Procedure Desk Reference

2015

More than 9,000 CPT® codes defined with coding tips.

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Table of ContentsIntroduction:

• Features ����������������������������������������������������� ii

Evaluation and Management Survival Guide � � � � � � � � � � � � � � � � � � � � � 1

Modifier Lay Terms and Explanations � � � � � � � � � � � � � � � � � � � � � � 71

Introduction to Surgical Coding and Surgical Terms � � � � � � � � � � � � � � � � 95

Procedure Eponyms� � � � � � � � � � � � � � � � 99

Basic Types of Anesthesia � � � � � � � � � 102

Normal Lab Values and Vital Signs� � � 104

Billing, Coding, and Reimbursement Terms � � � � � � � � � � � � 235

Abbreviations � � � � � � � � � � � � � � � � � � � � 288

Anatomical Illustrations� � � � � � � � � � � � 296

Lay Terms for Procedures and Services

• Evaluation and Management������������������ 329

• Anesthesia���������������������������������������������� 339

• Surgery

o Surgery/General ��������������������������������� 340

o Surgery/Integumentary System ���������� 341

o Surgery/Musculoskeletal System ������� 368

o Surgery/Respiratory System �������������� 488

o Surgery/Cardiovascular System ��������� 513

o Surgery/Hemic and Lymphatic Systems ���������������������������������������������� 574

o Surgery/Mediastinum and Diaphragm ������������������������������������������ 579

o Surgery/Digestive System ������������������ 580

o Surgery/Urinary System ��������������������� 643

o Surgery/Male Genital System ������������� 673

o Surgery/Female Genital System �������� 685

o Surgery/Maternity Care and Delivery � 712

o Surgery/Endocrine System ����������������� 724

o Surgery/Nervous System ������������������� 727

o Surgery/Eye and Ocular Adnexa �������� 773

o Surgery/Auditory System �������������������� 791

o Surgery/Operating Microscope ����������� 798

• Radiology ����������������������������������������������� 799

• Pathology and Laboratory ���������������������� 856

• Medicine ����������������������������������������������� 1020

• Category III codes �������������������������������� 1089

Medical Terms Glossary � � � � � � � � � � 1107

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or qualified healthcare professional who is actually providing management of some or all of a patient’s problem who actually is giving up this liabilities to another physician or other qualified healthcare professional who is certainly agrees to take this liability and who, from the initial visit, is not providing consultative services.

Remember: Consultation codes (99241-99255) should not be reported by physician or qualified healthcare professional who has already agreed to accept transfer of care before an initial visit, but it can be appropriate to report if decision to accept transfer of care can’t be made until after the initial consultation evaluation, in spite of type of service.

•• Counseling — a discussion with a patient and/or family concerning one or more of the following:

•♦ Diagnostic results, impressions and/or recommended diagnostic•♦ Studies prognosis•♦ Risks and benefits of treatment options•♦ Instructions for treatment and/or follow up•♦ Importance of compliance with chosen treatment options•♦ Risk factor reduction•♦ Patient and family education•♦ Patient or family questions

•• Family history — a review of medical events in the patient’s family that includes significant information about the following:

•♦ The health status or cause of death of parents, siblings and children•♦ Specific diseases related to problems identified in the chief complaint or history •♦ of present illness and/or system review•♦ Diseases of family members that may be hereditary or place the patient at risk

•• History of present illness (HPI) — a chronological description of the development of the patients present illness from the first sign and/or symptom to the present; this includes a description of location, quality, duration, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s)

•• Past history — a review of the patients past experiences with illnesses, injuries and treatments that includes significant information about prior major illnesses and injuries; prior operations; prior hospitalizations; current medications; allergies (drugs, food, etc.); age-appropriate immunization status; and age-appropriate feeding/dietary status

•• Social history — an age-appropriate review of past and current activities that includes significant information about marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol and tobacco; education level; sexual history; and other relevant social factors

•• System review — an inventory of body systems obtained through a series of questions to identify the signs and/or symptoms that the patient is/was experi encing; this helps define the problem, clarify the differential diagnosis, identify needed testing, or serve as baseline data for other systems that might be affected by any possible treatment options; the body systems are:

•♦ Constitutional symptoms (fever, weight loss, etc.)

•♦ Eyes•♦ Ears, nose, mouth and throat•♦ Cardiovascular•♦ Respiratory•♦ Gastrointestinal•♦ Genitourinary•♦ Musculoskeletal•♦ Integumentary (skin and/or breast)•♦ Neurological•♦ Psychiatric•♦ Endocrine•♦ Hematologic/lymphatic•♦ Allergic/immunologic.

Classification of E/M ServicesCPT® divides E/M services into office visits, hospital visits,

and consultations. These categories are further divided — office visits into new or established patients; hospital visits into initial and subsequent; and consultations into outpatient and inpatient. CPT® further divides such categories and subcategories based on the type and place of service and the patient’s status.

Keep in mind: A patient’s status may be more important in determining the correct E/M category than the patient’s location.

A patient in the inpatient bed might actually be a patient under observation for which the codes are different (99218-99220) and you cannot report the inpatient care codes (99221-99233).

CPT® uses the same basic format to describe the E/M service levels for most categories:

1. Listing a unique code;2. Specifying the place and/or type of service; for example, an

outpatient consultation;

3. Defining the services content; for example, a comprehensive history, comprehen sive examination and moderate medical decision-making;

4. Describing the nature of the presenting problem(s) usually associated with a given level; and specifying the time typically associated with the service.

Levels of E/M ServiceThere are three to five E/M service levels available for reporting

purposes within each E/M code category or subcategory. Levels of E/M services are not interchangeable among the different categories or subcategories. For example you may get different definitions between the new patient and established patient for the first levels of E/M services in the subcategory of office visit.

The levels of E/M services constitutes wide instance of change in skills, time, effort, responsibility, and medical knowledge required for the treatment of illness or injury or for the forestalling or diagnosis and the advancement of optimal health. Each E/M level of service may be used by all physicians or other qualified healthcare professionals. There are seven components recognizes for descriptors of E/M level, six of which are used for defining the E/M levels of services. These are:

1. History2. Examination3. Medical decision-making4. Counseling5. Coordination of care6. Nature of presenting problem7. Time

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The first three of these components (history, examination and medical decision making) are considered the key components when selecting an E/M service level.

The next three components (counseling, coordination of care and the nature of the presenting problem) are considered contributory factors in most encounters. Although the first two of these contributory factors are important E/M services, the healthcare provider doesn’t need to provide them at every patient encounter.

Important: You can report case management codes if coordination of care is done with other physicians/other healthcare professionals/agencies without patient visit on that day.

The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the E/M service levels. You may separately report your physician’s performance of diagnostic tests/studies for which specific CPT® codes are available, in addition to the appropriate E/M code. In addition, you may separately report the physicians interpretation of diagnostic tests/studies results with preparation of a separate distinctly identifiable signed written report using the appropriate CPT® code with modifier 26 (Professional component).

Different diagnosis not required on the day of E/M and procedure: If you found that the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the postop care associated with the procedure that was performed, you can be reported by adding modifier 25 to the appropriate E/M service (The E/M service may be caused or prompted by the symptoms or conditions) for which the procedure and/or service was provided. In this case, different diagnoses may not require for reporting of the procedure and E/M services on the same date.

Nature of Presenting ProblemA presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for an encounter with a healthcare provider, with or without a diagnosis being established at the time of the encounter. E/M codes recognize the following five types of presenting problems:

•• Minimal — a problem that may not require the physician’s presence, but the service is provided under the physician’s or other qualified healthcare professional’s supervision (for example, drawing blood for lab work).

•• self-limited or minor — a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with treatment/compliance (such as an insect bite).

•• Low severity — a problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected (for instance, sinusitis).

•• Moderate severity — a problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis or increased probability of prolonged functional impairment (for example, heart attack).

•• High severity — a problem for which the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment or high probability of severe, prolonged functional impairment (such as with sepsis).

Determining Levels of Physical Examinations during E/M Services

Using either the 1995 or 1997 guidelines, you should measure physical examinations during E/M services using the following standards:

•• A problem-focused examination, according to the 1995 guidelines, is a limited examination of the affected body area or organ system (one body area or organ system). The 1997 guidelines state that a problem-focused exam consists of performing and documenting one to five elements identified by a bullet in the following chart (or specific specialty exam where appropriate).

•• An expanded problem-focused examination is defined by the 1995 guidelines as a limited examination of the affected body area or organ system and other symptom atic or related organ system(s) (two to seven body areas or organ systems). The 1997 guidelines state that this consists of performing and documenting at least six elements identified by a bullet in the following chart (or specific specialty exam where appropriate).

•• A detailed examination is defined by the 1995 guidelines as an extended examina tion of the affected body area(s) and other symptomatic or related organ system(s) (two to seven body areas or organ systems with at least one body area examined in more detail). The 1997 guidelines state this consists of performing and document ing at least two elements identified by a bullet from each of six areas/systems and at least 12 elements identified by a bullet in two or more areas/systems for the general multi-system exam. See the following chart for bullets (or specific specialty exam where appropriate).

•• A comprehensive examination, the 1995 guidelines state, is a complete general multi-system examination or an examination of a single organ system (eight or more organ systems). The 1997 guidelines indicate that this consists of performing all elements identified by a bullet in at least nine organ systems or body areas and documenting at least two elements identified by a bullet from each of nine areas/ systems for the general multi-system exam. See the following chart for bullets (or specific specialty exam where appropriate).

System/Body Area

Elements of Examination

Constitutional •• Measurements of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

•• General appearance of the patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes •• Inspection of conjunctivae and lids•• Examination of pupils and irises (eg, reaction

to light and accommodation, size and symmetry )

•• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance ) and posterior segments (eg, vessel changes, exudates, hemorrhages)

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normal lab Values and Vital SignsLab Test Test Code Synonyms Normal Expected Values/Results/Lab Where Performed*11-Desoxycortisol FDOC2 Compound S,

11-Deoxycortisol11-Desoxycortisol, Serum ng/dL (SI: nmol/L = 0.0289 x ng/dL)Performed at National Institutes of Health, Bethesda MDEffective 25Jul13 - present:Males: <90.0Females: <50.0

17-Hydroxy Steroids, 24h Urine

17OH1 17-OH, 17OH, 17-Hydroxy Corticosteroids

17-Hydroxy Steroids, 24h Urine mg/24 hour (SI: mg/24 hour)Perfromed at Quest Diagnostics Nichols Institute, Chantilly VAEffective 24Apr07 - present:Male: 3-10Female: 2-6

21-Hydroxylase Antibody 21OH1, 21OK1

Anti-Adrenal 21 OH 21-Hydroxylase Antibody U/mLPerformed at Mayo Medical Labs, Rochester MNEffective 04Nov04 – present: 0.0 - 0.9

5’Nucleotidase 5NT6 5’Nucleotidase U/L (SI: U/L)Performed at ARUP Laboratories, Salt Lake City UTEffective 08Apr11 – present: 0 - 15

5-Hydroxyindolacetic Acid HIAA1 5HIAA 5-Hydroxyindolacetic Acid mg/24hr (SI = 5.2 x mcmol/d)Performed at Mayo Medical Labs, Rochester MNEffective 04Jan11 - present: <=8.0

AAcetaminophen ACM3 Tylenol Acetaminophen mcg/mL

Performed at Mayo Medical Labs, Rochester MNEffective 4Dec09 - present:Therapeutic <50 Toxic >=120 Half-life <4 hoursToxic half-life >4 hoursThe toxic level is dependent on half-life. When the half-life is 4 hours, hepetatotoxicity generally is not seen until the concentration is greater or equal to 120 mcg/mL. The level at which toxicity occurs decreases with increasing half-lives until it is encountered at values as low as 50 mcg/mL when the half-life reaches 12 hours.

Acetylcholine Receptor Binding Antibody

ACHR1 Acetylcholine Receptor Binding Antibody nmol/L (SI = nmol/L)Performed at Mayo Medical Labs, Rochester MNEffective 19Sep94 - present: 0.00 - 0.02

Acid Phosphatase, Prostatic

PAP PAP Prostatic Acid Phosphatase (PAP), Serum ng/mL (SI: U/L = 0.23 x ng/mL)Performed at Mayo Medical Labs, Rochester MNEffective 14Jan04 - present: 0.0 - 2.1Serum markers are not specific for malignancy and values may vary by method.

Acinetobacter Culture, Throat/ Groin - Throat

ACINC surveillance acinetobacter culture

Acinetobacter Culture, Throat/ GroinPerformed at the National Institutes of Health, Bethesda, MDEffective 22Feb11 - presentReference range = no Acinetobacter species isolated

Activated Partial Thromboplastin Time

PTT aPTT, PTT Partial Thromboplastin Time secondsPerformed at National Institutes of Health, Bethesda MDEffective 07Apr08 – present:Automated: 25.3 - 37.3Effective 20Jan99 – present:Fibrometer: 24.4 - 35.6

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SNormal Lab Values and Vital Signs

Lab Test Test Code Synonyms Normal Expected Values/Results/Lab Where Performed*Acute Care Panel ACUT7 Acute Care Panel

Performed at National Institutes of Health, Bethesda MDEffective 08Feb14 - present:Sodium 136-145 mmol/LPotassium 3.4-5.1 mmol/L Chloride 98-107 mmol/LTotal CO2(Bicarbonate) 22-29 mmol/L *Creatinine Male: 0.67-1.17 mg/dL Female: 0.51-0.95 mg/dLGlucose 74-106 mg/dLUrea Nitrogen 18Y-60Y: 6-20 mg/dL >60Y: 8-23 mg/dL*Pediatric Range 1Y-2Y: 0.2-0.4 2Y-10Y: 0.3-0.7 10Y-17Y: 0.3-1.0estimated GFR mL/Min/1.73sq.mEffective 08Feb14 - present:Unit : mL/min/1.73 sq.m(eGFR calculated using CKD-EPI equation)30-60 mL/min/1.73sq.m : Moderate decrease in GFR15-29 mL/min/1.73 sq.m: Severe decrease in GFR<15 mL/min/1.73 sq.m : Kidney failurePlease treat eGFR values > 90mL/min/1.73 sq.m with reserve due to increased variability of results at higher eGFR valuesCKD-EPI GFR Calculators for adultsNKDEP GFR Calculators for childrenAlert Limits: Sodium <120 or >155 mmol/LPotassium <3.0 or >6.0 mmol/LChloride <75 or >125 mmol/LTotal CO2 <10 or >40 mmol/LCreatinine >7.0 mg/dLGlucose <40 or >500 mg/dLUrea nitrogen >100 mg/dL

Adenovirus PCR, Urine - Urine

ADPC1 Adenovirus PCR, UrinePerformed at the National Institutes of Health, Bethesda MDEffective 04Apr12 - presentReference Range = Negative for Adenovirus

Adenovirus PCR; Quantitative, Blood - Blood

ADQB3 Adenovirus PCR; Quantitative, BloodPerformed at the National Institutes of Health, Bethesda , MDEffective 04Apr12-PresentReference range= Negative for Adenovirus

Adenovirus 40/41 - Stool ADST1 Adenovirus 40/41Performed at National Institutes of Health, Bethesda MDEffective 01Jan85 – present: Negative for Adenovirus 40/41 by EIA

Adenovirus Antibody ADEN2 Adenovirus AntibodiesPerformed at Focus Diagnostics, Cypress CAEffective 22Mar07 - present: <1:8Interpretive Criteria<1:8 Antibody Not Detected> or =1:8 Antibody DetectedSingle titers of > or =1:64 are indicative of recent or current infection. Titers of 1:8-1:32 may be indicative of either past or recent infection, since CF antibody levels persist for only a few months. A four-fold or greater increase in titer between acute and convalescent specimens confirms the diagnosis.

Adenovirus PCR, Eye Swab (conjunctiva) - Eye conjunctiva

ADPC1 Adenovirus PCR, Eye Swab (conjunctiva)Performed at the National Institutes of Health, Bethesda, MDEffective 04Apr12 - presentReference range = Negative for Adenovirus

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SNormal Lab Values and Vital Signs

Lab Test Test Code Synonyms Normal Expected Values/Results/Lab Where Performed*Aldosterone, Urine ALDOR, ALDU Aldosterone, Urine mcg/24hr (SI: 2.77 x mcg/24hr = nmol/d)

Performed at Mayo Medical Labs, Rochester MNEffective 30Dec13 - present:0D-30D : 0.7 - 11.0 31D-11M: 0.7 - 22.0 >=1Y: 2.0 - 20.0 Interpretation:Under normal circumstances, if the 24-hour urinary sodium excretion is >200 mEq, the urinary aldosterone excretion should be <10 mcg/24 hours.Urinary aldosterone excretion >12 mcg/24 hours as part of an aldosterone suppression test is consistent with hyperaldosteronism.24-Hour urinary sodium excretion should exceed 200 mEq to document adequate sodium repletion.

Alkaline Phosphatase ALK5 alk phos Alkaline Phosphatase U/L (SI: U/L)Performed at National Institutes of Health, Bethesda MDEffective 08Feb14 - present:Male >=18Y: 40-130Female >=18Y: 35-105Pediatric RangeMale:1Y-3Y 104 - 3454Y-6Y 93 - 3097Y-9Y 86 - 31510Y-12Y 42 - 36213Y-15Y 74 - 39016Y-17Y 52 - 171Female:1Y-3Y 108 - 3174Y-6Y 96 - 2977Y-9Y 69 - 32510Y-12Y 51 - 33213Y-15Y 50 - 16216Y-17Y 47 - 119

Alkaline Phosphatase, Heat Stable

ALKH5 Alkaline Phosphatase, Heat StablePerformed at National Institutes of Health, Bethesda MDEffective 08Feb14 – present:<20 percent residual activity suggests bone isoenzymes.25-55 percent residual activity suggests liver and/or intestinal isoenzymes.

Alpha-1 Antitrypsin AAT1 A-1, AAT Alpha-1 Antitrypsin mg/dL (SI: g/L = 0.01 x mg/dL)Performed at National Institutes of Health, Bethesda MDEffective 11Jun03 – present: 89 – 199

Alpha-fetoprotein AFP1 AFP, a1 Alpha-fetoprotein ng/mL (SI: mcg/L = 1 x ng/mL)Performed at National Institutes of Health, Bethesda MDEffective 5Aug08 - present: 0.6 - 6.6

Alpha-Fucosidase, Fibroblasts

AFUF2 Alpha-Fucosidase Fibroblasts nmol/min/mg proteinPerformed at Mayo Medical Labs, Rochester MNEffective 14Nov13 - present: >= 0.41Interpretation:Low alpha-fucosidase suggests fucosidosis when accompanied with clinical findings. Some patients exhibit measurable activity minimally below the normal range. These patients are not likely to have fucosidosis.

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Billing, Coding, and Reimbursement terms

Billing/Coding/Reimbursement Term DefinitionA “TIER” Is a specific list of drugs. Your plan may have several tiers,and your copayment amount

depends on which tier your drug is listed.Plans can choose their own tiers, so members should refer to their benefit booklet or contact the plan for more information.

ABSTRACT Is the collection of information from the medical record via hard copy or electronic instrument.

ABUSE A range of the following improper behaviors or billing practices including, but not limited to: Billing for a non-covered service; Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or Inappropriately allocating costs on a cost report.

ABUSE (PERSONAL) When another person does something on purpose that causes you mental or physical harm or pain.

ACCESS Your ability to get needed medical care and services.

ACCESSIBILITY OF SERVICES Your ability to get medical care and services when you need them.

ACCESSORY DWELLING UNIT (ADU)

A separate housing arrangement within a single-family home. The ADU is a complete living unit and includes a private kitchen and bath.

ACCREDITATION An evaluative process in which a healthcare organization undergoes an examination of its policies, procedures and performance by an external organization (“accrediting body”) to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.

ACCREDITATION CYCLE FOR M+C DEEMING

The duration of CMS’s recognition of the validity of an accrediting organization’s determination that a Medicare + Choice organization (M+CO) is “fully accredited.

ACCREDITATION FOR DEEMING Some States use the findings of private accreditation organizations, in part or in whole, to supplement or substitute for State oversight of some quality related standards. This is referred to as “deemed compliance” with a standard.

ACCREDITATION FOR PARTICIPATION

State requirement that plans must be accredited to participate in the Medicaid managed care program.

ACCREDITED (ACCREDITATION) Means having a seal of approval. Being accredited means that a facility or health care organization has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities and organizations. Organizations that accredit Medicare Managed Care Plans include the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the American Accreditation HealthCare Commission/URAC.

ACCREDITED STANDARDS COMMITTEE

An organization that has been accredited by ANSI for the development of American National Standards.

ACT/LAW/STATUTE Term for legislation that passed through Congress and was signed by the President or passed over his veto.

ACTIVITIES OF DAILY LIVING (ADL)* Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.

ACTUAL CHARGE The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount Medicare approves. (See Approved Amount; Assignment.)

ACTUARIAL BALANCE The difference between the summarized income rate and the summarized cost rate over a given valuation period.

ACTUARIAL DEFICIT A negative actuarial balance.

ACTUARIAL RATES One half of the expected monthly cost of the SMI program for each aged enrollee (for the aged actuarial rate) and one half of the expected monthly cost for each disabled enrollee (for the disabled actuarial rate) for the duration the rate is in effect.

ACTUARIAL SOUNDNESS A measure of the adequacy of Hospital Insurance and Supplementary Medical Insurance financing as determined by the difference between trust fund assets and liabilities for specified periods.

ACTUARIAL STATUS A measure of the adequacy of the financing as determined by the difference between assets and liabilities at the end of the periods for which financing was established.

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Billing/Coding/Reimbursement Term DefinitionADDITIONAL BENEFITS Health care services not covered by Medicare and reductions in premiums or cost sharing for

Medicare-covered services. Additional benefits are specified by the MA Organization and are offered to Medicare beneficiaries at no additional premium.Those benefits must be at least equal in value to the adjusted excess amount calculated in the ACR. An excess amount is created when the average payment rate exceeds the adjusted community rate (as reduced by the actuarial value of coinsurance, copayments, and deductibles under Parts A and B of Medicare). The excess amount is then adjusted for any contributions to a stabilization fund. The remainder is the adjusted excess, which will be used to pay for services not covered by Medicare and/or will be used to reduce charges otherwise allowed for Medicare-covered services. Additional benefits can be subject to cost sharing by plan enrollees. Additional benefits can also be different for each MA plan offered to Medicare beneficiaries.

ADJUSTED AVERAGE PER CAPITA COST (AAPCC)

An estimate of how much Medicare will spend in a year for an average beneficiary. (See Risk Adjustment.)

ADJUSTED COMMUNITY RATING (ACR)

How premium rates are decided based on members’ use of benefits and not their individual use of benefits.

ADMINISTRATIVE CODE SETS Code sets that characterize a general business situation, rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non-clinical or non-medical code sets. Compare to medical code sets.

ADMINISTRATIVE COSTS A general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States’ expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.

ADMINISTRATIVE DATA This refers to information that is collected, processed, and stored in automated information systems. Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.

ADMINISTRATIVE EXPENSES Expenses incurred by the Department of HHS and the Department of the Treasury in administering the SMI program and the provisions of the Internal Revenue Code relating to the collection of contributions. Such administrative expenses, which are paid from the SMI trust fund, include expenditures for contractors to determine costs of, and make payments to, providers, as well as salaries and expenses of CMS.

ADMINISTRATIVE LAW JUDGE (ALJ)

A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors.

ADMINISTRATIVE SERVICES ONLY An arrangement whereby a self-insured entity contracts with a Third Party Administrator (TPA) to administer a health plan.

ADMINISTRATIVE SIMPLIFICATION Title II, Subtitle F, of HIPAA which authorizes HHS to: (1) adopt standards for transactions and code sets that are used to exchange health data; (2) adopt standard identifiers for health plans, health care providers, employers, and individuals for use on standard transactions; and (3) adopt standards to protect the security and privacy of personally identifiable health information.

ADMINISTRATIVE SIMPLIFICATION COMPLIANCE ACT

Signed into law on December 27, 2001 as Public Law 107-105, this Act provides a one-year extension to HIPAA covered entities (except small health plans, which already have until October 16, 2003) to meet HIPAA electronic and code set transaction requirements. Also, allows the Secretary of HHS to exclude providers from Medicare if they are not compliant with the HIPAA electronic and code set transaction requirements and to prohibit Medicare payment of paper claims received after October 16, 2003, except under certain situations.

ADMINISTRATOR The Administrator of the Centers for Medicare and Medicaid Services.

ADMISSION DATE The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits.

ADMITTING DIAGNOSIS CODE Code indicating patient’s diagnosis at admission.

ADMITTING PHYSICIAN The doctor responsible for admitting a patient to a hospital or other inpatient health facility.

ADULT LIVING CARE FACILITY To be used when billing services rendered at a residential care facility that houses beneficiaries who cannot live alone but who do not need around-the-clock skilled medical services. The facility services do not include a medical component (Program Memo B-98-28).

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20501 - 20612Surgery/Musculoskeletal System

Surgery/Musculoskeletal System

20501When the patient is appropriately prepped and the area anesthetized, the provider identifies the opening of the sinus tract. She injects a diagnostic agent, such as fluoroscopic dye or contrast material, directly into the sinus tract. She may make use of imaging guidance as an aid in the injection process.

20520When the patient is appropriately prepped and the area anesthetized, the provider incises the skin over the targeted area and separates the tissues. When she reaches the muscle or tendon sheath, she inspects the area and removes the foreign body. She closes the surgical opening with sutures after thoroughly cleaning the site. The provider may rely on X ray images taken prior to the procedure to locate the foreign body in the soft tissue and a postprocedure image to ensure the complete removal of all foreign bodies.

20525When the patient is appropriately prepped and the area anesthetized, the provider incises the skin over the targeted area and separates the tissues. When she reaches the muscle or tendon sheath, the depth of the foreign body or presence of infection may require more difficult dissection or removal of necrotic, or dead, tissue. She removes the foreign body and closes the surgical opening with sutures after thoroughly cleaning the site. The provider may rely on X ray images taken prior to the procedure to locate the foreign body in the soft tissue and a postprocedure image to ensure the complete removal of all foreign bodies.

20526When the patient is appropriately prepped and the area anesthetized, the provider locates the injection site on the wrist area between the flexor tendon and the palmar muscle. She injects the appropriate amount of anesthetic or corticosteroid.

20527When the patient is appropriately prepped and anesthetized, the provider locates the planned injection site. He injects the appropriate amount of collagenase into three different but nearby positions of the Dupuytren's contracture. If necessary, he extends the patient's fingers manually to disrupt the abnormal fascial cord.

20550After administration of adequate anesthesia and prep and drape, the provider locates the injection site. The appropriate amount of corticosteroid, anesthetic, or anti-inflammatory drug is then injected into the aponeurosis of the tendon sheath and/or ligament.

20551When the patient is appropriately prepped and the area anesthetized, the provider prepares the site for injection. She may use radiological guidance to identify the tendon origin when it is not possible to visually locate the site of drug delivery. She injects the appropriate amount of corticosteroid, anesthetic, or antiinflammatory drug directly at the tendon origin or insertion and then withdraws the syringe. The provider observes the patient for any adverse reaction.

20552When the patient is appropriately prepped and the area anesthetized, the provider palpates, or touches, the muscle to determine the location of a trigger point. She applies firm pressure to the trigger point to assess for referred pain and a twitch response. Then, she slowly injects the appropriate amount of corticosteroid or anesthetic into the trigger point.

20553When the patient is appropriately prepped and the area anesthetized, the provider palpates the muscle to determine the location of a trigger point. He applies firm pressure to the trigger point to assess for the presence of referred pain and a twitch response. After proper localization, he slowly injects the appropriate amount of corticosteroid or anesthetic into the trigger point of each muscle.

20555When the patient is appropriately prepped and anesthetized, the provider inserts catheters or needles at the site of a malignancy with the help of radiological guidance. He uses the needle or catheter as the delivery route for the radiotherapy elements or seeds, inserting seeds at this time or on a subsequent encounter. He secures the catheters or needles in place. He adds or remove seeds throughout the treatment phase.

20600When the patient is appropriately prepped and anesthetized, the provider inserts a needle through

the skin into the joint or bursa. He then uses a syringe with the needle to remove fluid from the joint or bursa. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding. He does not use ultrasound guidance to perform this procedure. Use this code only when the provider performs aspiration or injection in a small joint or bursa without ultrasound guidance.

20604When the patient is appropriately prepped and anesthetized, the provider inserts a needle through the skin into the joint or bursa, typically the fingers or toes. Under ultrasound guidance, he then uses a syringe with the needle to remove fluid from the joint or bursa. The provider also permanently records the findings. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as for pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding.

20605When the patient is appropriately prepped and anesthetized, the provider inserts a needle through the skin into the joint or bursa. He then uses a syringe with the needle to remove fluid from the joint or bursa. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding. He does not use ultrasound guidance to perform this procedure. Use this code only when the provider performs an aspiration or injection in an intermediate joint or bursa without ultrasound guidance.

20606When the patient is appropriately prepped and anesthetized, the provider inserts a needle through the skin and into the medium sized joint or bursa typically the temporomandibular, acromioclavicular, wrist, elbow, ankle, or olecranon bursa. Under ultrasound guidance, he then uses a syringe with the needle to remove

fluid from the joint or bursa. The provider also permanently records the findings. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding.

20610When the patient is appropriately prepped and anesthetized, the provider inserts a needle through the skin into the joint or bursa. He then uses a syringe with the needle to remove fluid from the joint or bursa. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding. He does not use ultrasound guidance to perform this procedure. Use this code only when the provider performs aspiration or injection in a major joint or bursa without ultrasound guidance.

20611When the patient is appropriately prepped and anesthetized, the provider inserts a needle through the skin and into the large sized joint or bursa typically the shoulder, hip, knee, or subacromial bursa. Under ultrasound guidance, he then uses a syringe with the needle to remove fluid from the joint or bursa. The provider also permanently records the findings. After he aspirates the joint or bursa, he sends the fluid sample to the laboratory for further examination. He may also inject a drug into the joint or bursa for therapeutic purposes such as pharmacotherapy or lavage. He then removes the needle and applies pressure to stop any bleeding.

20612When the patient is appropriately prepped and the area anesthetized, the provider inserts a sharp needle through the external skin surface and into the ganglion cyst. Using a syringe, he aspirates the cyst to drain it of the colorless jellylike material inside. He may submit a sample to a laboratory for inspection. In some cases, the provider may inject a destructive or antiinflammatory substance into the ganglion cyst.

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36253 - 36406 Surgery/Cardiovascular System

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the renal artery, the provider may interpret this as a need for further interventions. If there is a need for flush aortogram, the provider advances the catheter to the aorta and identifies any possible abnormality in X-ray after giving contrast.The provider removes the catheter after he has taken the X-rays. The provider collects and stores images for appropriate interpretation. He applies pressure to the puncture site for stoppage of bleeding.

36253The provider ensures that the patient does not have an existing bleeding problem or pregnancy. After the patient is appropriately prepped and anesthetized, the provider inserts a needle into the femoral artery at groin level and passes a thin, long, flexible guide wire and small fine catheter into the artery. He removes the needle. He connects the catheter to a fluoroscope that sends X-ray images of the inside of the body to a display monitor. With the help of the visual fluoroscopic guidance, the provider gently pushes the catheter up to the second or higher order branches of the renal artery, which are the finer subdivisions of the main blood vessel supplying the kidney, and then he removes the guide wire.The provider injects a dye into the artery through the catheter. The dye shows up on X-ray, allowing the provider to visualize the renal blood vessels for any blockage, narrowing, or clots. The provider takes successive X-ray images as the dye moves through the blood vessels. The provider may inject a blood thinner through the catheter to avoid clotting at the site of action. The provider may perform pressure gradient measurement. In this procedure, with the help of a pressure guide wire, he studies the blood pressure at the renal artery versus the simultaneous blood pressure within the aorta. If there is a significant drop in pressure at the renal artery, the provider may interpret this as a need for further interventions. If there is a need for flush aortogram, the provider advances the catheter to the aorta and identifies any possible abnormality in X-ray after giving contrast.The provider removes the catheter after he has taken the X-rays. The provider collects and stores images for appropriate interpretation. He applies pressure to the puncture site for stoppage of bleeding.

36254The provider ensures that the patient does not have any existing bleeding problems or pregnancy. After the patient is appropriately prepped and anesthetized, the provider inserts a needle into the femoral artery at groin level and passes a thin long flexible guide wire and small fine catheter into the artery. He removes the needle. He connects the catheter to a fluoroscope that sends X-ray images of the inside of the body to a display monitor. With the help of the visual fluoroscopic guidance, the provider gently pushes the catheter up to the second or higher order branches of the renal artery, which are the finer subdivisions of the main blood vessel supplying the kidney and then removes the guide wire.The provider injects a dye into the artery through the catheter. The dye shows up on X-ray, allowing the provider to visualize the renal blood vessels for any blockage, narrowing, or clots. The provider takes successive X-ray images as the dye moves through the blood vessels. The provider may inject a blood thinner through the catheter to avoid clotting at the site of action. He performs the imaging on each kidney by second-order or higher catheterization. The provider may perform pressure gradient measurement. In this procedure, with the help of a pressure guide wire, he studies the blood pressure at the renal artery versus the simultaneous blood pressure within the aorta. If there is a significant drop in pressure at the renal artery, the provider may interpret this as a need for further interventions. If there is a need for flush aortogram, the provider advances the catheter to the aorta and identifies any possible abnormality in X-ray after giving contrast.The provider removes the catheter after he has taken the X-rays. The provider collects and stores images for appropriate interpretation. He applies pressure to the puncture site for stoppage of bleeding.

36260When the patient is appropriately prepped and anesthetized, the provider makes an incision over the targeted artery in the abdomen, separating it from nearby structures. He punctures it with a needle to introduce a guide wire. Over the guide wire, he pushes the catheter, confirms the position of the catheter, and attaches it to the infusion pump. To insert the infusion pump, the provider makes

an incision over the lower abdomen and creates a subcutaneous pocket in the abdominal cavity and secures the pump inside the pocket. He closes the skin with sutures.The provider may perform this procedure to place an infusion pump to deliver chemotherapy drugs to a patient with liver carcinoma. He makes an incision over the abdomen to locate the hepatic artery and punctures it with a needle. He then replaces the needle with a guide wire and drives the guide wire to the desired location in the artery. Next, he inserts catheter over the guide wire, and once catheter reaches the appropriate location, the provider removes the guide wire, leaving the catheter in place. At the end of the procedure, he attaches the catheter to the infusion pump and closes the surgical wound with sutures.

36261When the patient is appropriately prepped and anesthetized, the provider makes a small incision in the skin to explore the previously implanted infusion pump and catheter. The provider replaces the infusion pump in the subcutaneous layer of patient's lower abdominal area. In addition, the provider locates the targeted artery, detaches the catheter, and replaces it with the new catheter and then attaches it to the pump. He may also replace the pump. After surgery, the provider refills the pump with a chemotherapy drug or other fluid.

36262When the patient is appropriately prepped and anesthetized, the provider makes an incision in the skin to find the site of the previously implanted infusion pump and catheter. The provider removes the infusion pump from the subcutaneous layer of the patient's lower abdomen. The provider locates the artery where the catheter is located, detaches the catheter, and pulls it out of the artery. He also removes the infusion pump from its pocket in the abdomen. He repairs the puncture site of the artery and closes the subcutaneous pocket and skin with sutures.

36299The provider performs a vascular injection procedure hat is not represented by any of the standard and active CPT® codes available.

36400The provider or other qualified healthcare professional places the patient in a suitable position to

ensurenormal blood flow, applies a tourniquet a couple of inchesabove the site of puncture, and cleans the skin of the puncturesite. A needle attached to a flexible tube is inserted through theskin into the vein at an angle of approximately 20° or less (near parallel to the vein). When the vein is entered, the blood starts flowing into the needle. The needle is inserted very slowly and carefully to avoid piercing of the posterior wall of the vein.After the desired procedure of collection of blood or infusion of drug is over, the needle is withdrawn and the site of puncture is pressed with surgical wool to prevent bleeding.Use code 36400 when the venipuncture requires direct involvement of a provider, and the puncture is done on the jugular or femoral vein in a patient younger than 3 years of age.Do not report this code for routine venipuncture procedures which are reported by 36415 or S9529.

36405The provider places the patient in a suitable position to ensure normal blood flow and cleans the skin of the puncture site after parting and clipping the hair to the skin with adhesive tapes. He inserts a needle attached to a flexible tube through the skin into the vein of at an angle of approximately 20° or less parallel to the vein while putting thumb pressure to the skin a couple of inches below the puncture site which helps in steadying the vein during the puncture. The provider confirms the placement of the needle by checking the blood flow in the needle and inserts it farther very slowly and carefully to avoid piercing the posterior wall of the vein. After the desired procedure of collection of blood or infusion of drug is over, he withdraws the needle and applies the pressure to stop the bleeding.

36406The provider places the patient in a suitable position to ensure normal blood flow. He inserts a needle attached to a flexible tube through the skin into the vein while putting thumb pressure to the skin a couple of inches below the puncture site, which helps in steadying the vein during the puncture. The provider confirms the placement of the needle by checking the blood flow in the needle and inserts farther very slowly and carefully to avoid piercing the posterior wall of the vein. After collecting blood or infusing a drug, he withdraws the

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76641 - 76810 Radiology

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conditions. A chest ultrasound may include transverse, longitudinal, and oblique images of the chest wall with measurements of chest wall thickness. The provider reviews the images on the monitor and writes and places a report and images into to the patient's chart and sends the same to the requesting provider.

76641When the patient is appropriately prepped, the provider places a transducer probe on the affected breast. The probe generates sound waves that travel through tissues of different density. As these sound waves strike through various tissues in the breast, they reflect back, which the provider receives as images on the monitor. For a complete ultrasound, the provider images each breast quadrant and the central area that is behind the nipple and areola. The procedure might involve ultrasound of the axilla along with the breast.

76642When the patient is appropriately prepped, the provider places a transducer probe on the affected part of the breast. The probe generates sound waves that travel through tissues of different density. As these sound waves strike various tissues in the breast, they reflect back, which the provider receives as images on the monitor. For a complete ultrasound, the provider images each breast quadrant and the central area that is behind the nipple and areola. If the provider performs anything less than a complete ultrasound, you should use this code for the limited ultrasound. The procedure might involve ultrasound of the axilla along with the breast.

76700During an ultrasound, sound waves are used to create images. This particular CPT® code is used when the ultrasound is complete and requires real time image documentation. No ionizing radiation is used in the ultrasound technique.The provider or ultrasound technician applies conductive gel on the skin over the abdomen. This helps in the transmission of the sound waves. An ultrasound machine sends high-frequency sound waves through a probe which is called transducer. The transducer is then pressed against the skin and moved over the abdomen in order to produce the images of the internal organs on the monitor. The patient may be asked to hold his

breath during the examination.

76705 During an ultrasound, sound waves are used to create images. No ionizing radiation is used in the ultrasound technique. This particular CPT® code is used when the ultrasound is performed to examine a single organ, quadrant, or is used only for a follow up and requires real time image documentation.The provider or ultrasound technician applies conductive gel on the skin over the specific abdominal area to be examined. This helps in the transmission of the sound waves. An ultrasound machine sends high-frequency sound waves through a probe which is called transducer. The transducer is then pressed against the skin and moved over that area being studied in order to produce the image of that particular organ or quadrant on the monitor. The patient may be asked to hold his breath during the examination.

76770A retroperitoneal ultrasound is used to take images of the nodes, aorta, or renal structures present in the abdominal cavity behind the peritoneum. This particular CPT® code is used when the ultrasound is complete and requires real time image documentation.The provider or ultrasound technician applies conductive gel on the skin over the retroperitoneal area. This helps in the transmission of the sound waves. An ultrasound machine sends high-frequency sound waves through a probe which is called transducer. The transducer is then pressed against the skin and moved over the area being studied in order to produce the desired image on the monitor.

76775A retroperitoneal ultrasound is used to take images of the single nodes, aorta ,or renal structures or limited area present in the abdominal cavity behind the peritoneum. This particular CPT® code is used when the ultrasound is limited (e.g. renal, aorta, or nodes) and requires real time image documentation.The provider or ultrasound technician applies conductive gel on the skin over the particular area to be examined. This helps in the transmission of the sound waves. An ultrasound machine sends high-frequency sound waves through a probe which is called transducer. The transducer is then pressed against the skin and moved over the area being studied in order to

produce the desired image on the monitor.

76776The provider or sonographer applies conductive gel to the abdomen and then presses the transducer against the skin and sweeps it over the lower abdomen to take the pictures of the kidneys using the color doppler.

76800The provider positions the patient appropriately for the disease process or condition being investigated and aligns the ultrasound probe to appropriately direct the sound beam. The sound beam strikes each surface and bounces back into the probe tip, which converts the echoes into a picture that appears on a display screen for the provider's review. In newborns and infants, the provider may examine the spinal canal in the midline longitudinal plane or the transverse plane. In an adult intraoperative procedure, the surgeon or radiologist uses a sterilized probe or a probe prepared with a sterile cover or sheath, as the probe may be in direct contact with the organ or site. A provider may use ultrasound when he removes, or incises, all or part of the thin bony layer that covers and protects the spinal canal and spinal cord, a procedure called a laminotomy or laminectomy. He images the site in both longitudinal and transverse planes to visualize abnormalities, assesses how the operation is proceeding, and gauges the final outcome of the operation before finishing the surgery. The provider may also use ultrasound to slowly and carefully image the two planes during other spinal surgeries to locate a spinal tumor, guide an intraoperative biopsy, or ensure the completeness of a spinal lesion resection, removing the lesion from the spine.

76801A pregnancy ultrasound is an imaging test in which an ultrasound machine obtains images using ultrasound waves to examine the development of a fetus in the womb. Ultrasound waves are high frequency sound waves which pass through tissues of varying densities and reflect back to the receiving unit. The provider also uses it to examine the female pelvic organs. Ultrasound of a pregnant uterus is essential to study the number and size of fetuses, to examine the fetal heart beat, and to study the presence of any abnormality. In this procedure, the provider

applies gel to an ultrasound transducer head and places it over the patient's abdomen. Ultrasound waves transmit into the uterus and reflect back to the receiving unit, which receives these waves in the form of images of the developing fetus and female pelvic structures. Use 76801 for an ultrasound of a single or the first fetus, during the initial 14 weeks of pregnancy.

76802After performing an ultrasound examination of the first fetus, the provider during the same session performs another ultrasound using a transabdominal approach, to examine each additional fetus. He applies gel on the ultrasound transducer head and places it on the patient's abdomen. The provider then slowly moves the transducer over the mother's abdomen. Ultrasound waves are high frequency sound waves that travel through tissues of varying densities. The receiving unit or the monitor receives the sound waves after reflection and uses them to create images of the developing fetus. Use +76802 for each additional gestation, or fetal ultrasound during the first trimester, or initial 14 weeks of pregnancy.

76805A pregnancy ultrasound is an imaging test in which an ultrasound machine obtains images using ultrasound waves to examine the development of a fetus in the womb. Ultrasound waves are high frequency sound waves, which pass through tissues of different densities and reflect back to the receiving unit. The providers also uses the ultrasound in this service to examine the female pelvic organs. An ultrasound of the pregnant uterus after the first trimester is essential to monitor the growth and development of the fetus.In this procedure, the provider applies gel to the ultrasound transducer head and places it on the patient's abdomen. The provider then slowly moves the transducer over the mother's abdomen. Ultrasound waves transmit into the uterus and reflect back to the receiving unit, which receives these waves in the form of images of the developing fetus and female pelvic structures. Use 76805 for an ultrasound examination of both the developing fetus and mother after the initial 14 weeks of pregnancy.

76810After performing an ultrasound examination of the first fetus, the

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Medical Terms GlossaryMedical Term Description11 dexycortisol A precursor of cortisol; a steroid hormone, also known as Compound S.

23 valent A vaccine that contains 23 of the most common types of pneumococcal bacteria to help prevent infection.

Ab externo The term means outside the eye, and indicates the procedure of surgery starting from the eye’s exterior and proceeding to the anterior chamber.

Abbe Estlander operation Transfer of a full thickness section of one lip to the other lip ensuring survival of the graft.

Abdominal aorta Largest artery supplying the abdominal cavity, part of aorta and continuation of the descending aorta from the thorax; it divides further into iliac arteries.

Abdominal aortic aneurysm (AAA)

Widening of the abdominal aorta due to weakening in the wall of the aorta.

Abdominal approach The provider makes an incision in the abdomen to perform various operations in the abdomen.

Abdominal pregnancy When the fetus begins to grow within the peritoneal cavity; it can be located anywhere including the omentum, the abdominal wall, or the outside of the body of the uterus; a primary abdominal pregnancy means that the fertilization of the ovum takes place outside the entrance to the fallopian tube and the fertilized egg then travels to a close source of tissue, which it attaches to; a secondary abdominal pregnancy means that the fertilized ruptures from the tube and then implants in the abdominal cavity.

Abdominal wall May refer to muscle covering the abdomen, or to the skin, fascia, muscle, and membranes marking the boundaries of the abdominal cavity.

Abdominoperineal A surgical procedure that requires two approaches, one through the abdomen and a second through the perineum which requires excising the anal sphincter.

Abdominoperineal pull through procedure

A surgical procedure that involves two approaches, one through the abdomen and a second through the perineum.

Abdominoperineal resection

The surgical removal of the anus, rectum, and part of the sigmoid colon, along with regional lymph nodes, through incisions made in the abdomen and perineum.

Abduction Movement of the body part away from the medial line of the body.

Abduction pillow or splint

A medical device used to immobilize an extremity after a surgical procedure to help decrease the risk of a dislocation.

Abductor Muscle that draws a body part away from the midline of the body.

Abductor muscle of hip A group of muscles in the buttock that lifts the thigh out to the side.

Aberrant Unusual or abnormal.

Aberrant renal vessel A vessel of the kidney that is different from the norm anatomically.

Aberrant vessel Blood vessel having an unusual origin or course.

Ablation Removal of tissue, a body part, or an organ or destruction of its function.

ABO incompatibility An abnormal reaction between blood cells of incompatible blood groups; this results in destruction of blood cells and the formation of clumps.

Abortion The clinical term for the termination of a pregnancy before the age of viability, usually before twenty completed weeks of gestation; the provider removes the uterine contents surgically or by inducing labor, or the pregnancy may be expelled spontaneously; when it ends spontaneously, it is referred to as a miscarriage.

Abrasion Removal of superficial layers of skin.

Abrasion arthroplasty Refinishing the surfaces of a joint through a grinding process.

Abscess A collection of pus in tissue due to infection.

Abscess cavity Pocket formed due to the accumulation of purulent material, pus.

Absorption Taking in of substances by tissues.

Accelerometer Device to measure motion of a body.

Accessory nerve One of a pair of motor nerves that primarily supply the pharynx and muscles of the upper chest, back, and shoulders.

Accessory sinuses The accessory sinuses are posterior, above the middle turbinate, including the sphenoidal and posterior ethmoidal, and anterior, below the middle turbinate, including the anterior ethmoidal, frontal, and superior maxillary sinuses.

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Medical Term DescriptionACE-inhibitors A class of drugs known as antihypertensives, which are taken to aid in the reduction of hypertension or

blood pressure.

Acellular pertussis Very infectious respiratory disease; also called whooping cough.

Acetabular rim Margin of the acetabulum.

Acetabulum A hollow cavity or socket within the hip bone that is attached to the ball, or the top end, of the femur, which is the thigh bone.

Acetone A chemical liquid that evaporates rapidly and is used as solvent.

Acetylcholinesterase An enzyme that breaks up acetylcholine, a neurotransmitter.

Achilles tendon The tendon that connects the calf muscles to the heel bone.

Acid analysis, or gastric acid secretion test

A laboratory test to determine the presence and amount of gastrin, a hormone that regulates acid production in the stomach, and the pH, the acidity or alkalinity, in stomach fluid; acidity is normal, but too much acidity causes ulcers.

Acid-base balance The condition of the balance between the acid ions and the base or alkaline ions, a delicate mechanism, which controls the pH or acidity-alkalinity in the body.

Acid-fast bacilli Also called AFB, these bacteria resist loss of stain color when treated with a dilute acid, and are part of the taxonomic class, bacillus, that are typically rod shaped bacteria.

Acidosis Increased acidity in the blood due to increased hydrogen ions, causing a decrease in pH below 7.35; this affects all body functions especially metabolism and respiration.

Aciduria The presence of acid in urine, particularly in abnormal amounts.

Acne Eruptions of small oil secreting glands below the skin surface due to infection or inflammation; also known as pimples.

Acoustic cardiography Technique that records heart sounds, i.e., acoustic, simultaneously with the rhythm, i.e., electrical intervals, and represents them graphically.

Acromioclavicular, or AC, joint

Union of the acromion, or shoulder blade, and the clavicle, or collar bone.

Acromion Bony projection of shoulder blade that forms point of the shoulder.

Acromioplasty Removal of part of the acromion bone, the bony projection of the shoulder blade that forms the point of the shoulder.

Actinic keratoses Rough, scaly patches of skin that develop from prolonged exposure to sun.

Acute A disease or an ailment that has rapid onset or short course.

Acute circulatory failure A sudden drop in cardiac output.

Acute injury Refers to the first 24 to 48 hours after an injury due to a traumatic episode.

Acute pancreatitis Life threatening and painful condition that is short term, rather than chronic, and associated with severe inflammation of the pancreas.

Acute tubular necrosis A condition involving the death of cells that form the tubules of the kidneys; this condition commonly leads to acute kidney injury.

Acyanotic Absence of the bluish tint associated with deoxygenated blood.

Adaptive Able to adjust to situations or environment.

Adaptive behavior It is one behavior that helps the individual in adjusting to his surrounding environment.

Addison disease A serious chronic condition caused by a reduction of hormones produced by the adrenal cortex, located on the upper pole of each kidney.

Adductor A muscle that helps a body part to move toward the centerline of the body or limb.

Adductor aponeurosis A thin band of tissue that separates the two ends of ulnar collateral ligaments.

Adductor muscle Any muscle that draws a body part away from the body or an extremity.

Adductor tenotomy Procedure where the tendon of the adductor muscle is snipped to release the muscle.

Adductors A group of muscles of the thigh that moves the thigh toward the midline of the body.

Adenoma Benign tumor of a glandular structure.

Adenosine triphosphate, or ATP

ATP occurs when simple sugar glucose is broken down; it is a cell’s main energy source.

Adhesiolysis Separation of adhesions.

Adhesions Fibrous bands, which typically result from inflammation or injury during surgery, that form between tissues and organs; they may be thought of as internal scar tissue.