Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 18, 2013 PDF

Know the universal acronyms, then keep an eye out for practice-specific acronyms as well.

Do you know your AODM from your I&D? 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 OT (occupational therapy), ECG (electrocardiogram), or Fx (fracture) are familiar to most people in the medical field, whereas others (such as MTP, or Metatarsophalangeal) 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, or even which physician writes the note.

For instance: The physician documents "TKA" in the patient’s chart, which could stand for "total knee arthroplasty" or "total knee arthroscopy." During arthroplasty, the surgeon repairs or replaces a joint. During arthroscopy, by contrast, the surgeon uses minimally invasive techniques to look inside the patient’s joint to better diagnose problems and possibly provide some treatment. You’d have these two possibilities for this acronym if you aren’t sure what the doctor meant:

Possibility 1: The correct CPT® surgical code for total knee arthroplasty is 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing [total knee arthroplasty]).

Possibility 2: CPT® includes a range of codes for total knee arthroscopy, depending on the specific procedure, including 29871-29889.

Because of these differences, it’s very important to know what your doctor means when he documents TKA, or other terms.

Review the following ten examples and see if you can figure out what the physician did. Then turn to page 291 to determine whether you answered correctly.

Question 1. Inserted temp. ureteral cath. Ablated renal stone via cysto. with litho. Removed cath.

Question 2. 75 y.o. new pt. requires treatment for UTI determined by abn. C&S.

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

Question 4. PLIF at L5-S1.

Question 5. 67 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 BND with post op hematoma and wound breakdown, wound stable; cont wet to dry packing and f/u on Wed.

Question 9. IOL exchange. 65 y.o. est. pt. due to incorrect power.

Question 10. Repaired EPB, APL, BR, FDS ring, FDS long, PL, and FPL tendons.