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Medical Billing & Coding Basics

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    Introduction to Medical Terminology

    • Medical terminology is the language used by health care professionals to depict the human body, the body's systems, conditions, treatments, protocols and processes. It's derived from Greek/Latin and follows a systematic structure. The structure is based on the four distinct elements of the terms, which are the word root, prefix, suffix, and combining form. The word root is mostly found in the middle of the term and serves to identify its central meaning. The prefix is located before the word root and serves to convey additional information regarding the term (such as a specific region of the body). The suffix can be found at the end of a term and serves to illustrate distinct features; such as the status, development and practice relating to a medical condition.

      When it comes to medical terminology, you'll find that the combining form is mostly an "o" and typically located behind the prefix. Once you become familiar with commonly used elements, the terms become easier to identify. When you encounter a medical term, it's best to look at each of the structural components it holds. The educational website Thebody.com uses the term of the "pancytopenia" as an example. "Pan means "all" or "total," cyto refers to cells, and penia indicates a deficiency. So the definition of pancytopenia is a deficiency of all blood cells.

      There are many other websites devoted to medical terminology, and illustrate the parts of the word to help you see how they are constructed.

    Anatomy and Physiology Overview

    • Having a basic understanding of anatomy and physiology is necessary to interpret medical data. It also plays a big role when it comes to assigning codes; since the code manuals are divided by the different systems and parts of the human body. It's worth noting that anatomy refers to the structure of each of our body parts and connection they have to one another. Physiology, on the other hand, examines the functioning of the body's structures and the way they work. If you don't have a background in these subjects, it's a good idea to first familiarize yourself with the groups of systems that the body is divided into. This includes: the body structure/functions, cells/tssues/membranes, skeletal system, muscular system, nervous system, endocrine system, cardiovascular system, lymphatic system, respiratory system, digestive system, uinary system, and reproductive system.

    Medical Classifications and Coding Systems

    • As noted by Medical-Billing-coding.org, medical classification systems are used for: statistical analysis of diseases and therapeutic actions, reimbursement, examination of outbreaks, research, instruction and other relevant assessments. The American Health Information Management Association defines coding as the conversion of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric terms (www.ahima.org). Additionally, the codes must comply with all federal, legal and insurance regulations, agencies and providers.

      Although there are a number of coding systems that exist (depending on the specific field of medicine), the main ones that you'll want to know are: CPT (Current Procedural Terminology), HCPS (Healthcare Common Procedure Coding System) and ICD (International Statistical Classification of Diseases and Related Health Problems). Use the links below to gain a better understanding of the various coding systems and why they are used.

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