Medical Terminology Basics for Medical Coding

Introduction

Welcome to Day 2 of our Medical Coding Course.

Before learning ICD-10-CM, CPT, and HCPCS coding, it is very important to understand Medical Terminology. Medical terminology is the language used by healthcare professionals to describe diseases, symptoms, body parts, procedures, and medical conditions.

For a medical coder, understanding medical terminology helps you read and understand physician documentation, operative reports, diagnostic reports, discharge summaries, and medical records accurately.

In this Day 2 lesson, we will cover:

Medical Terminology Basics
Prefixes
Suffixes
Root Words
Medical Abbreviations
Directional Terms
How to break down medical terms
Medical terminology examples for coders
Exam tips
Practice questions

What Is Medical Terminology?

Medical terminology is a standardized language used to describe the human body, diseases, medical conditions, treatments, and procedures.

Most medical terms are built from several components:

Basic Components of a Medical Term

Prefix + Root Word + Suffix

Not every medical term contains all three components, but understanding these parts makes difficult words easier to understand.

Example:

Tachycardia

Tachy- = Fast
Cardi = Heart
-ia = Condition

Therefore:

Tachycardia = Condition of a fast heart rate

Another example:

Bradycardia

Brady- = Slow
Cardi = Heart
-ia = Condition

Bradycardia = Condition of a slow heart rate

Prefixes

A prefix is a word element placed at the beginning of a medical term.

Prefixes often tell us about:

Location
Number
Size
Speed
Position
Direction
Amount
Time
Negation or absence

Understanding prefixes is extremely useful when reviewing medical records.

Common Medical Prefixes

Prefix	Meaning	Example	Meaning of Example
a-, an-	Without, absence of	Anuria	Absence of urine
ab-	Away from	Abduction	Movement away from the body
ad-	Toward	Adduction	Movement toward the body
ante-	Before	Antepartum	Before childbirth
anti-	Against	Antibiotic	Against microorganisms
brady-	Slow	Bradycardia	Slow heart rate
tachy-	Fast	Tachycardia	Fast heart rate
bi-	Two	Bilateral	Both sides
uni-	One	Unilateral	One side
tri-	Three	Tricuspid	Three cusps
hyper-	Excessive, above normal	Hypertension	High blood pressure
hypo-	Below normal, deficient	Hypoglycemia	Low blood glucose
intra-	Within	Intravenous	Within a vein
inter-	Between	Intercostal	Between ribs
sub-	Under, below	Subcutaneous	Under the skin
supra-	Above	Suprapubic	Above the pubic area
peri-	Around	Pericardium	Around the heart
endo-	Within	Endoscopy	Examination within
ecto-/exo-	Outside	Exocrine	Secreting outward
post-	After	Postoperative	After surgery
pre-	Before	Preoperative	Before surgery
poly-	Many	Polyuria	Excessive urination
oligo-	Few, scanty	Oliguria	Decreased urine output
pan-	All	Pancytopenia	Reduction of all blood cell types
hemi-	Half	Hemiplegia	Paralysis of one side of the body
macro-	Large	Macrocephaly	Abnormally large head
micro-	Small	Microcephaly	Abnormally small head
neo-	New	Neonatal	Relating to a newborn
dys-	Difficult, abnormal, painful	Dysphagia	Difficulty swallowing

Coding Tip

Do not assign an ICD-10-CM code based only on the meaning of a prefix.

The complete medical documentation and provider's diagnosis must be reviewed before code selection.

Suffixes

A suffix is a word element placed at the end of a medical term.

Suffixes frequently describe:

A disease or condition
A procedure
Inflammation
Pain
Surgical removal
Examination
Study
Specialist
Blood condition

Common Medical Suffixes

Suffix	Meaning	Example	Meaning
-itis	Inflammation	Arthritis	Inflammation of a joint
-algia	Pain	Neuralgia	Nerve pain
-ectomy	Surgical removal	Appendectomy	Surgical removal of appendix
-otomy	Incision/cutting into	Laparotomy	Incision into abdomen
-ostomy	Creation of an opening	Colostomy	Creation of an opening from colon
-plasty	Surgical repair	Rhinoplasty	Surgical repair/reshaping of nose
-scopy	Visual examination	Colonoscopy	Visual examination of colon
-gram	Record or image	Mammogram	Image/record of breast
-graphy	Process of recording/imaging	Angiography	Imaging of blood vessels
-megaly	Enlargement	Cardiomegaly	Enlargement of heart
-pathy	Disease	Neuropathy	Disease/disorder of nerves
-oma	Tumor/mass	Lipoma	Fatty tissue tumor
-osis	Abnormal condition	Arthrosis	Abnormal joint condition
-emia	Blood condition	Anemia	Blood condition involving reduced healthy red blood cells
-uria	Urine condition	Hematuria	Blood in urine
-pnea	Breathing	Apnea	Absence of breathing
-rrhea	Flow/discharge	Diarrhea	Abnormally frequent/liquid stools
-rrhage	Excessive bleeding/flow	Hemorrhage	Excessive bleeding
-lysis	Breakdown/separation	Hemolysis	Breakdown of red blood cells
-stasis	Stopping/control	Hemostasis	Stopping bleeding
-centesis	Surgical puncture	Arthrocentesis	Surgical puncture of a joint
-scopy	Examination using a scope	Endoscopy	Examination using an endoscope
-logy	Study of	Cardiology	Study of the heart
-logist	Specialist	Cardiologist	Heart specialist

Root Words

The root word is the basic part of a medical term that identifies the main body part, organ, or concept.

Examples:

Root Word	Meaning	Example
cardi	Heart	Cardiology
gastr	Stomach	Gastritis
hepat	Liver	Hepatitis
neph	Kidney	Nephrology
ren	Kidney	Renal
neur	Nerve	Neurology
oste	Bone	Osteoporosis
arthr	Joint	Arthritis
my	Muscle	Myalgia
derm	Skin	Dermatology
hemat	Blood	Hematology
pneum	Lung/Air	Pneumonia
encephal	Brain	Encephalopathy
cephal	Head	Cephalic
enter	Intestine	Enteritis
col	Colon	Colitis
cyst	Bladder/Sac	Cystitis
gynec	Female reproductive system	Gynecology
hyster	Uterus	Hysterectomy
oophor	Ovary	Oophorectomy
salping	Fallopian tube	Salpingectomy
mamm	Breast	Mammography
ot	Ear	Otitis
rhin	Nose	Rhinoplasty
ophthalm	Eye	Ophthalmology
stomat	Mouth	Stomatitis
odont	Tooth	Odontology

Combining Vowels

A combining vowel, commonly "o", is often used to connect a root word with a suffix or another root.

Example:

Cardiology

Cardi = Heart
o = Combining vowel
logy = Study of

Cardiology = Study of the heart

Another example:

Gastroenterology

Gastr = Stomach
o = Combining vowel
Enter = Intestine
o = Combining vowel
logy = Study of

Gastroenterology = Study of the digestive system, particularly the gastrointestinal tract.

How to Break Down Medical Terms

One of the easiest ways to understand medical terminology is to break a word into smaller parts.

Example 1: Appendectomy

Append + ectomy

Append = Appendix
-ectomy = Surgical removal

Appendectomy = Surgical removal of the appendix

Example 2: Cholecystectomy

Chole + cyst + ectomy

Chole = Bile
Cyst = Bladder/sac
-ectomy = Surgical removal

Cholecystectomy = Surgical removal of the gallbladder

Example 3: Hysterectomy

Hyster + ectomy

Hyster = Uterus
-ectomy = Surgical removal

Hysterectomy = Surgical removal of the uterus

Example 4: Gastritis

Gastr + itis

Gastr = Stomach
-itis = Inflammation

Gastritis = Inflammation of the stomach

Example 5: Osteoarthritis

Oste + o + arthr + itis

Oste = Bone
o = Combining vowel
Arthr = Joint
-itis = Inflammation

Osteoarthritis = Degenerative joint disease involving cartilage and underlying bone.

Medical Abbreviations

Medical records frequently contain abbreviations.

A medical coder should understand commonly used abbreviations while also being careful about ambiguous abbreviations and facility-specific abbreviations.

Common Medical Abbreviations

Abbreviation	Meaning
BP	Blood Pressure
HR	Heart Rate
RR	Respiratory Rate
Temp	Temperature
Hx	History
Dx	Diagnosis
Tx	Treatment
Sx	Symptoms / Surgery depending on context
Rx	Prescription/Treatment
PMH	Past Medical History
PSH	Past Surgical History
FH	Family History
SH	Social History
ROS	Review of Systems
HPI	History of Present Illness
PE	Physical Examination
DOB	Date of Birth
ED	Emergency Department
ICU	Intensive Care Unit
OR	Operating Room
PACU	Post-Anesthesia Care Unit
NPO	Nothing by mouth
PRN	As needed
BID	Twice daily
TID	Three times daily
QID	Four times daily
PO	By mouth
IV	Intravenous
IM	Intramuscular
SQ/SubQ	Subcutaneous
STAT	Immediately
CBC	Complete Blood Count
BMP	Basic Metabolic Panel
CMP	Comprehensive Metabolic Panel
ECG/EKG	Electrocardiogram
MRI	Magnetic Resonance Imaging
CT	Computed Tomography
US/Ultrasound	Ultrasonography
CXR	Chest X-ray
ROM	Range of Motion
WNL	Within Normal Limits
NAD	No Acute Distress

Important Coding Tip

Never assume the meaning of an abbreviation when the documentation is unclear.

For coding, always follow:

Documentation → Official Coding Guidelines → Code assignment

When an abbreviation is ambiguous and affects code selection, follow your organization's approved clarification/query process.

Directional Terms

Directional terms describe the location or position of one body structure in relation to another.

These terms are extremely important in medical coding because medical documentation often describes the exact location of an injury, disease, or procedure.

Common Directional Terms

Superior

Means above or toward the head.

Example:

The chest is superior to the abdomen.

Inferior

Means below or away from the head.

Example:

The stomach is inferior to the heart.

Means toward the front of the body.

Example:

The sternum is anterior to the heart.

Posterior

Means toward the back of the body.

Example:

The spine is posterior to the heart.

Medial

Means toward the midline of the body.

Example:

The nose is medial to the eyes.

Lateral

Means away from the midline.

Example:

The ears are lateral to the eyes.

Proximal

Means closer to the point of attachment or origin.

Example:

The shoulder is proximal to the elbow.

Distal

Means farther from the point of attachment or origin.

Example:

The fingers are distal to the elbow.

Superficial

Means closer to the surface of the body.

Example:

The skin is superficial to the muscles.

Deep

Means farther from the surface of the body.

Example:

The bones are deep to the skin.

Ipsilateral

Means on the same side of the body.

Example:

The right arm and right leg are ipsilateral.

Contralateral

Means on the opposite side of the body.

Example:

The right arm and left leg are contralateral.

Bilateral

Means both sides.

Example:

Bilateral knee pain = pain in both knees.

Unilateral

Means one side.

Example:

Unilateral ear infection = infection affecting one ear.

Body Planes

Medical professionals also describe the body using anatomical planes.

Sagittal Plane

Divides the body into right and left portions.

Midsagittal Plane

Divides the body into equal right and left halves.

Coronal/Frontal Plane

Divides the body into anterior and posterior portions.

Transverse Plane

Divides the body into upper and lower portions.

These concepts are particularly useful when reading radiology and surgical documentation.

Common Medical Terms Every Beginner Coder Should Know

Here are some common terms that medical coding students should become familiar with:

Medical Term	Meaning
Hypertension	High blood pressure
Hypotension	Low blood pressure
Hyperglycemia	High blood glucose
Hypoglycemia	Low blood glucose
Tachycardia	Fast heart rate
Bradycardia	Slow heart rate
Dyspnea	Difficulty breathing
Apnea	Temporary cessation of breathing
Hematuria	Blood in urine
Hematemesis	Vomiting blood
Hemoptysis	Coughing up blood
Edema	Swelling caused by fluid accumulation
Erythema	Redness of the skin
Cyanosis	Bluish discoloration associated with reduced oxygenation
Nausea	Feeling of needing to vomit
Emesis	Vomiting
Dysphagia	Difficulty swallowing
Syncope	Fainting/loss of consciousness
Myalgia	Muscle pain
Arthralgia	Joint pain
Neuralgia	Nerve pain
Hepatomegaly	Enlarged liver
Splenomegaly	Enlarged spleen
Cardiomegaly	Enlarged heart

Medical Terminology and ICD-10-CM Coding

Medical terminology is the foundation for understanding diagnosis documentation.

For example, a provider documents:

"Acute cystitis with hematuria."

A coder needs to understand:

Cyst = bladder
-itis = inflammation
Hematuria = blood in urine

Understanding the terminology helps the coder locate the appropriate diagnosis category and then verify the specific ICD-10-CM code in the Alphabetic Index and Tabular List.

Important Rule

Do not select a code simply because you recognize the medical term.

Always verify:

The provider's documented diagnosis
The Alphabetic Index
The Tabular List
Inclusion/exclusion notes
Code first/use additional code instructions
Laterality, when applicable
Applicable official coding guidelines

Medical Terminology and CPT Coding

Medical terminology is also important for understanding CPT procedure descriptions.

For example:

Arthroscopy

Arthr = Joint
-scopy = Visual examination

A coder who understands the terminology can better understand that arthroscopy involves examination of a joint using an arthroscope.

However, CPT code selection requires more than understanding the word.

The coder must review:

Procedure performed
Surgical approach
Anatomical site
Technique
Extent of procedure
CPT guidelines
Parenthetical instructions
Code descriptors
Bundling and other applicable coding rules

Medical Terminology for Same-Day Surgery Coding

Medical terminology becomes especially important in Same-Day Surgery/Outpatient Surgery coding.

Common surgical terms include:

-ectomy

Removal

Example:

Appendectomy – removal of appendix

-otomy

Incision into

Example:

Laparotomy – surgical incision into the abdominal cavity

-ostomy

Creation of an opening

Example:

Colostomy – creation of an opening from the colon to the outside of the body

-plasty

Repair or reconstruction

Example:

Angioplasty – procedure to widen or restore blood vessel patency

-scopy

Visual examination

Example:

Colonoscopy – visual examination of the colon

-centesis

Surgical puncture

Example:

Thoracentesis – puncture of the chest/pleural space to remove fluid or air

Knowing these terms makes it easier to understand operative reports and procedure documentation.

Easy Method to Learn Medical Terminology

Use the following five-step method:

Step 1 – Identify the Suffix

Look at the end of the word.

Example:

Gastritis

Suffix = -itis

Meaning = inflammation

Step 2 – Identify the Root

Gastr = stomach

Step 3 – Identify the Prefix

If there is a prefix, identify it.

Step 4 – Combine the Meanings

Gastr + itis

= inflammation of the stomach

Step 5 – Apply the Meaning to the Medical Record

Understanding the term helps you interpret the documentation before looking up the appropriate code.

Day 2 Exam Preparation

For a Medical Coding exam or interview, make sure you can recognize the following.

Prefixes

Remember:

Hyper = Above/excessive
Hypo = Below/deficient
Tachy = Fast
Brady = Slow
Pre = Before
Post = After
Intra = Within
Inter = Between
Sub = Below
Peri = Around
Bi = Two
Uni = One
Poly = Many
Oligo = Few

Suffixes

Remember:

-itis = Inflammation
-ectomy = Removal
-otomy = Incision
-ostomy = Creation of opening
-plasty = Repair
-scopy = Visual examination
-megaly = Enlargement
-algia = Pain
-emia = Blood condition
-uria = Urine condition
-pnea = Breathing
-rrhage = Excessive bleeding
-centesis = Surgical puncture

Directional Terms

Remember:

Superior ↔ Inferior
Anterior ↔ Posterior
Medial ↔ Lateral
Proximal ↔ Distal
Superficial ↔ Deep
Ipsilateral ↔ Contralateral

Day 2 Practice Questions

Question 1

What does the prefix tachy- mean?

A. Slow
B. Fast
C. Below
D. Around

Answer: B. Fast

Question 2

What does the suffix -itis mean?

A. Removal
B. Pain
C. Inflammation
D. Enlargement

Answer: C. Inflammation

Question 3

What does bradycardia mean?

A. Fast heart rate
B. Slow heart rate
C. Heart inflammation
D. Heart enlargement

Answer: B. Slow heart rate

Question 4

What does bilateral mean?

A. One side
B. Both sides
C. Opposite side
D. Middle

Answer: B. Both sides

Question 5

Which term means "toward the midline"?

A. Lateral
B. Distal
C. Medial
D. Posterior

Answer: C. Medial

Question 6

Which suffix means surgical removal?

A. -itis
B. -ectomy
C. -scopy
D. -algia

Answer: B. -ectomy

Question 7

What does proximal mean?

A. Farther from point of attachment
B. Closer to point of attachment
C. Toward the back
D. Away from the midline

Answer: B. Closer to point of attachment

Question 8

What does hypoglycemia generally indicate?

A. High blood glucose
B. Low blood glucose
C. High blood pressure
D. Low blood pressure

Answer: B. Low blood glucose

Quick Revision Chart

PREFIX

Beginning of the word

Example:

Hyper + tension

Hyper = excessive/above normal

ROOT WORD

Main meaning/body part

Example:

Cardi = Heart

SUFFIX

End of the word

Example:

Cardi + itis

-itis = inflammation

DIRECTIONAL TERM

Describes anatomical location

Example:

Medial = toward the midline

Important Tips for Medical Coders

Medical terminology is not something you need to memorize in one day.

Build your vocabulary gradually.

When you see an unfamiliar medical term:

Break → Understand → Verify → Code

Do not guess a diagnosis or procedure from terminology alone.

Medical coders should always code from provider documentation and apply the appropriate coding guidelines.

For ICD-10-CM diagnosis coding, always verify the code in the current-year ICD-10-CM code set and review the Tabular List.

For CPT coding, use the current-year CPT code set and follow CPT guidelines and instructional notes.

What's Next?

In Day 3 of the Medical Coding Course, we will move from terminology into Human Anatomy & Physiology Basics.

We will cover:

Body planes
Body Cavities
Organ Systems

Keep learning, keep practicing, and build your medical coding knowledge step by step!

Disclaimer

This educational article is intended for medical coding students and beginners for learning purposes. Coding rules and code sets can change from year to year. Always refer to the current official ICD-10-CM, CPT, HCPCS Level II, and applicable official coding guidelines when performing actual coding.