It helps to have information at your fingertips when coding. You will find that physicians often use different terms when describing surgical procedures that affect coding and billing of services for a patient. Maintaining notes on each provider can help the coder move the coding process along.
Medical Coding Help: Understanding Suffixes
Understanding suffixes is necessary when coding surgical procedures. However, coders should recognize the differences and similarities of the various terms. Below is a chart that describes common terms for surgical procedures:
Incision: Exploratory, Drainage, Aspiration (-TOMY) Opening Into
Excision: Resection, Biopsy (-ECTOMY) Removal
Introduction/Removal: Insert tube, Catheter, or Prosthesis, Injection, Irrigation, Aspiration (-NON-INCISIONAL)
Application: Splints, Straps, Casts
Manipulation: Reduction of a Fracture or Dislocation
Reduction: Restoration of a Fracture or Dislocation
Endoscopy: Any scope
Suture: Closure of Wounds (-RRHAPHY)
Repair/Revision/Reconstruction: Revision, Reconstruction, and Closure: Example: Of the Fistula
(-PLASTY, -LYSIS, -STOMY)
Fixation: Hold, Secure, Fasten in Position (-DESIS, -PEXY)
Destruction: Fulguration, Cryosurgery, Laser, Electrodessication, Chemical
Medical coders may get confused when they see the abbreviation ORIF and think the orthopedic surgeon is only treating an open fracture. This is not the case. ORIF stands for Open Reduction and Internal Fixation of a Fracture and this procedure can be performed on both an open and closed fracture.
So what exactly is an ORIF?
• Incision into the skin
• Dissecting the tissues to expose the fracture fragments
• Putting bones together by stabilizing the fracture with screws, plates or rods.
A patient may have a closed fracture; but in order to repair and re-align the closed fracture, the surgeon must open the area to expose the bone and make repairs. This is considered an open repair. If a fracture is considered open (piercing – protruding through the skin), the procedure for repair would still be considered open because the surgeon is still entering the opened area by dissecting tissue and using internal fixations to stabilize the fracture.
Sometimes a closed fracture is clean and requires a simple manipulation to re-align the bones. In this case, there is no need for an ORIF.
ORIF – Closed Fracture: Fractured bone(s) does not pierce skin but require incision, tissue dissection, and fixations to repair broken bone(s)
ORIF – Open Fracture: Fractured bones(s) protrude through the skin and require further opening, tissue dissection and fixations to repair broken bones
Closed Fracture: Fracture is clean and well aligned and can be treated with a closed manipulation – no incisions or fixations required.