Medical Coding Terminology

The Medical Terminology Glossary for Medical Coders is a quick-reference tool designed to support coding accuracy, documentation review, and everyday efficiency. This alphabetized glossary includes clear, coder-focused definitions for clinical terms commonly encountered across ICD-10-CM, ICD-10-PCS, and CPT coding.

A

• Acute – A condition with a rapid onset and/or short duration.
• Adhesion – Bands of scar tissue that bind together internal organs.
• Anastomosis – Surgical connection between two structures, often intestines or blood vessels.
• Anemia – A deficiency of red blood cells or hemoglobin in the blood.

B

• Benign – Non-cancerous growth or condition.
• Biopsy – The removal of tissue for diagnostic examination.
• Bilateral – Affecting both sides of the body.

C

• Chronic – A long-term or recurring condition.
• Comorbidity – A condition present in addition to the primary diagnosis.
• Congenital – A condition present at birth.
• Cyst – A closed sac-like structure filled with liquid or semisolid material.

D

• Debridement – Removal of dead, damaged, or infected tissue.
• Deficiency – Lack or shortage of a substance necessary for health.
• Diagnosis – Identification of a disease or condition from signs and symptoms.
• Dysplasia – Abnormal growth or development of cells, tissues, or organs.

E

• Edema – Swelling caused by fluid accumulation.
• Excision – Surgical removal of tissue or organ.
• Etiology – The cause or origin of a disease.

F

• Fracture – A break in bone or cartilage.
• Fistula – Abnormal connection between two body parts.
• Fulguration – Destruction of tissue using electric current.

G

• Gastrostomy – Surgical opening into the stomach.
• Gravida – Total number of times a woman has been pregnant.

H

• Hematoma – Localized collection of blood outside the blood vessels.
• Hernia – Protrusion of an organ through the wall that contains it.
• Hyperplasia – Increase in the number of cells in an organ or tissue.
• Hypoxia – Deficiency in oxygen supply to the tissues.

I

• Incision – A surgical cut made to access internal structures.
• Infarction – Tissue death due to loss of blood supply.
• In situ – In its original place; often used to describe cancer that has not spread.
• Iatrogenic – Condition caused by medical treatment or diagnostic procedure.

J

• Jaundice – Yellowing of the skin and eyes due to elevated bilirubin, often indicating liver dysfunction.
• Joint Effusion – Accumulation of fluid in or around a joint.

K

• Kyphosis – Abnormal forward curvature of the spine, leading to a hunchback appearance.
• Keratitis – Inflammation of the cornea, often affecting vision.

L

• Laceration – A deep cut or tear in skin or tissue.
• Lesion – Abnormal tissue or change due to disease or trauma.
• Lysis – Destruction or breakdown of cells or tissue.

M

• Malignant – Cancerous and potentially life-threatening.
• Metastasis – Spread of cancer from one part of the body to another.
• Myopathy – Disease of the muscles.

N

• Necrosis – Death of body tissue.
• Nosocomial – Infection acquired in a hospital setting.
• Neoplasm – New or abnormal tissue growth; may be benign or malignant.

O

• Obstruction – Blockage of a passage or organ.
• Oophorectomy – Surgical removal of one or both ovaries.
• Orthopedic – Pertaining to bones, joints, and muscles.

P

• Perforation – A hole made through a structure or organ.
• Polyp – Growth projecting from a mucous membrane.
• Prophylactic – Preventative medical treatment.
• Pyelonephritis – Kidney infection.

Q

• Quadriplegia – Paralysis affecting all four limbs, typically caused by spinal cord injury.
• Quarantine – Isolation of individuals to prevent the spread of infectious disease (may appear in documentation for public health encounters).

R

• Resection – Surgical removal of part of an organ or structure.
• Revision – Correction or modification of a previous procedure.
• Rupture – Tearing or bursting open of an organ or structure.

S

• Sepsis – The body's serious response to an infection that could be life-threatening.
• Stenosis – Narrowing of a bodily passage or opening.
• Suture – Stitch used to close wounds or surgical incisions.
• Syncope – Temporary loss of consciousness (fainting).

T

• Thrombosis – Formation of a blood clot inside a blood vessel.
• Tracheostomy – Surgical opening into the trachea.
• Tumor – An abnormal growth of tissue, may be benign or malignant.

U

• Ulcer – An open sore on the skin or mucous membrane.
• Urolithiasis – Formation of stones in the urinary tract.

V

• Vascular – Pertaining to blood vessels.
• Volvulus – Twisting of the intestine causing obstruction.

W

• Wound Dehiscence – Reopening of a wound that has been surgically closed.
• Wheezing – High-pitched whistling sound during breathing, typically seen in respiratory conditions like asthma.

X

• Xerosis – Abnormal dryness of the skin, eyes, or mucous membranes.
• Xanthoma – Yellowish fatty deposit under the skin, often related to lipid disorders.

Y

• Yawn Reflex – Involuntary reflex that may be documented in neurological assessments (rarely coded, but occasionally referenced).
• Yersiniosis – Bacterial infection from the Yersinia genus, often linked to gastroenteritis.

Z

• Zoster – Another term for shingles, a reactivation of the varicella-zoster virus.
• Zygoma – The cheekbone; often referenced in facial trauma or surgery coding.