Medical Terminology and Anatomy/Physiology
What this domain tests
Terminology items test word roots, prefixes, suffixes, directional terms, planes, cavities, organ systems, and the link between anatomy and code selection.
Core rules
- A combining form is a root plus a vowel, such as chol/e (bile) or cyst/o (bladder). The suffix often determines the procedure type.
- -ectomy is excision; -otomy is incision; -ostomy is creation of an opening; -plasty is repair; -pexy is fixation; -rrhaphy is suture repair.
- Directional terms include proximal (nearer the trunk), distal, medial, lateral, superior, inferior, anterior, and posterior.
- Body planes are sagittal, coronal, and transverse. Major cavities are cranial, spinal, thoracic, abdominal, and pelvic.
- Anatomy drives code choice through site, laterality, approach, and depth, not through the diagnosis alone.
Worked example
The term cholecystectomy combines cholecyst (gallbladder) and -ectomy (excision). The procedure is removal of the gallbladder. If the record describes a laparoscopic approach, report 47562; an open approach would be 47600. The suffix identifies the procedure, while the approach and site determine the correct CPT code.
Traps
Confusing -otomy with -ostomy; mixing proximal and distal; missing laterality; choosing a code by diagnosis rather than documented site and approach; misreading roots with similar spellings.