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Unit 2

SX Symptoms; subjective evidence of diease or physical disturbance. (Also symtom tab in the software.)
HX History (Tab)
PX Physical Exam (same as PE)
DX Diagnosis
MEDCIN A medical nomencalutre
DM Diabetes Mellitus
RX take thou; prescribe; treatment; therapy
Heent Head, eyes, ears, nose, throat
HIT Health Information Technology also as Healthcare Information Technology
GI/GU Gastrointestinal/Genitorinary body system
ROS Reveiw Of Systems
Sig instructions for labeling a prescription (Latin Signa)
CC Cheif Complaint
HPI History of Present Illness which is a chronological discription of the development of the patient present illness from the first sign or symptom or from the previous encounter to the present
PFSH Past History, Family History, and Social History obtained from patient or other family member
CBC Complete Blood Count
EMR Electronic Medical Record
MDM Medical Decision Making (a key component)
E & M Evaluation and Management codes which area subset of CPT-4 codes used to bill for nearly every kind of patient encounter
NEC Not Elsewhere Classified (diagnosis codes)
NOS Not Otherwise Specified (diagnosis codes)
OIG Office of Inspector General (Department of Health and Human Services)
primary diagnosis first-listed diagnosis, used in the outpatient sertting to identify the reason for the encounter
ENT Ears, Nose, and Throat
Dis- apart
-blast immature cell, germ cell, embryonic cell
-dynia pain, ache
-ar pertaining to
bradykinesia Slowness of motion or movement
neuromyopathic Pertaining to a disease condition involving both nerves and muscles
myofibroma Tumor that contains muscle and fiber
myoplast Surical repair of a muscle
tenodesis Band of fibrous connective tissue serving for the attachment of muscles to bones; a giant cell tumor of tendon sheath is a benign, small, yellow, tumorlioke nodule
massage Kneading that applies pressure and friction to external body tissues
con- with together
quadri- four
syn- together, with
dactyl/o finger or toe
-oid resemble, like, similar
-ceps head
-ure process
combination code A code from one section of the precedural code book combined with a code from another section that is uesed top completely describe a procedure performed
multuiple code dual using more than one ICD code
morphology code study of a form or a shape
neoplasm tumroms new thing form
in situ within a site refers to tumor cells that remain and have not invaded tissue
benign not progressive
malignant pertaining to a bad wandering
malignant hypertension life treating high blood presssure