Key Takeaways
- Medical terms are built from four components: word roots, prefixes, suffixes, and combining vowels.
- The word root is the foundation of every medical term and identifies the body part or structure involved.
- A combining vowel (usually "o") is used between a word root and a suffix that begins with a consonant to make the term easier to pronounce.
- Prefixes modify the meaning of the root by indicating location, number, time, or status (e.g., "hyper-" means excessive, "sub-" means under).
- Suffixes indicate the condition, procedure, or disease associated with the root (e.g., "-itis" means inflammation, "-ectomy" means surgical removal).
- Understanding word parts allows coders to decode unfamiliar medical terms without memorizing every individual word.
- Directional terms such as superior, inferior, anterior, posterior, medial, and lateral are essential for understanding operative reports.
- Body planes (sagittal, coronal/frontal, transverse) and body cavities (thoracic, abdominal, pelvic, cranial) are frequently referenced in coding documentation.
Medical Terminology Foundations
Medical terminology is the specialized language of healthcare. For CPC coders, understanding medical terms is not optional — it is the foundation of accurate code assignment. Every operative report, progress note, and diagnosis description uses these terms. Knowing how to break down and analyze unfamiliar terms is a critical skill on the CPC exam.
Building Blocks of Medical Terms
Medical terms are constructed from four key components:
1. Word Roots
The word root is the core of every medical term. It identifies the body part, organ, or structure being referenced.
| Word Root | Meaning | Example Term |
|---|---|---|
| cardi/o | Heart | Cardiology (study of the heart) |
| gastr/o | Stomach | Gastritis (inflammation of the stomach) |
| arthr/o | Joint | Arthroscopy (visual examination of a joint) |
| dermat/o | Skin | Dermatitis (inflammation of the skin) |
| oste/o | Bone | Osteoporosis (porous bone condition) |
| nephr/o | Kidney | Nephrectomy (surgical removal of a kidney) |
| pulmon/o | Lung | Pulmonary (pertaining to the lungs) |
| neur/o | Nerve | Neurology (study of the nervous system) |
| hepat/o | Liver | Hepatitis (inflammation of the liver) |
| my/o | Muscle | Myalgia (muscle pain) |
2. Combining Vowels
A combining vowel (almost always the letter "o") links a word root to a suffix or to another word root. The combining vowel is used when the suffix begins with a consonant.
Rules:
- Use a combining vowel between a word root and a suffix that starts with a consonant: gastr + o + scope = gastroscope
- Do NOT use a combining vowel when the suffix begins with a vowel: gastr + itis = gastritis (not "gastroitis")
- Use a combining vowel between two word roots, regardless of the second root's starting letter: gastr + o + enter + itis = gastroenteritis
3. Prefixes
Prefixes are added to the beginning of a term to modify its meaning. They indicate location, time, number, or status.
| Prefix | Meaning | Example |
|---|---|---|
| hyper- | Excessive, above | Hypertension (high blood pressure) |
| hypo- | Deficient, below | Hypoglycemia (low blood sugar) |
| sub- | Under, beneath | Subcutaneous (under the skin) |
| supra- | Above | Suprapubic (above the pubic bone) |
| peri- | Around | Pericardium (membrane around the heart) |
| inter- | Between | Intercostal (between the ribs) |
| intra- | Within | Intravenous (within a vein) |
| bi- | Two | Bilateral (both sides) |
| uni- | One | Unilateral (one side) |
| poly- | Many | Polyuria (excessive urination) |
| dys- | Difficult, painful | Dyspnea (difficulty breathing) |
| a-/an- | Without, absence | Apnea (absence of breathing) |
| anti- | Against | Antibiotic (against bacteria) |
| pre- | Before | Prenatal (before birth) |
| post- | After | Postoperative (after surgery) |
4. Suffixes
Suffixes are added to the end of a word root (with or without a combining vowel) to indicate a condition, procedure, or diagnostic test.
| Suffix | Meaning | Example |
|---|---|---|
| -itis | Inflammation | Appendicitis (inflammation of the appendix) |
| -ectomy | Surgical removal | Cholecystectomy (removal of the gallbladder) |
| -otomy | Cutting into / incision | Tracheotomy (incision into the trachea) |
| -ostomy | Creating an opening | Colostomy (creating an opening in the colon) |
| -plasty | Surgical repair | Rhinoplasty (surgical repair of the nose) |
| -scopy | Visual examination | Colonoscopy (visual examination of the colon) |
| -graphy | Process of recording | Mammography (imaging of the breast) |
| -gram | Record/image | Electrocardiogram (heart rhythm recording) |
| -ology | Study of | Pathology (study of disease) |
| -algia | Pain | Neuralgia (nerve pain) |
| -osis | Abnormal condition | Stenosis (abnormal narrowing) |
| -emia | Blood condition | Anemia (deficient blood/hemoglobin) |
| -pathy | Disease | Neuropathy (nerve disease) |
| -megaly | Enlargement | Cardiomegaly (enlarged heart) |
| -rrhage/-rrhagia | Bursting forth (bleeding) | Hemorrhage (excessive bleeding) |
Anatomical Directional Terms
Understanding directional terms is critical for reading operative reports and assigning codes with correct laterality and anatomical specificity.
| Term | Meaning | Opposite |
|---|---|---|
| Superior (cranial) | Toward the head / upper | Inferior (caudal) — toward the feet / lower |
| Anterior (ventral) | Toward the front | Posterior (dorsal) — toward the back |
| Medial | Toward the midline | Lateral — away from the midline |
| Proximal | Closer to the trunk/origin | Distal — farther from the trunk/origin |
| Superficial | Near the surface | Deep — away from the surface |
| Ipsilateral | Same side | Contralateral — opposite side |
Body Planes
Body planes are imaginary flat surfaces used to divide the body for anatomical reference and imaging:
| Plane | Division | Used In |
|---|---|---|
| Sagittal (lateral) | Divides body into left and right halves | MRI scans, neurological imaging |
| Coronal (frontal) | Divides body into anterior and posterior portions | Chest X-rays, coronal CT reconstructions |
| Transverse (horizontal/axial) | Divides body into superior and inferior portions | CT scans (standard axial slices) |
Body Cavities
| Cavity | Contents | Coding Relevance |
|---|---|---|
| Cranial | Brain | Neurosurgery codes (CPT 61000-62258) |
| Spinal | Spinal cord | Spine surgery codes (CPT 63001-63308) |
| Thoracic | Heart, lungs, great vessels | Cardiothoracic surgery, chest codes |
| Abdominal | Stomach, liver, intestines, kidneys | Digestive system surgery codes |
| Pelvic | Bladder, reproductive organs, rectum | Urinary and genital system codes |
The medical term "cholecystectomy" can be broken down into which components?
When is a combining vowel used in building a medical term?
Match each medical prefix to its correct meaning:
Match each item on the left with the correct item on the right
The suffix "-ectomy" means surgical _____ of a body part.
Type your answer below
A surgeon documents that a lesion is on the "anterior lateral aspect of the right lower extremity." Where is the lesion located?
The transverse (axial) plane divides the body into which two portions?
Which of the following suffixes indicate a SURGICAL PROCEDURE? (Select all that apply)
Select all that apply