Once, when I was working with a DME company, I noticed what seemed to be a bizarre pattern in the medical records. All patients with a diagnosis of CP were receiving disposable diapers or underpads. What?
Why, I wondered, would patients with chest pain need diapers? And then I realized: These were patients with cerebral palsy. That experience reinforced an important lesson: Context is everything. The meaning of abbreviations used by providers depends on the medical specialty.
DME illustrates the point. As a medical professional, you probably realized I was referring to durable medical equipment. But in other contexts, DME could also refer to Development, Modernization, and Enhancement—defined by the U.S. Department of Energy as “the project cost for new projects, changes or modifications to existing systems to improve capability or performance.” If you were an airplane pilot, you would recognize DME as Distance Measuring Equipment, an electronic device that tells you how far you are from a particular ground station.
It’s easy to understand why abbreviations are so prevalent in healthcare. The full terms are cumbersome to spell out on patient records, especially given the already imposing documentation burden on providers. Abbreviations are commonly used in particular specialties and are often easy to interpret. MI (for myocardial infarction) and PE (for pulmonary embolism) are two examples that may come to mind.
In other cases, however, the intent is not obvious without more context because some abbreviations can apply to multiple medical conditions.
That’s why it’s essential for coders always to go back and read the documentation, even if they think they know what the abbreviation means. (It’s also important for providers, wherever possible, to be mindful of the potential for confusion when they apply abbreviations.)
This isn’t an exhaustive list, but here are some examples of medical abbreviations that can describe very different diagnoses:
| AMS | Altered Mental Status, Acute Maxillary Sinusitis, Aseptic Meningitis Syndrome, Acute Mountain Sickness, or Atypical Measles Syndrome |
| CLD | Chronic Liver Disease or Chronic Lung Disease |
| CP | Chest Pain, Cerebral Palsy, or Chronic Prostatitis |
| DC | Discharge or Discontinue |
| DHF | Dengue Hemorrhagic Fever or Diastolic Heart Failure |
| DNR | Did Not Respond, Do Not Report, or Do Not Resuscitate |
| ED | Erectile Dysfunction, Eating Disorder, Emotional Disorder, or Elbow Disarticulation |
| HD | Hansen’s Disease, Hodgkin’s Disease, or Huntington’s Disease |
| IBS | Ichthyosis Bullosa of Siemens or Irritable Bowel Syndrome |
| LL | Left Leg, Left Lung, Lower Lid, Lower Limb, or Lower Lip |
| MS | Mitral Stenosis or Multiple Sclerosis |
| MV | Mechanical Ventilation, Manual Ventilation, or Mitral Valve |
| PD | Paget’s Disease, Panic Disorder, Parkinson’s Disease, Personality Disorder, or Peyronie’s Disease |
| RS | Raynaud’s Syndrome, Reiter’s Syndrome, Rett Syndrome, Reye’s Syndrome, or Richter’s Syndrome |
| SJS | Schwartz-Jampel Syndrome, Stevens-Johnson Syndrome, or Swyer-James Syndrome |
| TS | Tay-Sachs Disease, Tourette Syndrome, Tuberous Sclerosis, or Turner Syndrome |
| WC | Wheelchair or Workers Comp |
| WS | Waardenburg Syndrome, Werner Syndrome, West Syndrome, or Williams Syndrome |
Got a question about E/M coding? We’d love to hear from you.
Submit your questions by emailing us at coders@calmwatersai.com
Michelle Sergei-Casiano CPC, CFPC, CEMC Senior Manager, Regulatory and Coding Compliance coders@calmwatersai.com