Review - HITT 2231 - Med Term Advance (Plemons)

Modifying the anatomic structure of a body part without affecting the function of the body part

Principal purpose is to improve appearance

Examples Face lift, breast augmentation

Altering the route of passage of the contents of a tubular body part

Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes.

Examples Coronary artery bypass, colostomy formation

Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane

All change procedures are coded using the approach External.

Examples Urinary catheter change, gastrostomy tube change

Stopping, or attempting to stop, post-procedural bleeding

The site of the bleeding is coded as an anatomical region and not to a specific body part.

Examples Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage

Making a new structure that does not physically take the place of a body part

Used only for sex change operations where genitalia are made

Examples Creation of vagina in a male, creation of penis in a female

Eradicating all or a portion of a body part

Used for the actual physical destruction of all or a portion of a body part by the direct use of energy, force or a destructive agent. None of the body part is taken out.

Examples Fulguration of rectal polyp, cautery of skin lesion

Cutting off all or a portion of an extremity

Cutting off all or part of the upper or lower extremities

Examples Below knee amputation, disarticulation of shoulder

Expanding an orifice or the lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.

Examples Percutaneous transluminal angioplasty, pyloromyotomy

Separating, without taking out, a body part

All or a portion of the body part is separated into two or more portions.

Examples Spinal cordotomy, osteotomy

Taking or letting out fluids and/or gases from a body part

The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies.

Examples Thoracentesis, incision and drainage

Cutting out or off, without replacement, a portion of a body part

The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.

Examples Partial nephrectomy, liver biopsy

Taking or cutting out solid matter from a body part

The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out.

Examples Thrombectomy, choledocholithotomy

Pulling or stripping out or off all or a portion of a body part

The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies.

Examples Dilation and curettage, vein stripping

Breaking solid matter in a body part into pieces

The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions.

Examples Extracorporeal shockwave lithotripsy, transurethral lithotripsy

Joining together portions of an articular body part rendering the articular body part immobile

The body part is joined together by fixation device, bone graft, or other means.

Examples Spinal fusion, ankle arthrodesis

Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

Examples Insertion of radioactive implant, insertion of central venous catheter

Visually and/or manually exploring a body part

Visual exploration may be performed with or without optical instrumentation.Manual exploration may be performed directly or through intervening body layers.

Examples Diagnostic arthroscopy, exploratory laparotomy

Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Applicable only to the cardiac conduction mechanism and the central nervous system

Examples Cardiac mapping, cortical mapping

Completely closing an orifice or the lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice.

Examples Fallopian tube ligation, ligation of inferior vena cava

Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Vascular circulation and nervous pathways may or may not be reestablished.

Examples Reattachment of hand, reattachment of avulsed kidney

Freeing a body part

Eliminating an abnormal constraint of a body part by cutting or by use of force.Some of the restraining tissue may be taken out but none of the body part is taken out.

Examples Adhesiolysis, carpal tunnel release

Taking out or off a device from a body part

If taking out a device and putting in a similar device is performed with an external approach, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed.

Examples Drainage tube removal, cardiac pacemaker removal

Restoring, to the extent possible, a body part to its normal anatomic structure and function

Used only when the method to accomplish the repair is not one of the other root operations

Examples Herniorrhaphy, suture of laceration

Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part.

The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement.

Examples Total hip replacement, free skin graft

Moving to its normal location or other suitable location all or a portion of a body part.

The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location.

Examples Reposition of undescended testicle, fracture reduction

Cutting out or off, without replacement, all of a body part.

Total nephrectomy, total lobectomy of lung

Partially closing an orifice or the lumen of a tubular body part.

The orifice can be a natural orifice or an artificially created orifice.

Examples Esophagogastric fundoplication, cervical cerclage

Correcting, to the extent possible, a malfunctioning or displaced device.

Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin.

Examples Adjustment of pacemaker lead, adjustment of hip prosthesis

Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of the body.

The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part.

Examples Herniorrhapy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement, abdominal wall herniorrhaphy using mesh.

Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part.

The body part transferred remains connected to its vascular and nervous supply.

Examples Tendon transfer, skin pedicle flap transfer

Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part.

The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function.

Examples Kidney transplant, heart transplant

Excision Cutting out or off, without replacement, a portion of a body part

Resection Cutting out or off, without replacement, all of a body part

Detachment Cutting off all or a portion of an extremity

• Destruction Eradicating all or a portion of a body part
• Extraction Pulling or stripping out or off all or a portion of a body part

Drainage Taking or letting out fluids and/or gases from a body part

Extirpation Taking or cutting out solid matter from a body part

Fragmentation Breaking solid matter in a body part into pieces

Division Separating, without taking out, a body part

Release Freeing a body part

Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Transfer Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part

Reposition Moving to its normal location or other suitable location all or a portion of a body part

Restriction Partially closing an orifice or the lumen of a tubular body part

Occlusion Completely closing an orifice or the lumen of a tubular body part

Dilation Expanding an orifice or the lumen of a tubular body part

Bypass Altering the route of passage of the contents of a tubular body part

Insertion Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

Replacement Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part

Supplement Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of the body.

Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane

Removal Taking out or off a device from a body part

Revision Correcting, to the extent possible, a malfunctioning or displaced device

Inspection Visually and/or manually exploring a body part

Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function

Control Stopping, or attempting to stop, post-procedural bleeding

Fusion Joining together portions of an articular body part rendering the articular body part immobile

Alteration Modifying the anatomic structure of a body part without affecting the function of the body part

Creation Making a new structure that does not physically take the place of a body part

• Open
• Percutaneous
• Percutaneous Endoscopic

Via Natural or Artificial Opening

Via Natural or Artificial Opening Endoscopic

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure

Examples: Open CABG, Open endarerectomy, Open resection cecum, Abdominal hysterectomy

Entry, by puncture or minor incision, of instrumentation through the skin ormucous membrane and any other body layers necessary to reach the site of the procedure

Examples:  Percutaneous needle core, Biopsy kidney, Liposuction, Percutaneous drainage of ascites, Needle biopsy of liver

Entry, by puncture or minor incision, of instrumentation through the skin ormucous membrane and any other body layers necessary to reach and visualize the site of the procedure

Example: Laparoscopic Cholecystectomy, Laparoscopy with destruction of endometriosis, Endoscopic drainage sinus, Arthroscopy

Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure

Example:  Transurethral cystoscopy with removal bladder stone, Endoscopic ERCP, Hysteroscopy, EGD, Sigmoidoscopy

Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure

Example:  Laparoscopic-assisted, Vaginal hysterectomy (LAVH)

Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.

Examples:  Resection of tonsils, Closed reduction of fracture, Excision of skin lesion, Cautery nosebleed, Manual rupture joint adhesions, Reattachment severed ear

Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane

auscultation and percussion

arterial blood gas

acute myocardial infarction

atrial septal defect

atrioventricular

twice a day

bowel movement

basic metabolic panel

blood pressure

• benign prostatic hypertrophy;
• benign prostatic hyperplasia

blood urea nitrogen

with

culture & sensitivity

coronary artery bypass graft

computed axial tomography

coronary artery disease

complete blood count

chief complaint

congestive heart failure

carcinoma in situ

comprehensive metabolic panel

chronic obstructive pulmonary disease

computed tomography

cerebrovascular accident

dilation and curettage

diabetic ketoacidosis

digital rectal exam

electrocardiogram

electrocardiogram

electroencephalogram

electrocardiogram

extracorporeal shock wave lithotripsy

frozen section

gastroesophageal reflux disease

gastrointestinal

history & physical

hematocrit

head, eyes, ears, nose, throat

hemoglobin

hypertension

incision & drainage

kidneys, ureters, bladder

loop electrosurgical excision procedure

luteinizing hormone

magnetic resonance imaging

no known drug allergy

open reduction, internal fixation

after

posterior anterior

postanesthetic care unit

pupils equal, round, and reactive to light and accommodation

positron-emission tomography

percutaneous transluminal coronary angioplasty

partial thromboplastin time

every

review of systems

shortness of breath

immediately

tonsillectomy and adenoidectomy

transient ischemic attack

transurethral resection of the prostate

urinary tract infection

within normal limits

• this is standing erect, facing forward, arms at sides, palms forward, legs parallel, toes pointed forward; used for descriptions
• and studies of the body.

on back, with legs bent and separated, feet flat; used for obstetrics and gynecology

• on back, head of bed raised about 18 in., knees elevated; used to ease breathing
• and for drainage

• on back with shoulders elevated, legs flexed and thighs at right angles to the
• abdomen; used to introduce a tube into the urethra

• on knees, head and upper chest on table, arms crossed above head; used in
• gynecology and obstetrics and for flushing the intestine

on the side with one leg flexed; arm position may vary

on back legs flexed on abdomen, thighs apart, used for gynecologic and urologic surgery

• to clean; scraping of a wound using a spoon like cutting instrument called a
• curette; this is used in debridement

• removal of dead tissue from a wound or burn site to promote healing and prevent
• infection

destruction of tissue by freezing

red

sweat

tissue

fat

skin

fish

hard

white

black

fungus

nail

formation

purple

sebum (oil)

scale

hair

dry

yellow

bruise

wart; caused by a virus

mole with precancerous changes

crooked/stiff

humped-back

smooth

bent

loin

bone marrow or spinal cord

muscle

bone

knee cap

• hip bone/
• pelvic cavity

radius

rod shape striated(skeletal)

flesh

twisted

vertebra

sternum

tendon

chest

tone/tension

ulna

• •shoulder
• •pelvis
• •upper and lower extremities

• •skull
• •vertebral column
• •chest
• •hyoid bone

bones of arms and legs

bones of wrists and ankles

bones of ribs, shoulder blades, pelvis and skull

bones of vertebrae and face

round bones found near joints

surgical removal, excision, cutting out

stretching, dilation, enlargement

cutting, incision

new opening

suture

flow, discharge

bursting forth

drooping, sagging, prolapse

inflammation

condition, abnormal condition

tumour, cyst, hernia

tracing, picture, record

instrument for recording, picture

recording, process of recording a picture or record

viewer, instrument for visual examination

see, visual examination

stomach, belly

kidney

kidney

heart

skin

blood

left

sclera, white of eye, hard

horny, hard, cornea

nose

liver

right side

mouth

abdomen

pregnant woman

to bear

• S - Subjective (What the patient describes)
• O - Objective (Observable information)
• A - Assessment (Patient’s progress and evaluation of the plan’s effectiveness; any newfound problem or diagnosis is noted here)
• P - Plan (Decision to proceed or to alter the plan strategy)

• Also note:
• The SOAP method of documenting a patient’s progress is the most common.

The letters represent the order in which progress is noted as each complaint or problem is addressed.