Daftar Kode Diagnosis dan Tindakan

INA - CBG BPJS

Orthopaedi

Januari 2014
Residen wajib mengisi lembar RM 1, Lembar Verifikasi dan laporan operasi sesuai
dengan diagnosis dan tindakan yang tertera secara lengkap, setiap selesai operasi
 DAFTAR DIAGNOSIS (ICD 10) DAN TINDAKAN (ICD 9)

DIVISI ORTHOPAEDI DAN TRAUMATOLOGI

Hand (kelainan dan luka di tangan)

Keterangan ICD 10 Diagnosis ICD 9 Prosedur Plafon

Remove implant Z47.0 Follow-up care involving 78.69 removal implant Kls 1 4.755.800
removal of fracture plate and other device from the bone Kls 2 4.076.400
internal fixation device Kls 3 3.397.000
Luka terbuka di tangan, crush S67.8 Crushing injury of other and 84.03 amputation through Kls 1 16.674.300
injury unspecified parts of wrist and hand hand. Kls 2 14.292.300
S55.1 injury of radial artery at forearm Kls 3 11.910.200
level
Luka kotor /infeksi di jaringan M65.89 Other synovitis and 82.04 incision and drainage Kls 1 9.789.500
lunak tenosynovitis, site unspecified of palmar at thenar space, Kls 2 8.391.000
86.66 homograft to skin Kls 3 6.992.500
Infeksi jaringan L02.8 Cutaneous abscess, furuncle and 82.04 incision and drainage Kls 1 9.789.500
carbuncle of other sites of palmar at thenar space, Kls 2 8.391.000
86.66 homograft to skin Kls 3 6.992.500
ganglion M67.4 ganglion 82.29 Excision of other lesion Kls 1 9.269.800
of soft tissue of hand Kls 2 7.945.500
Kls 3 6.621.300
Fracture pada pergelangan S62.8 fracture at wrist and hand level 79.34 open reduction of Kls 1 9.269.800
tangan dan tangan fracture with internal fixation Kls 2 7.945.500
, carpals and metacarpals. Kls 3 6.621.300

Luka berat pada jari, tangan S68.8 traumatic amputasion of 84.04 amputation and Kls 1 16.674.300
(perlu amputasi) wrist and hand level disarticulation of hand Kls 2 14.292.300
S55.1 injury of radial artery at forearm Kls 3 11.910.200
 level
Deformitas/ kelainan pada jari M20.0 Deformity of finger 84.03 amputation and Kls 1 1.164.400
disarticulation of Hand Kls 2 8.712.400
Kls 3 7.260.300
Jepitan pada syaraf/carpal S64.7 injury of nerves at wrist and 05.9 other operation on Kls 1 6.889.300
tunnel syndrome hand nervous system Kls 2 5.905.100
level Kls 3 4.921. 000
Syndactili Q70.9 Syndactili 86.85 correction of Kls 1 9.269.800
syndactyly Kls 2 7.945.500
Kls 3 6.621.300
Dislokasi pada jari S63.1 dislocation and sprain of joints 79.84 open reduction of Kls 1 9.269.800
and ligaments at wrist and hand level dislocation of hand and Kls 2 7.945.500
finger Kls 3 6.621.300

Tumor ganas pada ekstremitas C40.1 malignant neoplasm of short 84.03 amputation of through Kls 1 16.674.300
atas bones of upper limb hand Kls 2 14.292.300
S55.1 injury of radial artery at forearm Kls 3 11.910.200
leve

Infeksi pada sendi M00 Pyogenic infection 81.29 arthhrodesis of other

specified joints
86.66 homograft to skin
Kerusakan sendi krn rematik M05 .38 rheumatoid arthritis with 81.29 arthhrodesis of other Kls 1 9.789.500
rheumatoid factor specified joints Kls 2 8.391.000
M65.80 other synovitis and 86.66 homograft to skin Kls 3 6.992.500
tenosynovitis Tanpa homograft
Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000
Kerusakan sendi bukan karena M06.9 other rheumatoid arthritis 81.29 arthhrodesis of other Kls 1 9.789.500
rematik specified joints Kls 2 8.391.000
86.72 pedicle or flap graft, Kls 3 6.992.500
not otherwise specified
Deformitas/ kelainan pada jari M20.0 Deformity of finger 82.89 other plastic operation Kls 1 9.269.800
Kls 2 7.945.500
 on hand, Kls 3 6.621.300

kontracture M24.59 contracture unspecified site 82.3 other excision of soft Kls 1 9.269.800
tissue of hand; Kls 2 7.945.500
Kls 3 6.621.300
polidactili Q69.9 polidactyli 84.03 amputation and Kls 1 10.164.400
disarticulation of finger: Kls 2 8.712.400
86.66 homograft to skin Kls 3 7.260.300

Raw surface, defek soft tissue, L98.9 other disorders of skin and 82.89 other plastic Kls 1 9.789.500
sural flap, semua tindakan flap subcutaneous tissue, not elsewhere operation on hand Kls 2 8.391.000
86.70 pedicle or flap graft, Kls 3 6.992.500
not otherwise spesified
Traumatic amputasi perlu S68.9 traumatic amputasion of wrist 84.22 finger reattachment Kls 1 16.798.200
replantasi and hand level 86.70 pedicle or flap graft, Kls 2 14.398.400
S55.1 injury of radial artery at forearm not otherwise spesified Kls 3 11.998.700
leve

Trauma (Fracture)

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur Plafon

1. Non union perlu bone graft M84.90 disorder of continuity of 78.00 bone graft Kls 1 9.789.500
bone , unspecified 86.66 homograft to skin Kls 2 8.391.000
Kls 3 6.992.500

2. Fracture clavikula S42.8 fracture of shoulder and upper 79.30 ORIF,unspecified site Kls 1 8.801.800
arm Kls 2 7.544.400
Kls 3 6.287.000
3. Fracture clavikula dengan S.06.9 intracranial injury 79.30 ORIF,unspecified site Kls 1 11.065.800
cedera kepala S42.8 fracture of shoulder and Kls 2 9.485.000
upper arm Kls 3 7.904.200
4. Fracture tibia/fibula S82.21 Fracture of shaft tibia 79.36 ORIF , tibia and fibula Kls 1 16.306.800
tibia prox/plateu Kls 2 13.977.300
Kls 3 11.647.700
5. Fracture distal tibia S82.2 Fracture of shaft tibia 79.36 ORIF Kls 1 16.036.800
Kls 2 13.977.300
Kls 3 11.647.700
6. Fracture femur S72.31 fracture shaft femur 79.35 ORIF , femur Kls 1 13.618.500
Kls 2 11.673.000
Kls 3 9.727.500
7. Fracture radius S52.3 fracture shaft radius 79.32 ORIF , radius and ulna Kls 1 9.269.800
Kls 2 7.945.500
Kls 3 6.621.300
8. Fracture ulna S52.2 fracture shaft ulna 79.32 ORIF , radius and ulna Kls 1 9.269.800
Kls 2 7.945.500
Kls 3 6.621.300
9. Fr antebrachii S52.7 fracture shaft forearm 79.32 ORIF , radius and ulna Kls 1 9.269.800
Kls 2 7.945.500
Kls 3 6.621.300
10. Fracture humerus S42.3 fracture shaft humerus 79.31 ORIF humerus Kls 1 9.269.800
Kls 2 7.945.500
Kls 3 6.621.300
11. Fracture pada tangan, S62 fracture at wrist and hand level 79.34 ORIF phalank of hand Kls 1 9.269.800
metacarpal, phalang Kls 2 7.945.500
Kls 3 6.621.300
12. Fracture subtrochanter femur S72.2 subtrochanteric fracture of 79.35 ORIF , femur Kls 1 13.618.500
perlu ORIF femur Kls 2 11.673.000
Kls 3
9.727.500
Hip implant :
6000.000
13. Fracture intercondylar femur, S72 fracture shaft femur 79.35 ORIF , femur Kls 1 13.618.500
Kls 2 11.673.000
Kls 3
9.727.500
Knee implant :
6000.000
14. Fracture intertrochanter femur M81.65 Osteoporosis 79.35 ORIF , femur Kls 1
S72.14 Intertrochanteric fracture of Kls 2
femure Kls 3

Hip implant :
6000.000
15. Fracture galeazi S52.3 fracture shaft radius 79.32 ORIF , radius and ulna ; Kls 1 9.209.800
Kls 2 7.945.500
Kls 3 6.621.300
16. Fracture montegia S52.2 shaft ulna 79.32 ORIF , radius and ulna Kls 1 9.209.800
;, Kls 2 7.945.500
Kls 3 6.621.300
17. Fracture prksimal humerus,neck S42.20 fracture of upper end of 79.31 ORIF humerus Kls 1 9.209.800
humerus humerus Kls 2 7.945.500
Kls 3 6.621.300
18. OA Sendi lutut perlu TKR M17.4 other secondary gonarthrosis , 81.54 Total Knee Kls 1 12.744.600
bilateral Replacement Kls 2 10.924.000
M19.26 secondary of the joint , lower Kls 3 9.103.300
leg

19. OA Sendi perlu TKR M17.4 other secondary gonarthrosis , 81.47 other repair of knee Kls 1 16.306.800
bilateral Kls 2 13.977.300
M19.26 secondary of the joint , lower Kls 3 11.647.700
leg Knee replacement
3.000.000

20. OA sendi Hip perlu THR M19.26 secondary of the joint , lower 81.51 Total Hip Replacement Kls 1 12.744.600
leg Kls 2 10.924.000
Kls 3 9.103.300
21. OA Sendi perlu THR M19.26 secondary of the joint , lower 81.40 Repair of hip, not Kls 1 13.618.500
leg elsewhere classified Kls 2 11.673.000
Kls 3
9.727.500
Hip implant :

22. Fracture collum femur, M81.65 Osteoporosis 81.40 Repair of hip, not Kls 1 17.399.100
Kls 2 14.913.500
Kls 3 12.427900
S72.0 fracture of head and neck of elsewhere classified
femur Hip implant :
3000.000

23. Fracture plateau tibia S82.1 Fracture of tibia 79.36 ORIF , tibia and fibula Kls 1 16.306.800
) Kls 2 13.977.300
Kls 3 11.647.700
24. Fracture acetabulum S32.4 fracture acetabulum 79.30 ORIF , unspecified site Kls 1 6.889.300
05.9 other operation on Kls 2 5.905.100
nervous system Kls 3 4.921.000
Tanpa kode 05.9
Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000

Hip implant :
6000.000
25. Fracture S82.90 Fracture of lower leg , 79.37 ORIF tarsal,metatarsal Kls 1 9.342.700
pedis,metacarpale,ankle including ankle Kls 2 8.008.000
Kls 3 6.673.300
26. Fracture patella s820.1 fracture of patella,open 81.44 patellar stabilization Kls 1 16.306.800
Kls 2 13.977.300
Kls 3 11.647.700
27. Infeksi pada sendi, M01 direct infection of joint in 81.9 other operation on joint Kls 1
infectious and parasitic disease structure Kls 2
classified elsewhere 86.66 homograft to skin Kls 3

28. Infeksi tulang, tromboemboli M86.9 Osteomyelitis, 79.60 debridement of Kls 1 9.789.500
open fracture site ; Kls 2 8.391.000
86.70 pedicle or flap graft, Kls 3 6.992.500
not otherwise specified
29. Dislokasi pinggul S73.0 Dislocationand sprain of joint 79.75 closed reduction of Kls 1 4.069.000
and ligament of hip dislocation , hip Kls 2 3.487.700
Kls 3 2.906.400
30. Dislokasi bahu S43.0 Dislocation and sprain of joint 79.71 closed reduction of Kls 1 3.248.000
and ligament of shoulder dislocation shoulder Kls 2 2.784.000
Kls 3 2.320.000
31. Dislokasi siku S53.1 Dislocation and sprain of joint 79.72 closed reduction of Kls 1 3.248.000
and ligament of elbow dislocation , elbow Kls 2 2.784.000
Kls 3 2.320.000
32. Fracture neglected M84.9 disorder of continuity of 78.40 other repair of Kls 1 9.789.500
bone,unspesified plastic operation of bone Kls 2 8.391.000
78.70 osteoclasis,unspecified Kls 3 6.992.500
site Tanpa homograft
86.66 homograft to skin Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000

33. Ruptur Tendon Achilles

 Paediatrik (kelainan dan fracture pada anak < 15 th)

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur Plafon

1. Reposisi dan pasang gip S62.80 fracture at wrist and hand 79.04 closed reduction of Kls 1 3.248.000
ekstremitas atas dengan GA level fracture without internal Kls 2 2.784.000
fixation Kls 3 2.320.000

2 Reposisi dan pasang gip S82.7 fracture of lower leg 79.07 closed reduction of Kls 1 3.248.000
ekstremitas bawah dengan GA fracture without internal Kls 2 2.784.000
fixation Kls 3 2.320.000

3 Rekonstruksi ibu jari kaki , halux M20.1 halux valgus/acquired 82.89 other plastic operation Kls 1 9.342.700
valgus on hand Kls 2 8.008.000
77.59 other buninectomy Kls 3 6.673.300

4 Fracture neglected M84.9 disorder of continuity of 78.40 other repair of Kls 1 9.789.500
bone,unspesified plastic operation of bone Kls 2 8.391.000
78.70 osteoclasis,unspecified Kls 3 6.992.500
site Tanpa homograft
86.66 homograft to skin Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000

5 Kelainan congenital,CTEV,Blount Q66.3 other congenital varus 78.40 other repair of plastic Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000

disease deformities of feet, operation of bone

6 Pemanjangan tulang Q66.3 other congenital varus 78.30 limb Kls 1 8.801.800
deformities of feet, lengthening Kls 2 7.544.400
procedure Kls 3 6.287.000
 Tumor Tulang

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur plafon

1. Biopsi tumor D21.9 other benign neoplasm and 80.31 biopsy of joint Kls 1 3.253.600
other soft tissue structure Kls 2 2.788.000
Kls 3 2.324.000
2 Eksisi tumor C40.9 malignant neoplasm of bone 82.29 excision of other Kls 1 9.269.800
and articular cartilage of limb,. lesion of hand Kls 2 7.945.500
Kls 3 6.621.300
3 Amputasi tumor di atas C40.9 malignant neoplasm of bone 84.17 amputation above Kls 1 28.329.300
lutut(above knee) and articular cartilage of limb,. S85.0 knee/transfemoral Kls 2 24.282.300
injury of popliteal artery Kls 3 20.235.200
4 Amputasi tumor di bawah lutut C40.9 malignant neoplasm of bone 84.15amputation below knee Kls 1 28.329.300
(below knee) and articular cartilage of limb,. S85.0 Kls 2 24.282.300
injury of popliteal artery Kls 3 20.235.200
5 Eksisi luas (wide eksisi) D49.2 neoplasm of unspecified 77.60 local excision of lesion Kls 1
behavior of bone , soft tissue , skin or tissue of bone unspecified Kls 2
S85.0 injury of popliteal artery site Kls 3
86.66 homograft to skin
6 Fraktur dengan tumor tulang C40.9 malignant neoplasm of bone 79.3 ORIF Kls 1 9.789.500
and articular cartilage of limb,. 86.66 homograft to skin Kls 2 8.391.000
Kls 3 6.992.500
Tanpa homograft
Kls 1 8.801.800
Kls 2 7.544.400
Kls 3 6.287.000

7. Operasi tumor ganas C40.9 malignant neoplasm of bone 78.40 other repair of Kls 1 20.855.200
and articular cartilage of limb,. S85.0 plastic operation of bone; Kls 2 17.875.900
injury of popliteal artery 86.70 pedicle or flap graft, Kls 3 14.896.600
not otherwise spesified
8 Ganti sendi pada kasus tumor C79.9 secondary malignant neoplasm 81.40 repair of hip Kls 1 13.618.500
tulang/AMP of unspecified site Kls 2 11.673.000
Kls 3 9.727.500