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Chapter 07 MedCoding
2018 Medical Coding Training: CPC
| Term | Definition |
|---|---|
| The largest organ system in the body | skin |
| epidermis | the outermost portion of skin; comprised of many layers but does not contain blood vessels; contains pigment melanin; composed of stratified squamous epithelium; thinner on the eyelids and thicker on the palms and soles |
| dermis | under the epidermis; performs most of the skin's functions; consists of blood vessels, connective tissue, nerves, lymph vessels, glands, receptors, sebum, and hair shafts; contains sebaceous glands that secrete oil |
| subcutaneous tissue | located under the dermis; primarily fat cells that give the skin a smooth appearance and act as cushioning; not a layer of skin, but is just below it |
| FNA | Fine Needle Aspiration; a diagnostic procedure most often used to determine the nature of superficial (just under the skin) lumps or masses. |
| squamous cells | flat, scaly cells on the surface of the skin |
| basal cells | round cells |
| melanocytes | give the skin color |
| The 2 layers of the dermis | papillary layer (upper portion) and reticular layer (lower portion) |
| FBR | Foreign Body Removal |
| Integumentary system | skin, hair, and nails |
| Functions of the skin | protection from injury, fluid loss, and microorganisms, temperature regulation, fluid balance, and sensation |
| The 5 layers of the epidermis | stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale |
| Stratum Corneum | The outermost layer of the dermis, which is also known as the horny layer. It is composed of 10 to 30 layers, the thickest layer being in the palms and soles. |
| Stratum Lucidum | A clear or translucent layer found only in the palms and soles. |
| Stratum Granulosum | The Keratinocytes in this layer lose their nuclei and cytoplasm and appear less granular. |
| Stratum Spinosum | Also known as the spinous layer, produces lamellar bodies, enriched with polar lipids. Langerhans cells, which help with immunity, are present in this layer. |
| Stratum Basale | Also known as germinativum. It is attached to the basement membrane. Melanocytes, keratinocytes, and merkel cells are found here with large numbers of touch-sensitive sites such as the fingertips and lips. |
| debridement | the removal of infected, dead, or damaged tissue |
| Biopsy | A sample of tissue or cells, surgically removed from the body to be examined/analyzed in a laboratory when considered to be abnormal. |
| Calculus | Caused by skin pressure usually on soles of the feet or side of toes as an area of thick, toughened skin. |
| Corn | Caused by skin frictions, corns may appear on the tops or sides of toes or sides of the feet as a small, thickened area with a dense central area. |
| Cutting, Cut | Refers to a penetration or an opening with a sharp edge, surgical incision. Surgical cutting instruments used for cutting, include scalpels, drills, burs, saws, scissors, or rongeurs. |
| Icthyosis Follicularis (Karatosis Pilaris) | Abnormal keratinization of hair follicules manifesting as tiny follicular papules (usually solid conal elevations), commonly seen on the outer surface of the arms and thighs. |
| Seborrheic Keratosis | Benign skin tumor due to abnormal increase in keratinocytes which present as slightly raised lesions. |
| Paring | To remove by cutting off, or peeling away the other coat. To gradually decrease or diminish the surface or part of something. |
| Palmar and Plantar Keratosis | A congenital, often hereditary, thickening of the stratum corneum of the skin in the palms and soles, sometimes with painful lesions resulting in the formation of fissures. |
| Seed Corn | Tiny callus that can be very tender on the bottom of the foot. Can be caused by blocked sweat glands. |
| Soft Corn | Has much thinner surface than other corns and usually occurs between the 4th and 5th toes. |
| Senile Keratosis | Slightly raised flat papules, which are generally associated with aging and exposure to sunlight, which can become cancerous. |
| Nonpigmented Nevus | Form of the melanocytic nevus, which presents itself with a skin-colored mole elevated from the skin's surface, generally associated with hair growth. These moles are benign and slow growing. |
| Seborrheic Keratosis | Most common benign lesion in older patients caused by epidermal proliferation and keratin cysts. |
| Warts | Skin growth caused by HPV virus. |
| Rhinophyma | A condition in which the nasal skin thickens and the sebaceous glands enlarge. Skin appears red or purplish and may be bulbous, pitted, and scarred. Generally present in the nose tip; may result in irregular nodular growths and deformity of the nose. |
| Molluscum Contagiosum | Skin infection caused by molluscum virus, which results in raised lesions and bumps. |
| Angiofibroma | Small reddish-brown or flesh-colored papules about 0.1-0.3 cm on side of nose or medial portions of cheeks, which contain fibrous tissue. |
| Cauterization | Refers to the use of heat or chemicals to destroy abnormal cells or to seal a wound. |
| Papilloma | Small wart-like growth from the epidermis layer of the skin or mucous membrane, which is generally benign. |
| Basal Cell Carcinoma | Lesion that arises from the basal cells of epidermis. Rarely spreads to other sites beyond the original tumor site. |
| Cutaneous Horn | A conical-shaped lesion that resembles a horn above the surface of the skin, which is composed of compacted keratin. |
| Dermafibroma | Refers to a benign, fibrous tumor. |
| Skin Tags | These are skin growths, which are harmless, benign, painless, and typically acquired. Present in the creases, such as the neck, armpit, groin, buttock folds, under breasts, and eyelids as projections from the surface of the skin. |
| Stucco Keratosis | Churchspire-like projections of epidermal cells on the skin, which is a few millimeters in size, present in the lower extremities of older individuals. |
| Acrochordon | Also known as the Achrocorda, this refers to Skin Tags. |
| Keratoacanthoma (KA) | Low-grade skin cancer that originates in the hair follicles (pilosebaceous glands). |
| Squamous Cell Carcinoma (SCC) | This is a malignancy of the epithelial cells. Major form of skin cancer, which can also occur in the lining of the digestive tract, mouth, esophagus, urinary bladder, prostate, lung, vagina, and cervix. |
| Pigmented Nevi | Caused due to proliferation of pigment cells such as the melanocytes. |
| Dermatology | Branch of medicine that specializes in diseases of the skin, hair, and nails. |
| Vascular Lesions | These are pediatric birth marks which includes port-wine stain, hemangiomas, salmon patch. |
| Squamous Cell Carcinoma (SCC) in situ | This is a surface form of cancer which grows locally without invasive roots. Invasive SCC grows inward and may spread. Red scaly patch usually seen in areas exposed to the sun. Biopsy is necessary for diagnosis. |
| Actinic Keratosis (AK) | Scaly, crusty lesions caused by damage from the sun, typically on face, scalp, lips, and back of hands. If left untreated, up to 10% develop into Squamous Cell Carcinoma (SCC). |
| Sebaceous Hyperplasia | Causes single or multiple lesions that are yellowish, soft, small papules on the face of sebaceous glands in adults of middle or older age. |
| Basal Cell Carcinoma (BCC) | Lesion that arises from the basal cells of epidermis. Rarely spreads to other sites beyond the original tumor site. |
| Hutchinson's Melanotic Freckle | This is a condition prevalent in age group 70-80, which can be present for 5-15 years before turning malignant. |
| Premalignant Skin Lesions | These are benign lesions, however if left untreated may become malignant skin cancers. |
| Dermafibroma | Benign fibrous tumor. |
| Ablation | Removal of tissue by vaporization, electrosection, electrocoagulation, electrodessication, and fulguration, or application of intense cold to destroy tissue, or chemical eradication of tissue, or curetting. |
| Molluscum Contagiosum | Skin infection caused by molluscum virus, which results in raised lesions and bumps. |
| Warts | Skin growth caused by HPV virus. |
| Seborrheic Keratosis | Most common benign lesion in older patients caused by epidermal proliferation and keratin cysts. |
| Hyponichium | Thickened portion under the free edge of the nail plate (the line along the interface of the nail bed and the nail plate). |
| Nail Matrix | Cells at the base of the nail that rapidly divide and soon fill with protein, keratin. |
| Eponychium | Tight band of living tissue at the base of the nail, which protects the area between the nail and the epidermis from exposure to bacteria. |
| Nail Bed | Layer of cells under the fingernail or toenail. |
| Cuticle | A thin layer of dead tissue riding on the nail plate to form a seal between the eponychium and the nail plate. It pulls away beneath the eponychium and attaches to the nail plate. |
| Nail Sinus | The base of the nail under the skin, which originates from the matrix. |
| Lateral Nail Fold | An extension of the proximal nail fold, which protects the sides of the nail plate. |
| Nail Plate | Hard translucent portion of the nail, composed of keratin. An average person has 50 layers of keratin cells that make up the nail plate. |
| Lanula | Crescent-shaped white area of the bed of the fingernail or toenail (the visible part of the nail root). |
| Dermatophytosis | Also known as Athlete's Foot or tinea pedis is a fungal infection of the foot, commonly between the toe and toenail. |
| Avulsion | Most common surgical procedure performed on the nail, which involves the excision of the nail plate body from its attachments which includes the nail bed or proximal nail fold. |
| Nondystrophic Nails | Small wart-like growth from the epidermis layer of the skin or mucous membrane, which is generally benign. |
| Onychia | Infection of soft parts around the nail or the matrix beneath it. |
| Onychocryptosis | Also referred to as Ingrown nail, is a growth of one or both lateral margins of the nail into the adjacent soft tissue, causing pain, inflammation, and possible infection. |
| Onychomycosis | Fungal infection of the toenails or fingernails. |
| Paronchyia | Inflammation of tissues adjacent to the nail of either the finger or toe, usually with infection and pus formation. |
| Subungual Hematoma | Blood and fluid collects beneath the fingernail or toenail. Usually caused by traumatic injury, such as stubbing toe, or hitting finger, leading to increased pressure under the nail. |
| Extirpation | The complete removal or eradication of an organ or tissue. |
| Vermilion | The lips are covered on the outside by skin and on the inside by a mucous membrane. The transition zone, where the two kinds of covering tissue meet is the vermilion (red colored). |
| Dog Ears | Refer to excess puckering of skin and/or fat at the end of a surgical incision. |
| Subunit | The surface of the face can be divided into units comprised of the forehead, eyes, nose, lips, and chin. They are then further divided into subunits based on skin thickness, color, elasticity, and underlying structural support. |
| RSTL | Relaxed Skin Tension Lines. Incisions placed within RSTL will have minimal tension and will heal in a narrow line. |
| Undermining | A surgical technique for cutting the fibers that connect the skin to the underlying fascia. |
| Cellular Dermal Matrix | Type of soft tissue substitute in which the epidermis is removed, specially developed for reconstructive surgery. It forms a strong scaffolding that is quickly revascularized. It will integrate successively and finally be replaced by autologous tissue. |
| Autograft | Tissue or bone that is taken from a part of a person's body and transplanted to another location of that same person's body. |
| Dermatome | An instrument for cutting thin slices of skin for grafting. |
| Allogenic graft/allograft/homograft | Tissue taken from one person's body and transplanted into another person's body. |
| Dermal Graft | A de-epithelialized split-thickness graft, used to minimize poor color match in the recipient site and donor site morbidity. |
| Keloid | A nodular, firm, and often linear mass of hyperplastic, thick scar tissue. |
| Xenograft | Tissue from one species grafted into human tissue, such as pig skin graft used in a human as a graft. |
| Allograft | Tissue taken from one person's body and transplanted into another person's body. |
| Skin Mesher | Commonly used for split-thickness grafts, makes small holes in the graft, allowing it to expand to up to nine times the size of the skin graft. |
| Eschar | A thick, crusty covering or slough developing after a thermal or chemical burn or cauterization of the skin. |
| Cultured Epidermal Autograft | Tissue growth from one's own skin cells for use in placing on the person's own body. |
| Split-Thickness Graft or STSG | A graft that includes the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the patient. |
| Transposition | Transposition flaps are more complex and involve rotating an adjacent piece of tissue, resulting in the creation of a new defect which must then be closed. |
| Rotation | A rotation flap is similar to an advancement flap except instead of being stretched in a straight line, the flap is stretched in an arc. |
| Free | Free skin implies the skin is completely detached from the blood supply at the donor site. |
| Advancement | Advancement flap occurs when an incision is extended out from the wound, creating a rectangle with one edge remaining intact. This is freed from the deeper tissues and stretched, or advanced, forward to cover the wound. |
| Ischium | Semi-circular area of the pelvis. |
| Coccyx | aka Tailbone |
| Trochanter | The greater trochanter is the rounded edge at the top of the femur where the femur meets the pelvis. |
| Pressure ulcers, Stage I: non-blanchable erythema | The skin has areas of redness over a bony prominence that does not blanch. Blanching means that when pressed, the reddened area turns white briefly and then the color returns to the area. |
| Pressure ulcers, Stage II: partial thickness | There is a partial thickness of dermis lost. |
| Pressure ulcers, Stage III: full thickness | The ulcer is down to the full thickness of the epidermis and may expose the subcutaneous fat. There also may be undermining. |
| Pressure ulcers, Stage IV: full thickness with tissue loss | There is full thickness skin tissue loss and there is exposed bone, tendon, or muscle tissue. There is often tunneling or undermining. |
| Ulcer locations | Ankle, back, buttock, coccyx, contiguous site of back or buttock or hip, elbow, face, head, heel, hip, sacral region (tailbone), or other specified site |
| First Degree Burns | Also termed as Superficial Burn they affect only the first layer of skin (epidermis). They usually do not require any medical attention, however they can be painful. |
| Second Degree Burns | The skin blisters immediately and the epidermis and dermis layers are involved. Blisters can be superficial or may involve deeper damage to the dermal layer. These are extremely painful, since the nerve endings are exposed, and may also leave a scar. |
| Third Degree Burns | Full-thickness involving the epidermis, dermis, and varying levels of subcutaneous tissues. |
| Fourth Degree Burns | This classification of burns involve the muscles, tendons, and bones. |
| Compression Syndrome | With burns, interstitial pressure can rise and may cause impairment of venous outflow, followed by reduced arterial inflow resulting in compartment syndrome. |
| Eschar | A thick, crusty covering or slough developing after thermal or chemical burn or cauterization of the skin. An escharotomy is a surgical incision through the necrotic skin, usually performed in the first 24 hours of burn injury to release the pressure. |
| Atypical Fibroxanthoma | Skin cancer of the head and neck primarily in older individuals, usually due to sun exposure. |
| Dermatofibrosarcoma Protuberans (DFSP) | Rare type of soft tissue sarcoma in the deep layers of skin, with tentacles that can grow into surrounding fat, muscle, and even bone. |
| Extirpation | The complete removal or eradication of an organ or tissue. |
| Extramammary Paget's Disease (EMPD) | Rare, slow-growing, usually noninvasive intraepithelial adenocarcinoma outside the mammary gland and includes Paget's disease of the vulva or penis (very rare). |
| Keratoacanthoma (KA) | Similar to squamous cell carcinoma, it originates in the skin's hair follicles. It is rapid-growing over a few weeks to months, rarely is it invasive or metastatic. |
| Vermillion | The lips are covered on the outside by skin and on the inside by a mucous membrane. The transition zone, where the two kinds of covering tissue meet is the vermillion (red colored). |
| Undermining | A surgical technique for cutting the fibers that connect the skin to the underlying fascia. |
| Female Breast Composition | Adipose tissue, connective tissue, ligaments, blood vessels, lymph vessels, and nerves. |
| Lobules | Inside the lobes of the breasts, these produce milk in a lactating mother. Milk travels from the lobules, which connect to the ducts, until it reaches the nipple, from where it exits through the skin. |
| Ductogram/Galactogram | A special type of contrast enhanced mammography used for imaging the breast. |
| Incision | Surgical opening made with an instrument such as a scalpel or knife. |
| Medial | Pertain to the middle, in or toward the middle. |
| Lateral | Pertain to the side, in or toward the side. |
| Mamm/o | Breast |
| Lobo | Lobe |
| Galact/o | Milk |
| Lact/o | Milk |
| Breast Abscess | Painful collection of pus that forms in the breast. |
| Breast Cyst | Benign, non-cancerous, fluid-filled sac. |
| Breast Mass or Lump | Solid non-cancerous tumor, formed due to fibrocystic changes or fibroadenoma. |
| Hematoma | Collection of blood due to internal bleeding in the breast tissue as a result of either traumatic or non-traumatic conditions. At times can be caused due to puncture or compression after a breast surgery. Sometimes requires an ultrasound for diagnosis. |
| Seroma | A collection of yellow fluid, which is usually the "Serum" component of the blood. |
| Clavicle (Collarbone) | Marks the upper boundary of the breast tissue. |
| Breast Calcifications | Tiny calcium deposits that develop in the breast tissue and may be found on diagnostic breast imaging. Very common, especially after menopause, and are usually benign. If microcalcifications are clustered together, this could be a sign of malignancy. |
| Ductal Carcinoma In Situ (DCIS) | This is a cancer of the Milk Ducts and is the most common type of non-invasive breast cancer. |
| Invasive Ductal Carcinoma/Infiltrative Ductal Carcinoma (IDC) | The cancer cells grow and extend beyond the ducts. This type of breast cancer accounts for 70-80% of all breast cancers, and is most commonly found in men. |
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