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EBook CPT Coding Essentials For Anesthesiology and Pain Management 2019 1St Edition Ebook PDF Version PDF Docx Kindle Full Chapter
EBook CPT Coding Essentials For Anesthesiology and Pain Management 2019 1St Edition Ebook PDF Version PDF Docx Kindle Full Chapter
Anesthesia and
Pain Management 2019
3
This page is left intentionally blank.
Introduction
Unlike other specialty coding books on the market, CPT® Coding specialty, nor all sites within impacted body systems. Similarly, the
Essentials for Anesthesia and Pain Management 2019 combines CPT to ICD-10-CM crosswalks are intended to illustrate those
anesthesia and pain management-specific procedural coding conditions that would most commonly present relative to the
and reimbursement information with verbatim guidelines procedure and the specialist. The crosswalks are not designed to
and parenthetical information from the Current Procedural be an exhaustive list of all possible conditions for each procedure,
Terminology (CPT®) codebook. Additionally, CPT® Coding nor medical necessity reasons for coverage.
Essentials for Anesthesia and Pain Management 2019 enhances that The “CPT Procedural Coding” section is complemented by
CPT-specific information by displaying pertinent diagnostic codes, other sections that review anesthesia and pain management ter-
procedural descriptions, illustrations, relative value units (RVUs), minology and anatomy, ICD-10-CM conventions and coding,
and more on the same page as the CPT code being explained. This ICD-10-CM documentation tips, and ICD-10 procedure coding
one book provides anesthesia and pain management coding and system (ICD-10-PCS) coding and format. The appendices contain
billing knowledge that otherwise might take years of experience data from the CMS National Correct Coding Initiative, multiple
or multiple resources to accumulate. It sets a foundation for ICD-10-CM compliant anesthesia and pain management condi-
anesthesia and pain management coders and subspecialty coding tion documentation checklists, and evaluation and management
experts that facilitates correct code assignment. (E/M) documentation guidelines.
This book includes reporting rules for CPT code submission as
written and enforced by the Centers for Medicare and Medicaid Sections Contained Within This Book
Services (CMS). CPT® Coding Essentials for Anesthesia and Pain
What follows is a section-by-section explanation of CPT® Coding
Management 2019 is not intended to equip coders with infor-
Essentials for Anesthesia and Pain Management 2019.
mation to make medical decisions or to determine diagnoses or
treatments; rather, it is intended to aid correct code selection that Terminology, Abbreviations, and Basic Anatomy
is supported by physician or other qualified health care profes- This section provides a quick reference tool for coders who may
sional (QHCP) documentation. This reference work does not come across unfamiliar terminology in medical record documen-
replace the need for a CPT codebook. tation. This review of basic terminology displays lists of alphabet-
ized Greek and Latin root words, prefixes, and suffixes associated
About the CPT® Coding Essentials with anesthesia and pain management.
Editorial Team and Content Selection The combination of root words with prefixes and suffixes is the
The CPT® Coding Essentials series is developed by a team of vet- basis of medical terminology and enables readers to deduce the
eran clinical technical editors and certified medical coders. When meaning of new words by understanding the components. For
developing the content of this book, the team members consider example, neuro is a root word for nerve, and –algia is a suffix for
all annual new, revised, and deleted medical codes. They adhere pain; thus, neuralgia describes nerve pain.
to authoritative medical research; medical policies; and official Also included in this section are a glossary of anesthesia and pain
guidelines, conventions; and rules to determine the final con- management-specific terms and a list of anesthesia and pain man-
tent presented within this book. Additionally, the team monitors agement acronyms and abbreviations. Keep in mind that these
utilization and denial trends when selecting the codes highlighted glossary definitions are anesthesia and pain management-specific.
in CPT® Coding Essentials for Anesthesia and Pain Management The same word may have a different meaning in a different spe-
2019. cialty. In some cases, a parenthetical phrase after the anesthesia
The main section of CPT® Essentials for Anesthesia and Pain and pain management term may provide the reader with a com-
Management 2019 is titled “CPT® Procedural Coding.” This section mon acronym or synonym for that term. Pay particular atten-
is organized for ease of use and simple lookup by displaying CPT tion to the use of capitalization in the abbreviation and acronym
codes in numeric order. Each code-detail page of this section presents list, as the same letters sometimes have varied meaning in clinical
a single code or multiple codes representing a code family concept. nomenclature, depending on capitalization.
The procedures featured in the CPT® Coding Essentials for Anesthesia Introduction to ICD-10-CM and ICD-10-PCS
and Pain Management 2019 are those commonly performed by an For coders who want a review, CPT® Coding Essentials for
anesthesiologist or pain management specialist, but more difficult Anesthesia and Pain Management 2019 recaps the development
to understand or miscoded in claims reporting. This book does of the ICD-10-CM and ICD-10-PCS code sets and outlines
not provide a comprehensive list of all services performed in the important concepts pertaining to the ICD-10-CM code set.
5
Introduction CPT® Coding Essentials for Anesthesia and Pain Management 2019
Lists of common diagnoses and conditions from the ICD-10-CM management conditions that require a high level of specificity for
code sets for each selected CPT code or code range may be found documentation and reporting.
within the “CPT Procedural Coding” section. The documentation information is presented in an easy-to-
The ICD-10-CM content provided within this book complements understand bulleted format that enables the physician, QHCP,
your use of the ICD-10-CM 2019 codebook. This section provides and/or coder to quickly identify the specificity of documentation
a chapter-by-chapter overview of ICD-10-CM that includes com- required for accurate ICD-10-CM code abstraction. This section
mon new diagnoses and their codes, as well as identification of new also includes coding exercises to assess mastery of the anesthesia
or substantially changed chapter-specific guidelines for 2019. and pain management documentation topic.
ICD-10-PCS was commissioned by CMS and developed by CPT® Procedural Coding
3M Health Information Systems for inpatient reporting of pro- “CPT Procedural Coding” is the main section of this book and
cedures to replace ICD-9-CM Volume 3. ICD-10-PCS is not displays pertinent coding and reimbursement data for each tar-
used for reporting physician services; however, an understand- geted CPT code or code family on code-detail pages. The follow-
ing of ICD-10-PCS is essential to physician practices because ing is presented within each surgical code detail page:
physician inpatient surgical documentation is used by hospitals
for the abstraction of ICD-10-PCS codes for hospital billing. • CPT code and verbatim description with icons (when
The nomenclature and structure of ICD-10-PCS diverges sig- required)
nificantly from ICD-9-CM Volume 3 and from CPT codes. An • Parentheticals (when they exist)
overview of this structure is reviewed in this section. • Official AMA Coding Guidelines
• Plain English descriptions
ICD-10-CM Anatomy and Physiology • Illustrations
Advanced understanding of the nervous system, anatomy and • ICD-10-CM diagnostic codes
pathophysiology is essential to accurate coding for anesthesia and • AMA CPT® Assistant newsletter references
pain management. A detailed study of the anatomy and physiol-
• CMS Pub 100 references
ogy of anesthesia and pain management gives beginner or inter-
• CMS base units or relative value units
mediate anesthesia and pain management coders the information
• CMS global periods
boost they may need to accurately abstract the medical record.
• CMS modifier edits
Neuron Category III codes and codes from diagnostic chapters will con-
Schwann tain a truncated version of the code-detail page content, as diag-
cell Myelin
sheath nostic tests are too broad for all data elements contained in the
Axon
code-detail pages.
Dendrite
AMA Coding Guidelines
The guidelines and parenthetical instructions included in the
CPT codebook provide coders with insight into how the AMA
Axon hillock
Axon CPT Editorial Panel and CPT Advisory Committee intend the
terminals
Membrane codes to be used. This information is critical to correct code selec-
Microtubules Nucleus tion, and until now, has been unavailable in books other than the
official AMA CPT codebook.
Nucleolus
Section guidelines for the pertinent sections of the CPT code-
book (Anesthesia, Surgery, Radiology, Pathology, and Medicine)
appear before the code-detail pages associated with the respec-
tive CPT section. Guidelines that appear elsewhere within a CPT
The anatomy and physiology explanations are accompanied by codebook section are displayed on the code-detail page, whenever
labeled and detailed illustrations for anesthesia and pain manage- appropriate. The reproduction of anesthesia and pain manage-
ment, beginning at the cellular level and extending to the func- ment coding guidelines and parenthetical information in CPT®
tions and interactions of the various body parts. This section also Coding Essentials for Anesthesia and Pain Management 2019 is ver-
includes discussion of common disorders of the nervous system batim from the AMA CPT codebook.
and other anatomical systems affected by anesthesia, their patho- CPT Codes and Descriptions
physiology, as well as coding exercises to assess mastery of the
CPT codes are listed in numerical order and include anesthesia,
anesthesia and pain management coding topic.
surgery, radiology, laboratory, and medicine codes pertinent to
ICD-10-CM Documentation anesthesia and pain management.
Accurate, complete coding of diseases, disorders, injuries, condi- The CPT code set has been developed as stand-alone descrip-
tions, and even signs and symptoms using ICD-10-CM codes tions of medical services. However, not all descriptions of CPT
requires extensive patient encounter documentation. This sec- codes are presented in their complete form within the code set. In
tion highlights commonly encountered anesthesia and pain some cases, one or more abbreviated code descriptions (known as
6
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Introduction
child codes) appear indented and without an initial capital letter. a CPT code is the subject of discussion in a past issue of CPT®
Such codes refer back to a common portion of the preceding code Assistant, the volume and page numbers are noted beneath the
description (known as a parent code) that includes a semi-colon (;) code to direct readers to the relevant newsletter archives to keep
and includes all of the text prior to the semi-colon. An example of abreast of compliant coding rules.
this parent–child code system follows:
Plain English Description
00120 Anesthesia for procedures on external, middle, and A simple description of what is included in the service repre-
inner ear including biopsy; not otherwise specified sented by each CPT code is provided as a guide for coders to
00124 otoscopy select the correct CPT code while reading the medical record.
Not all approaches or methodologies are described in the Plain
00126 tympanotomy
English Description; rather, the most common approaches or
The full descriptions for indented codes 00124 and 00126 are: methodologies are provided. In some cases, the description pro-
00124 Anesthesia for procedures on external, middle, and inner vides an overview to more than one code, as some code-detail
ear including biopsy; otoscopy pages have multiple codes listed.
00126 Anesthesia for procedures on external, middle, and inner Illustrations
ear including biopsy; tympanotomy Streamlined line drawings demonstrate the anatomical site of the
When a group of similar codes is found on a code-detailed page in procedure, illustrating the basics of the procedure to assist in code
CPT® Essentials, a full description of each code will be displayed. selection. In some cases, not all codes on the code-detail page and
not all approaches or methodologies are captured in the single
Icons illustration.
Icons on the code-detail page may affect ICD or CPT codes. The
Diagnostic Code Crosswalk
male (|) and female (~) edit icons are applied to ICD codes. New
ICD-10-CM codes commonly associated with the service repre-
or revised CPT codes are identified with a bullet (●) or triangle
sented on the code-detail page are listed with their official code
(▲), respectively. The plus sign (Ã) identifies add-on codes. Add-
descriptions. Keep in mind that in some cases, only the most com-
on codes may never be reported alone, but are always reported
mon diagnoses for a procedure are listed due to space constraints.
secondarily to the main procedure, and should never be reported
with modifier 51, Multiple Procedures. While most codes support the medical necessity of the procedure
performed, medical necessity rules vary by payer, and the accept-
A bullet with the numeral 7 within it (7) is displayed next to
ability of these diagnoses for medical necessity purposes cannot
ICD-10-CM codes that require a seventh character. Consult the
be guaranteed.
ICD-10-CM codebook for appropriate seventh characters.
The mappings from CPT to ICD-10-CM in CPT® Coding Essentials
The bolt symbol (~) identifies CPT codes for vaccines pending
for Anesthesia and Pain Management 2019 were prepared by clinical
FDA approval.
coding experts.
The star symbol (Í) identifies CPT codes that may be used to
The most common ICD-10-CM codes appropriate to the proce-
report telemedicine services when appended by modifier 95.
dure or services represented on the code-detail page are provided.
The right/left arrows symbol (⇄) identifies where the full range of When a seventh character is required for a code, a bullet with
lateral codes would be appropriate. In an effort to conserve space the numeral 7 within it (7) alerts the coder. Sometimes, a sev-
in the CPT® Coding Essentials series, we have chosen to use this enth character is appended to a code with only three, four, or five
icon to denote laterality. characters. In those cases, place holding Xs are to be appended to
New to this 2019 edition of the CPT® Coding Essentials series is the codes so that only the seventh character must be added. For
an icon () to denote the CPT® QuickRef, a mobile app created example, the following ICD-10-CM diagnosis code:
by the AMA and available from the App Store and Google Play. T88.4 Failed or difficult intubation
The icon indicates that additional dynamic information can be
requires a seventh character; therefore, it is displayed with six
accessed within the app (in-app purchases required).
characters in this manner:
Parenthetical Information (7) T88.4XX Failed or difficult intubation
The CPT code set sometimes provides guidance in the form of a
parenthetical instruction. For example: Within ICD-10-CM, many diagnoses have different codes based on
laterality (for example, right plantar nerve, left plantar nerve, unspec-
(For donor nephrectomy, use 00862) ified plantar nerve). Due to space constraints, not every laterality
Code-detail pages include parenthetical instructions specific to code is listed. Rather, a representative code is listed along with an
both the code and the section within which the code is placed icon indicating that other laterality code versions are available.
within the CPT code set. Not all codes and/or sections have asso- The provided crosswalks are not meant to replace your ICD-10-CM
ciated parenthetical statements. codebook. Please consult your manual for all seventh characters
CPT® Assistant References needed to complete listed codes and additional laterality choices, as
CPT® Assistant is a monthly newsletter published by the AMA well as ICD-10-CM coding conventions essential to proper use.
that provides supplemental guidance to the CPT codebook. If
7
Introduction CPT® Coding Essentials for Anesthesia and Pain Management 2019
Pub 100 ultrasound CPT code as the physician, but the physician would use
CMS Pub 100 (Publication 100-04, “Medicare Claims Processing modifier 26 to indicate the professional component only, and the
Manual”) is an online resource of federal coding regulations that technician would report modifier TC, which is a Healthcare Com-
often relate to CPT coding. If a CPT code or its associated proce- mon Procedure Coding System (HCPCS) Level II modifier identify-
dure is the topic of discussion in a CMS Pub 100 entry, the Pub 100 ing the service as the technical portion only. If the physician performs
reference is noted so that coders may access it online at www.cms. the ultrasound and interprets the results, no modifier is required.
gov/regulations-and-guidance/guidance/manuals/internet-only- When such circumstances affect the code, users may find the
manuals-IOMs.html. payment information provided for the full code, the professional
Payment Grids services–only code, and the technical component–only code.
Information in the payment grids that appear on the code-detail Many modifiers affect payment for services or with whom
pages comes from CMS. These grids identify the base units used payment is shared when multiple providers or procedures are
to compute allowable amounts for anesthesia services or the rela- involved in a single surgical encounter. CMS provides definitions
tive value of providing a specific professional service in relation to for the payments, based on the number listed in the modifier’s field.
the value of other services, the number of postoperative follow-up
Modifier 50 (bilateral procedure)
days associated with each CPT code, and other reimbursement
edits. All data displayed in the payment grids are relevant to phy- 0 150% payment adjustment for bilateral procedures does not
sicians participating in Medicare. apply. If a procedure is reported with modifier 50 or with modi-
fiers RT and LT, Medicare bases payment for the two sides on the
Global Period lower of (a) the total actual charge for both sides or (b) 100% of
During the follow-up, or global surgery period, any routine care the fee schedule amount for a single code. For example, the fee
associated with the original service is bundled into the original schedule amount for code XXXXX is $125. The physician reports
service. This means that, for example, an evaluation and manage- code XXXXXLT with an actual charge of $100 and XXXXXRT
ment (E/M) visit to check the surgical wound would not be bill- with an actual charge of $100.
able if occurring during the global surgery period. Payment would be based on the fee schedule amount ($125)
Possible global periods under Medicare are 0, 10, and 90 days. XXX because it is lower than the total actual charges for the left and
indicates that the global period concept does not apply to the service. right sides ($200). The bilateral adjustment is inappropriate for
codes in this category (a) due to physiology or anatomy or (b)
Base Units because the code descriptor specifically states that it is a unilateral
All Anesthesia charges are based on units. Base unit amounts are procedure and there is an existing code for the bilateral procedure.
published yearly and are based on the complexity of the case and
1 150% payment adjustment for bilateral procedures applies. If
the expected workload of the anesthesia provider required to per-
a code is billed with the bilateral modifier or is reported twice
form the work. Base units are then added to time units and then
on the same day by any other means (such as with RT and LT
any modifiers to derive payment.
modifiers or with a 2 in the units field), payment is based for
Relative Value Units (RVUs) these codes when reported as bilateral procedures on the lower of
Relative value unit (RVU) data shows the breakout of work, (a) the total actual charge for both sides or (b) 150% of the fee
practice expense (PE), and malpractice expense (MP) associated schedule amount for a single code. If a code is reported as a bilat-
with a code, and provides a breakout for the service depending eral procedure and is reported with other procedure codes on the
on whether it was performed in the physician’s office or in a facil- same day, the bilateral adjustment is applied before any applicable
ity not belonging to the physician. Understandably, the physi- multiple procedure rules are applied.
cian payment for a surgical procedure is reduced if a procedure is 2 150% payment adjustment for bilateral procedure does not apply.
hosted by a facility, as the facility would expect payment to cover RVUs are already based on the procedure being performed as a bilat-
its share of costs. A physician who performs the surgery in his or eral procedure. If a procedure is reported with modifier 50, or is
her own office is not subject to the same cost-sharing. This cost reported twice on the same day by any other means (such as with
difference shows up in the PE column. RT and LT modifiers with a 2 in the units field), payment is based
The payment information provided is sometimes used to set rates for both sides on the lower of (a) the total actual charges by the phy-
or anticipate payments. Payment information may be affected by sician for both sides, or (b) 100% of the fee schedule amount for a
modifiers appended to the CPT code. single code. For example, the fee schedule amount for code YYYYY
is $125. The physician reports code YYYYYLT with an actual charge
Modifiers of $100 and YYYYYRT with an actual charge of $100.
Sometimes, modifiers developed by the AMA and by CMS may be Payment would be based on the fee schedule amount ($125)
appended to CPT codes to indicate that the services represented by because it is lower than the total actual charges for the left and
the codes have been altered in some way. For example, modifier 26 right sides ($200). The RVUs are based on a bilateral procedure
reports the professional component of a service that has both a pro- because (a) the code descriptor specifically states that the proce-
fessional and a technical component. A patient who undergoes an dure is bilateral, (b) the code descriptor states that the procedure
ultrasound might have a technician perform the ultrasound itself, may be performed either unilaterally or bilaterally, or (c) the pro-
while the physician interprets the ultrasound results to determine a cedure is usually performed as a bilateral procedure.
diagnosis. The technician’s service would be reported with the same
8
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Introduction
3 The usual payment adjustment for bilateral procedures does not same group practice using the same group National Provider
apply. If a procedure is reported with modifier 50, or is reported Identifier [NPI]) to the same beneficiary on the same day, effec-
for both sides on the same day by any other means (such as with tive for services July 1, 2010, and after. Physician Component
RT and LT modifiers or with a 2 in the units field), Medicare (PC) of diagnostic imaging services are subject to a 25% payment
bases payment for each side or organ or site of a paired organ on reduction of the second and subsequent imaging services effective
the lower of (a) the actual charge for each side or (b) 100% of the Jan. 1, 2012.
fee schedule amount for each side. If a procedure is reported as a 5 Selected therapy services are subject to MPPR methodology.
bilateral procedure and with other procedure codes on the same Therapy services are subject to 20% of the Practice Expense (PE)
day, the fee schedule amount for a bilateral procedure is deter- component for certain therapy services furnished in office or
mined before any applicable multiple procedure rules are applied. other non-institutional settings, and a 25% reduction of the PE
Services in this category are generally radiology procedures or component for certain therapy services furnished in institutional
other diagnostic tests that are not subject to the special payment settings. Therapy services are subject to 50% reduction of the PE
rules for other bilateral procedures. component for certain therapy services furnished in both institu-
9 Concept does not apply. tional and non-institutional settings.
Modifier 51 (multiple procedures) 6 Diagnostic services are subject to the MPPR methodology. Full
This modifier indicates which payment adjustment rule for mul- payment is made for the TC service with the highest payment under
tiple procedures applies to the service. the Medicare Physician Fee Schedule (MPFS). Payment is made at
75% for subsequent TC services furnished by the same physician
0 No payment adjustment rules for multiple procedures apply. If (or by multiple physicians in the same group practice using the
the procedure is reported on the same day as another procedure, same group NPI) to the same beneficiary on the same day.
payment is based on the lower of (a) the actual charge or (b) the
fee schedule amount for the procedure. 7 Diagnostic ophthalmology services are subject to the MPPR
methodology. Full payment is made for the TC service with the
1 This indicator is only applied to codes with a procedure status highest payment under the MPFS. Payment is made at 80% for
of “D.” If a procedure is reported on the same day as another subsequent TC services furnished by the same physician (or by
procedure with an indicator of 1, 2, or 3, Medicare ranks the pro- multiple physicians in the same group practice using the same
cedures by the fee schedule amount, and the appropriate reduc- group NPI) to the same beneficiary on the same day.
tion to this code is applied (100%, 50%, 25%, 25%, 25%, and
by report). Carriers and Medicare Administrative Contractors 9 Concept does not apply.
(MACs) base payment on the lower of (a) the actual charge or (b) Modifier 62 (two surgeons)
the fee schedule amount reduced by the appropriate percentage. This field provides an indicator for services for which two sur-
2 Standard payment adjustment rules for multiple procedures geons, each in a different specialty, may be paid.
apply. If the procedure is reported on the same day as another 0 Co-surgeons not permitted for this procedure.
procedure with an indicator of 1, 2, or 3, carriers and MACs rank
the procedures by the fee schedule amount and apply the appro- 1 Co-surgeons could be paid. Supporting documentation is
priate reduction to this code (100%, 50%, 50%, 50%, 50%, and required to establish medical necessity of two surgeons for the
by report). MACs base payment on the lower of (a) the actual procedure.
charge or (b) the fee schedule amount reduced by the appropriate 2 Co-surgeons permitted. No documentation is required if two
percentage. specialty requirements are met.
3 Special rules for multiple endoscopic procedures apply if a pro- 9 Concept does not apply.
cedure is billed with another endoscopy in the same family (that
is, another endoscopy that has the same base procedure). The base Modifier 66 (surgical team)
procedure for each code with this indicator is identified in field This field provides an indicator for services for which team sur-
31G of Form CMS-1500 or its electronic equivalent claim. The geons may be paid.
multiple endoscopy rules apply to a family before ranking the 0 Team surgeons not permitted for this procedure.
family with other procedures performed on the same day (for
1 Team surgeons could be paid. Supporting documentation is
example, if multiple endoscopies in the same family are reported
required to establish medical necessity of a team; paid by report.
on the same day as endoscopies in another family or on the same
day as a non-endoscopic procedure). If an endoscopic procedure 2 Team surgeons permitted; paid by report.
is reported with only its base procedure, the base procedure is not 9 Concept does not apply.
separately paid. Payment for the base procedure is included in the
payment for the other endoscopy. Modifier 80 (assistant surgeon)
This field provides an indicator for services for which an assistant
4 Diagnostic imaging services are subject to Multiple Procedure
at surgery is never paid.
Payment Reduction (MPPR) methodology. Technical Compo-
nent (TC) of diagnostic imaging services are subject to a 50% 0 Payment restriction for assistants at surgery applies to this pro-
reduction of the second and subsequent imaging services fur- cedure unless supporting documentation is submitted to establish
nished by the same physician (or by multiple physicians in the medical necessity.
9
Introduction CPT® Coding Essentials for Anesthesia and Pain Management 2019
10
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Introduction
RVUs are national Medicare relative
Official CPT code description(s) Citations for CPT® Assistant are value units, or a breakdown of the
Master code or code family
for the master code(s) enable provided so coders know when costs of medical care based on
for this code-detail page. All
coders to double-check their to seek further information from CPT code. Physician work, practice
information on this page links to
CPT
code selections.
®
Coding Essentials for Anesthesia & Pain Management this authoritative reference.
2019 36430 expense,
expense, malpractice
or crosswalks to this code(s).
and total expense differ for facility
● New ▲ Revised à Add On Modifier 51 Exempt ÍTelemedicine CPT QuickRef ~FDA Pending ⇄ Laterality 7Seventh Character |Male ~Female
CPT © 2018 American Medical Association. All Rights Reserved. 483
11
Introduction CPT® Coding Essentials for Anesthesia and Pain Management 2019
12
Terminology
Terminology&&Abbreviations
Terminology, Abbreviations, and Basic Anatomy
Abbreviations
The Terminology, Abbreviations, and Basic Anatomy chapter can Root Words/Combining Forms
be used as a reference tool if there is confusion when reading abdomin/o abdomen
medical record documentation and when a more extensive acous/o hearing
understanding of medical terminology is needed. The following
acr/o extremities, top, extreme point
includes terms, abbreviations, symbols, prefixes, suffixes, and
anatomical illustrations that will help clarify some of the more aden/o gland
difficult issues, and give a firmer understanding of information, adip/o fat
that is in medical record documentation. andr/o male
ankyl/o stiff, bent, crooked
Medical Terminology anter/o front
A majority of medical terms are composed of Greek and Latin arthr/o joint
word parts and are broken down into different elements. One ather/o yellowish, fatty plaque
element is the root word. The root word is the foundation of audi/o hearing
the medical term and contains the fundamental meaning of the aur/o ear
word. All medical terms have one or more roots. aut/o self
Examples: axill/o armpit
hydr = water balan/o glans penis
bi/o life
lith = stone
blast/o developing cell
path = disease
blephar/o eyelid
Combining forms (or vowel, usually “o”) links the root word to brach/o arm
the suffix or to another root word. This combining vowel does
bronch/o bronchial tubes
not have a meaning on its own; it only joins one part of a word
to another. carcin/o cancer
card/o heart
Prefixes and suffixes are two of the other elements used in medical cheil/o lip
terminology and consist of one or more syllables (prepositions or
chol/o gall, bile
adverbs) placed before or after root words to show various kinds
of relationships. Prefixes are before the root word and suffixes are cholangi/o bile duct
after the root word and consist of one or more letters grouped chondr/o cartilage
together. They are never used independently; however, they can cis/o to cut
modify the meaning of the other word parts. Many prefixes and colp/o vagina
suffixes are added to other words with a hyphen, but medical coron/o heart
dictionary publishers are opting to drop the hyphen on many of cost/o ribs
the more common prefixed medical words.
crani/o skull
Examples: cry/o cold
Prefixes: cutane/o skin
micro = small cyan/o blue
peri = surrounding cyt/o cell
Suffixes: cyst/o urinary bladder
dacry/o tear duct, tear
algia = pain
derm/o skin
an = pertaining to
dermat/o skin
The following are lists of prefixes and suffixes typically seen in dipl/o double, two
Anesthesia/Pain Management:
dips/o thirst
dist/o distant, far
13
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
14
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
15
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
16
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
Edema – Swelling; generally, an abnormal accumulation of body Migraine with Aura – Symptoms are the same as a migraine
fluids, often accompanying inflammation. without aura. In addition, the migraine is accompanied by visual,
sensory, or speech disorders.
Endorphin – A substance the body manufactures that acts like
morphine in the brain and central nervous system. This natural Migraine without Aura – The most common type of migraine.
pain-relieving agent can be stimulated by exercise. Symptoms typically include: unilateral headache, pulsating
pain, moderate to severe in intensity, aggravated by physical
17
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
activity, associated with nausea/vomiting, sensitivity to light Physiological Dependence – A condition that occurs with
(photophobia) and/or sound (phonophobia), duration typically opioids and other drugs whereby the body becomes accustomed
4-72 hours. to a chemical. Often confused with addiction or psychological
Myopathy – Any abnormal disease or condition of muscle tissue, dependence, this condition is common and not associated with
often involving pain. drug abuse. The hallmark of physiological dependence is the need
to avoid abrupt discontinuation of the drug, which will cause a
Myotome – A term related to sections of the body that are predictable withdrawal syndrome. Discontinuation of the drug
associated with a muscle or muscle group including the insertions can be easily accomplished by tapering the dose of the medication
sites at either end of the muscle fibers. slowly under the direction of the physician.
Nervous System – The organs and tissues of the body that provide Posterior – Close to, or at the back of the body. Also called
for communication with other body systems and including “dorsal.”
the higher centers of reasoning; the brain and spinal cord are
components of the central nervous system, and the nerves outside Pruritus – Itching.
those structures make up the peripheral nervous system. Pseudoaddiction – A drug seeking behavior pattern of pain
Neuralgia – Pain in the distribution of a specific nerve or nerves. patients who are not getting adequate pain relief. For example, a
patient is given a pain pill that only last for four hours, but only
Neuritis – Acute and/or chronic inflammation of nerves. allowed to take it every six hours. This behavior can be mistaken
Neuropathic Pain – Pain syndrome in which the predominant for addiction and other psychological and behavioral factors,
mechanism is aberrant somatosensory processing. May be including overwhelming obsession with obtaining and using
restricted to pain originating in peripheral nerves and nerve roots. drugs, despite harm to self or others. Addiction is feared, but very
rare in chronic pain analgesic users. Also known as “psychological
Neuropathy – A functional disturbance or pathological change
dependence.”
in the peripheral nervous system, sometimes limited to non-
inflammatory lesions as opposed to neuritis. Psychosomatic – A term used to describe a physical disorder
thought to be caused partly or entirely by psychological problems.
Nociceptor – A receptor for pain, preferentially sensitive to a
noxious stimulus or to a stimulus that would become noxious if Radiculalgia – Pain along the distribution of one or more sensory
continued. Pain is a perception that takes place at higher levels of nerve roots.
the central nervous system. Radiculitis – Inflammation of one or more nerve roots.
Non-Steroidal Anti-inflammatory Drug (NSAID) – This is a Radiculopathy – A usually painful disturbance of function or
specific class of drugs that reduces inflammation and swelling pathologic change in one or more spinal nerve roots.
in and around the site of injury or irritation. These drugs (such
as ibuprofen) are widely used in acute pain management and in Referred Pain – Pain that is felt in a place different from the place
chronic inflammatory conditions such as arthritis. of origin. For example, pain from pressure in the liver is often felt
in the right upper chest or shoulder.
Noxious Stimulus – Stimulus that is potentially or actually
damaging to body tissue. Somatosensory – Pertaining to sensations received from all
tissues of the body (skin, muscles).
Opioid – A narcotic used to help treat pain.
Sonogram – Using high frequency sound waves. Also a technique
Osteoarthritis – The most common form of arthritis often to apply heat during physical therapy.
associated with aging. It may occur in one joint or in many and is
Titration – Increasing or decreasing a medication in an
often degenerative in nature.
incremental manner, to reach a desired level. This method is used
Pain – Sensation of discomfort, distress, or agony, resulting to allow the body to adjust, or to find an effective dose. Titration
from the stimulation of specialized nerve endings. It serves is used with anti-depressants, steroids, opioids and other drugs.
as a protective mechanism (induces the sufferer to remove or
Tolerance – A physiological phenomenon that develops in some
withdraw).
patients with long term opioid use where the body requires
Pain Threshold – Pain threshold is the least experience of pain increasing amounts of drug to achieve the same level of effect.
that a subject can recognize. There are several theories that may explain tolerance including the
Pain Tolerance Level – The greatest level of pain that a patient body becoming a more effective metabolizer of the medication,
is able to tolerate. and the body making less receptor sites for a drug after long
exposure. Often confused with addiction.
Paresthesia – An abnormal sensation, such as burning, or
prickling, that may be spontaneous or in response to stimulus. It Transcutaneous Electrical Nerve Stimulation (TENS) – A
has the same clinical limitations as the pain tolerance level. cutaneous intervention that relieves pain by sending electrical
stimulation to nerve fibers and interfering with pain signal
Patient-Controlled Analgesia (PCA) – An intravenous drug
transmission. This method employs electrodes placed on the skin
delivery system, generally used after surgery, that allows patients
in various locations, using various degrees of intensity to achieve
to control the amount of pain medicine they receive, by pushing
pain relief.
a button that causes the system to administer a dose of medicine.
Patients are taught to administer pain medication depending on Transdermal – Referring to delivery through the skin. Patches
the level of pain. This method has been shown to provide effective that deliver medication are transdermal.
pain relief using less medication.
18
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
A&P anterior and posterior; auscultation and percussion ASCVD arteriosclerotic cardiovascular, disease
ab away from, Abductor, (leading away from); aboral (away from mouth) AU both ears
ACT anticoagulant therapy; active motion bi twice, double Biarticulate (double joint); bifocal (two foci); bifurcation
(two branches)
ACTH adrenocorticotropic hormone
BID twice a day
Ad to, toward, near to, Adductor, (leading toward); adhesion, (sticking to);
adnexa (structures joined to); adrenal (near the kidney) bilat bilateral
Ambi both, Ambidextrous, (ability to use hands equally); ambilateral (both sides) C&S culture and sensitivity
Amphi about, on both sides, both, Amphibious, (living on both land and water) Ca calcium, cancer, carcinoma
19
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
20
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
21
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
22
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
23
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
24
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
25
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
Anatomical Planes
26
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
Male Figure
(Anterior View)
Parietal region
Frontal region
Orbital region Temporal region
Nasal region
Oral region
Mental region
Anterior neck region
Lateral neck region
Infraclavicular region
Deltoid region
Sternal region
Pectoral region Axillary region
Brachial region
Hypochondriac region
Cubital region Epigastric region
Umbilical region
Antebrachial region Lateral abdominal region
Inguinal region
Pubic region
Femoral region
Knee region
Crural region
27
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
Female Figure
(Anterior View)
Parietal region
Frontal region
Orbital region Temporal region
Nasal region
Oral region
Mental region
Anterior neck region
Lateral neck region
Infraclavicular region
Deltoid region
Sternal region
Pectoral region Axillary region
Brachial region
Hypochondriac region
Epigastric region
Cubital region
Umbilical region
Antebrachial region Lateral abdominal region
Inguinal region
Pubic region
Femoral region
Knee region
Crural region
28
CPT® Coding Essentials for Anesthesia and Pain Management 2019 Terminology, Abbreviations, and Basic Anatomy
Frontalis m.
Temporalis m.
Orbicularis oculi m. Zygomaticus minor m.
Zygomaticus major m.
Masseter m. Orbicularis oris m.
Buccinator m. Depressor anguli oris m.
Sternocleidomastoid m.
Levator scapulae m.
Trapezius m.
29
Terminology & Abbreviations Terminology, Abbreviations, and Basic Anatomy CPT® Coding Essentials for Anesthesia and Pain Management 2019
Skeletal System
(Vertebral Column – Left Lateral View)
Atlas (C1)
Axis (C2)
C7
T1
Intervertebral discs
T12
L1
Intervertebral foramina
L5
Sacrum
Pelvic curve
Coccyx
30
Another random document with
no related content on Scribd:
DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.