Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 26, 2010 PDF

Know the universal acronyms, then keep an eye out for regional acronyms as well.

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

Because 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.

Some acronyms, such as COPD (chronic obstructive pulmonary disease), ECG (electrocardiogram), or AMI (acute myocardial infarction) are familiar to most people in the medical field, whereas others (such as MLC, or midline catheter) might throw you for a loop.

And although many acronyms (such as DNR, or "do not resuscitate") are common throughout the U.S., others can vary based on where you work.

"Remember that acronyms are actually regionally-based, and what they are and how they are used are a function of where the physician was trained," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Healthcare Solutions in Tinton Falls, NJ.

Tip: Once you know the universal acronyms, make a list of those used just by your practice or within your region.

Review the following eight examples and see if you can figure out what the physician did. Then turn to page 116 to determine whether you answered correctly.

Question 1. PLIF at L5-S1.

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

Question 3. 85 y.o. est. pt.requires THR for AVN.

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

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

Question 6. WBC is WNL.

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

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