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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
Remove implant

ICD 10 Diagnosis
S52.90

Luka terbuka di tangan, crush


injury

S67.8 Crushing injury of other and


84.03 amputation through
unspecified parts of wrist and hand
hand.
S55.1 injury of radial artery at forearm
level
M65.8 Synovitis and tenosynovitis
82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
L.02.51 Cutaneus abscess of the hand. 82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
M67.4 ganglion
82.29 Excision of other lesion
of soft tissue of hand

14.952.975

Fracture pada pergelangan


tangan dan tangan

S62.8 fracture at wrist and hand level

12.485.355

Luka berat pada jari, tangan


(perlu amputasi)

S68 traumatic amputasion of wrist


84.04 amputation and
and hand level
disarticulation of hand
S55.1 injury of radial artery at forearm

Luka kotor /infeksi di jaringan


lunak
Infeksi jaringan

ganglion

ICD 9 Prosedur
78.69 removal implant
device from the bone

79.34 open reduction of


fracture with internal fixation
, carpals and metacarpals.

Plafon
3.765.791

8.403.235

8.403.235

12.485.355

14.952.971

Deformitas/ kelainan pada jari

level
M20.0 Deformity of finger

Jepitan pada syaraf/carpal


tunnel syndrome
Syndactili

84.03 amputation and


disarticulation of Hand

9099.408

S64 injury of nerves at wrist and hand


level
Q70 Syndactili

05.9 other operation on


nervous system
86.85 correction of
syndactyly

11.164.055

Dislokasi pada jari

S63.1 dislocation and sprain of joints


and ligaments at wrist and hand level

79.84 open reduction of


dislocation of hand and
finger

12.485.355

Tumor ganas pada ekstremitas


atas

C40.1 malignant neoplasm of short


84.03 amputation of through
bones of upper limb
hand
S55.1 injury of radial artery at forearm
leve

14.952.975

Infeksi pada sendi

M00 Pyogenic infection

8.404.231

Kerusakan sendi krn rematik

M05 .38 rheumatoid arthritis with


rheumatoid factor
M65.80 other synovitis and
tenosynovitis

81.29 arthhrodesis of other


specified joints
86.66 homograft to skin
81.29 arthhrodesis of other
specified joints
86.66 homograft to skin

Kerusakan sendi bukan karena


rematik

M06 other rheumatoid arthritis

8.403.235

Deformitas/ kelainan pada jari

M20.0 Deformity of finger

81.29 arthhrodesis of other


specified joints
86.72 pedicle or flap graft,
not otherwise specified
82.8 other plastic operation

12.485.355

8.403.235

12.485.355

on hand,
kontracture

M24.59 contracture unspecified site

82.3 other excision of soft


tissue of hand;

12.485.355

polidactili

Q69 polidactyli

84.03 amputation and


disarticulation of finger:
86.66 homograft to skin

8.403.235

Raw surface, defek soft tissue,


sural flap, semua tindakan flap

L98.9 other disorders of skin and


subcutaneous tissue, not elsewhere

Traumatic amputasi perlu


replantasi

82.8 other plastic operation


on hand
86.72 pedicle or flap graft,
not otherwise spesified
S68.9 traumatic amputasion of wrist
84.22 finger reattachment
and hand level
86.72 pedicle or flap graft,
S55.1 injury of radial artery at forearm not otherwise spesified
leve

8.403.235

ICD 10 Diagnosis
M84.90 disorder of continuity of
bone , unspecified
S42 fracture of shoulder and upper
arm
S.06.9 intracranial injury
S42 fracture of shoulder and upper
arm

ICD 9 Prosedur
78.69 bone graft
86.66 homograft to skin
79.30 ORIF,unspecified site

Plafon
8.403.235

79.30 ORIF,unspecified site

7.691.543

8.403.235

Trauma (Fracture)
No
1.

Keterangan
Non union perlu bone graft

2.

Fracture clavikula

3.

Fracture clavikula dengan


cedera kepala

3.835.376

4.

Fracture tibia/fibula

S82.21 Fracture of shaft tibia

79.36 ORIF , tibia and fibula

21.963.542

5.

Fracture distal tibia

S82.2 Fracture of shaft tibia

79.36 ORIF

21.963.542

6.

Fracture femur

S72.31 fracture shaft femur

79.35 ORIF , femur

7.

Fracture radius

S52.3 fracture shaft radius

79.32 ORIF , radius and ulna

Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
12.485.355

8.

Fracture ulna

S52.2 fracture shaft ulna

79.32 ORIF , radius and ulna

12.485.355

9. Fr antebrachii
10. Fracture humerus

S52.7 fracture shaft forearm


S42.3 fracture shaft humerus

79.32 ORIF , radius and ulna


79.31 ORIF humerus

12.485.355
12.485.355

11. Fracture pada tangan,


metacarpal, phalang
12. Fracture subtrochanter femur
perlu ORIF

S62 fracture at wrist and hand level

79.34 ORIF phalank of hand

12.485.355

S72.2 subtrochanteric fracture of


femur

79.35 ORIF , femur

Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183

13. Fracture intercondylar femur,

14. Fracture intertrochanter femur

S72 fracture shaft femur

M81.65 Osteoporosis
S72.14 Intertrochanteric fracture of
femure

79.35 ORIF , femur

Hip implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183

79.35 ORIF , femur

Knee implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183

Hip implant :
6000.000
12.485.355

15. Fracture galeazi

S52.3 fracture shaft radius

79.32 ORIF , radius and ulna ;

16. Fracture montegia

S52.2 shaft ulna

79.32 ORIF , radius and ulna


;,

12.485.355

17. Fracture prksimal humerus,neck


humerus
18. OA Sendi lutut perlu TKR

S42.20 fracture of upper end of


humerus
M17.4 other secondary gonarthrosis ,
bilateral
M19.26 secondary of the joint , lower
leg

79.31 ORIF humerus

12.485.355

81.54 Total Knee


Replacement

5.978.592

19. OA Sendi perlu TKR

M17.4 other secondary gonarthrosis ,


bilateral
M19.26 secondary of the joint , lower
leg

81.47 other repair of knee

Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542

20. OA sendi Hip perlu THR

M19.26 secondary of the joint , lower


leg

81.51 Total Hip Replacement

21. OA Sendi perlu THR

M19.26 secondary of the joint , lower


leg

81.40 Repair of hip, not


elsewhere classified

Knee replacement
3.000.000
5.978.592

Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :

22. Fracture collum femur,

M81.65 Osteoporosis

81.40 Repair of hip, not

Klas 1= 8.898.656

S72.0 fracture of head and neck of


femur

23. Fracture plateau tibia


24. Fracture acetabulum

S82 Fracture of tibia


)
S32.4 fracture acetabulum

elsewhere classified

79.36 ORIF , tibia and fibula


79.30 ORIF , unspecified site
05.9 other operation on
nervous system

Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
3000.000
21.963.542
11.164.055

25. Fracture
pedis,metacarpale,ankle
26. Fracture patella

S82.90 Fracture of lower leg ,


including ankle
822.1 fracture of patella,open

79.37 ORIF tarsal,metatarsal

Hip implant :
6000.000
8.855.736

81.44 patellar stabilization

21.963.542

27. Infeksi pada sendi,

M01 direct infection of joint in


infectious and parasitic disease
classified elsewhere

81.9 other operation on joint


structure
86.66 homograft to skin

28. Infeksi tulang, tromboemboli

M86 Osteomyelitis,

29. Dislokasi pinggul

S73.0 Dislocationand sprain of joint


and ligament of hip

79.6 debridement of open


fracture site ;
86.72 pedicle or flap graft,
not otherwise specified
79.75 closed reduction of
dislocation , hip

30. Dislokasi bahu

S43.0 Dislocation and sprain of joint


and ligament of shoulder

79.71 closed reduction of


dislocation shoulder

1.948.000

31. Dislokasi siku

S53.1 Dislocation and sprain of joint


and ligament of elbow

79.72 closed reduction of


dislocation , elbow

1.948.000

3481.352

32. Fracture neglected

M84.9 disorder of continuity of


bone,unspesified

78.4 other repair of plastic


operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin

33. Ruptur Tendon Achilles

Paediatrik (kelainan dan fracture pada anak < 15 th)


No
1.

Keterangan
Reposisi dan pasang gip
ekstremitas atas dengan GA

ICD 10 Diagnosis
S62.80 fracture at wrist and hand
level

ICD 9 Prosedur
79.04 closed reduction of
fracture without internal
fixation

Plafon
1.948.000

Reposisi dan pasang gip


ekstremitas bawah dengan GA

S82.7 fracture of lower leg

79.07 closed reduction of


fracture without internal
fixation

1.948.000

Rekonstruksi ibu jari kaki , halux


valgus

M20.1 halux valgus/acquired

82.89 other plastic operation


on hand
77.51 other buninectomy

8.855.731

Fracture neglected

M84.9 disorder of continuity of


bone,unspesified

Kelainan congenital,CTEV,Blount Q66.3 other congenital varus

78.4 other repair of plastic


operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
78.4 other repair of plastic

12.485.355

disease

deformities of feet,

operation of bone

Pemanjangan tulang

Q66.3 other congenital varus


deformities of feet,

78.3 limb lengthening


procedure

21.953.542

Tumor Tulang
No
1.

Keterangan
Biopsi tumor

ICD 10 Diagnosis
D21.9 other benign neoplasm and
other soft tissue

ICD 9 Prosedur
80.31 biopsy of joint
structure

plafon
2.049.737

Eksisi tumor
Amputasi tumor di atas
lutut(above knee)

82.29 excision of other


lesion of hand
84.17 amputation above
knee/transfemoral

12.485.355

Amputasi tumor di bawah lutut


(below knee)

84.15amputation below knee

9.099.400

Eksisi luas (wide eksisi)

C40.9 malignant neoplasm of bone


and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
D49.2 neoplasm of unspecified
behavior of bone , soft tissue , skin
S85.0 injury of popliteal artery

12.485.355

Fraktur dengan tumor tulang

7.

Operasi tumor ganas

77.60 local excision of lesion


or tissue of bone unspecified
site
86.66 homograft to skin
79.3 ORIF
86.66 homograft to skin
78.4 other repair of plastic
operation of bone;
86.72 pedicle or flap graft,
not otherwise spesified

C40.9 malignant neoplasm of bone


and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery

9.099.400

8.403.235

Ganti sendi pada kasus tumor


tulang/AMP

C79.9 secondary malignant neoplasm


of unspecified site

81.40 repair of hip

8.403.235

Arthroscopy , Shoulder (bahu) dan Knee (lutut)


No
1.

Keterangan
Infeksi sendi lutut,

ICD 10 Diagnosis
M17.9 Gonarthrosis , unspecified
M01.56 arthritis in other bacterial
disease lower leg
M35.4 diffuse fasciitis

ICD 9 Prosedur
81.47 other repair of knee

plafon
21.000.000

Bahu kaku/frozen shoulder/


adhesive capsulitis

M75.0 adhesive capsulitis of shoulder


M35.4 diffuse fasciitis

80.21 arthroscopy shoulder

7.691.547

Mengeluarkan benda asing di


lutut/loose bodies

M25.68 stiffness of joint


M65.26 calcific tendinitis

81.47 other repair of knee

21.000.000

4
5

Debridement shoulder

M25.68 stiffness of joint


M65.26 calcific tendinitis M35.4
diffuse fasciitis

80.21 arthroscopy shoulder;

Klas 3 = 7.691.547
Klass 2 =9226.000
Klass1: 10.768.160

6
7

Rotator cuff tear

M75.1 complete rotator cuff tear or


rupture not specified as traumatic

80.21 arthroscopy shoulder;


80.49 division of joint,

9.229.852

M35.4 diffuse fascitis

ligament or cartilage of other


specified site

Rupture meniscus

M23.2 dearrangement of meniscus


due to old tear or injury

81.47 other operation of


knee

21.000.000

Osteoarthritis lutut derajat


ringan (1-2)/ artroscopy
debridement

S83.2 tear of meniscus,current


M35.8 other specified systemic
involvement connective tissue

81.47 other operation of


knee

21.000.000

Ligament ACL/PCL lutut putus

M23.61 other spontaneous disruption


of ligament of knee, ACL /Anterior
horn medial meniscus

81.47 other operation of


cruciate ligament

Klas 3= 21.963.542
Klas 2= 26.356.251
Klas 1= 30.748.959

10
11

Implant knee :
6000.000
12
13

14

Ganti sendi lutut/ total knee


arthroplasty/osteoarthritis
derajat berat

Rematik di lutut derajat berat


perlu ganti sendi

M17 osteoartritis of knee


)

M05.661 rhaumatoid arthritis of left


knee with involvement of other organ
and system

81.47 other operation of


knee

81.47 other operation of


knee

Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000

15

Spine/ Tulang Belakang


No
1.

Keterangan
scoliosis

ICD 10 Diagnosis
M41.55 scoliosis
S25.9 injury of unspecified blood
vessel of thorax
M43.54 vertebral subluxation

ICD 9 Prosedur
81.60 , 360 degree spinal
fusion, single incision
approach
83.74 reattachment of
muscle
77.31 other division of
scapula, clavicle,and thorax
(rib and sternum)

plafon
34.590.151

Spondilolisthesis, canal stenosis

M43.15 spondilolisthesis; M48.05


spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax

Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390

3.

Tumor tulang belakang

C41.2 malignant neoplasm of


vertebral column ; M48.05 spinal
stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax

03.09 other exploration and


decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

HNP/canal stenosis di cervical


dengan tetraparese dengan
implan

M50.1 cervical disc disorder;


M48.05 spinal stenosis
M48.54 collapse vertebrae

03.09 other exploration and


decompression of spinal
canal

Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390

Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390

G82.4 flaccid tetraplegia

84.51 insertion of other


spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

HNP/canal stenosis di
thorakal/lumbal dengan implan

M51.1 thoraxic , thoracolumbal and


lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax

Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390

HNP/Canal stenosis di cervical


tetraparese tanpa implan

M50.1 cervical disc disorder;


M48.02 spinal stenosis
M48.52 collapse vertebrae
G82.4 flaccid tetraplegia

03.09 other exploration and


decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

25.165.278

HNP/canal stenosis di
thorakal/lumbal tanpa implant

M51.1 thoraxic , thoracolumbal and


lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae

03.09 other exploration and


decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

19.950.055

Fraktur tulang belakang dengan


implan

S32.7 fracture of lumbar spine and


pelvis;
M48.0 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax

03.09 other exploration and


decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390

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