The Importance of Knowing Medical Abbreviations

ASC coders must keep a watchful eye when reviewing operative reports. Physicians often use medical abbreviations that, if not understood, can be confusing and contribute to coding errors and lost revenue.

While inappropriate use of medical abbreviations in physician documentation can cause other major problems, such as the misinterpretation of medication orders, this coding tip focuses on abbreviations that may cause hiccups with ASC coding.

In situations where the intent of the abbreviation is conflicting or unclear, query the provider for clarification. Obtaining clarification on the documentation will be key to ensuring coders capture the correct codes and file clean claims. Keeping open lines of communication with your physicians can help expedite the query process and get coders the information they need for proper coding quicker.

Here are six commonly used abbreviations in medical records that can hinder accurate and timely ASC coding and what they may stand for:

• OCD: osteochondritis dissecans; osteochondral defect

• AC: alternating current; axiocervical; anticoagulant; anterior chamber; abdominal circumference; acromioclavicular; can also be confused with "ac," which can mean "acute"

• AS: arteriosclerosis; aortic stenosis; ankylosing spondylitis; left ear (auris sinistra)

• TKA: total knee arthroplasty; trochanter knee ankle

• CSM: circulation, sensory, and motor; cervical spondylotic myelopathy

• Cx: culture; conscious; cervix/cervical; cancel

This is just a short list of examples of common abbreviations. Reviewing it should help you further appreciate the potential for confusion and errors when abbreviations are used and help you become a more proactive coder while reading operative reports. Accurately understanding the intention of the documentation is essential to capturing the correct coding and reducing the likelihood of denials and payment delays.