FDS ring, FDS long, PL, and FPL tendons.

The physician in this case repaired the patient's extensor pollicis brevis (EPB), the abductor pollicis longus (APL), the brachioradialis (BR), the ring finger flexor digitorum superficialis (FDS ring), the middle finger flexor digitorum superficialis (FDS long), the palmaris longus (PL), and the flexor pollicis longus (FPL) tendons.

Acronym 3 -- 85 y.o. est. pt. requires THR for AVN.

The 85-year-old established patient in this example required a total hip replacement (THR) for avascular necrosis (AVN).

Acronym 4 -- Inserted temp.ureteral cath. Ablated renal stone via cysto. with litho. Removed cath.

In this case, the doctor inserted a temporary ureteral catheter (cath) and then broke up a kidney stone via a cystourethroscopy (cysto) and lithotripsy (litho). He then removed the temporary catheter.

Acronym 5 -- 35 y.o. new pt.requires examination. CC is BS. Pt.Previous dx: AODM.

The doctor in this case saw a 35-year-old new patient (pt) requiring examination and evaluation due to a chief complaint (CC) of a blind spot (BS) in her vision. The patient has a previous diagnosis of adult onset diabetes mellitus (AODM).

Acronym 6 -- WBC is WNL.

The patient's white blood count(WBC) is within normal limits (WNL)

Acronym 7 -- PE and NP reveal NED. Plan CT neck and strobe f/u for definitive recon.

This patient's physical exam (PE) and nasopharyngoscopy (NP) reveal no evidence of disease (NED), according to Julie Keene, CPC,CENTC, otolaryngology coding and reimbursement specialist with the University of Cincinatti.

The practitioner planned a neck computed tomography (CT) and strobe followup for definitive reconstruction (recon).

Acronym 8 -- 66 y/o TL BND with post op hematoma and wound breakdown, wound stable; cont wet to dry packing, f/u on Wed.

This 66-year-old (y/o) patient had a total laryngectomy (TL) and bilateral neck dissection (BND) with postoperative hematoma and wound breakdown, and the wound was stable, Keene says. Continue (cont) wetto-dry packing and follow-up (f/u) on Wednesday.