The Importance of Directional Anatomy for ASC Coding Accuracy

Understanding the anatomy of the human body is one of the most important skills for a medical coder. If you browse the different proposed course requirements for institutions offering medical coding classes, you'll find that many either require or highly recommend taking a human anatomy and physiology course. Students often realize why this education is so important once they join the workforce and begin applying their knowledge of anatomy for their day-to-day coding work.

Let's review a few instances where expertise in a specific type of anatomy — directional anatomy — plays a critical role in coding cases quickly and accurately.

Directional Anatomical Terms

Directional anatomical terms describe relative positions of body parts and consist of opposite pairs. Here are examples of directional anatomical term pairs and their definitions.

Superior vs. Inferior

• Superior: toward the head; upper; above
• Inferior: toward the feet; lower; below

Anterior vs. Posterior

• Anterior: front; in front of; ventral
• Posterior: back; in back of; dorsal

Medial vs. Lateral

• Medial: toward the midline of the body
• Lateral: toward the side of the body; away from the midline

Proximal vs. Distal

• Proximal: toward or nearest the trunk of the body or nearest point of origin of one of its parts
• Distal: away from or farthest from the trunk of the body or origin of a body part

Superficial vs. Deep

• Superficial: nearer the surface
• Deep: farther away from the body surface

Applying the Knowledge

ASC coders can save valuable time by learning, understanding, and applying directional anatomical term knowledge during the coding process. The following three scenarios represent only a few theoretical examples of how knowledge of directional anatomical terms can help a coder improve CPT coding accuracy and prevent wasting valuable time researching multiple facets of a surgical case. Note: The directional anatomical terms included in these scenarios are italicized for emphasis.

Patient A

Postoperative diagnosis: Left 3 part intra-articular distal radius fracture

Planned procedure: Open reduction internal fixation Distal radius

Apply term knowledge: Recognize inclusion of "distal." This should direct a coder toward the correct CPT code range for the procedure and avoid getting lost among all the possible options for open reduction and internal fixation of a fracture are available in the CPT code book.

Patient B

Postoperative diagnosis: Mechanical ptosis right eyelid

Planned procedure: Blepharoptosis repair superior rectus with fascial sling

Apply the knowledge: Recognize "superior" and land in the correct CPT code range for this procedure after a quick search for the key phrase "superior rectus."

Patient C

Postoperative diagnosis: Muscle wasting and atrophy of the right ankle

Planned procedure: Right ankle superficial muscle biopsy

Apply the knowledge: Recognize "superficial" and land in the correct CPT code range for this procedure. Available options for muscle biopsy include the terms "deep" and "superficial." Given this information, recognizing and understanding the directional term takes away much of the guesswork and allows a coder to quickly read, interpret, and apply the codes accurately.

Value of Directional Anatomical Term Knowledge

These coding scenario examples capture only a small snapshot of how important it is for ASC coders to have a strong working knowledge of directional anatomical terms. Knowledge of human anatomy and related terms can save a medical coder significant time while drastically decreasing the likelihood of coding errors.