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1. Apa yang anda ketahui tentang Rekam Medis?

2. Apa yang anda ketahui mengenai ICD-X dan ICD 9CM?

Pilih kode diagnosa utama yang tepat menggunakan ICD-X :

1. (a) Abscess of lung

(b) Lobar pneumonia
Select lobar pneumonia (J18.1).
2. (a) Hepatic failure
(b) Bile duct obstruction
(c) Carcinoma of head of pancreas
Select carcinoma of head of pancreas (C25.0).

3. (a) Bronchopneumonia
(b) Cerebral infarction and hypertensive heart disease
Select cerebral infarction (I63.9). There are two reported sequences terminating in the condition first
entered on the certificate; bronchopneumonia due to cerebral infarction, and bronchopneumonia due to
hypertensive heart disease. The originating cause of the first-mentioned sequence is selected.

4. Measles pneumonia

Kode menggunakan (B05.2† J17.1*).

5. Main condition: Fracture of neck of femur caused by fall due to tripping on uneven pavement
Other conditions: Contusions to elbow and upper arm
Code to fracture of neck of femur (S72.0) as “main condition”. The external cause code for fall on same
level from slipping, tripping or stumbling on street or highway (W01.4) may be used as an optional additional code

6. Main condition : Abdominal pain
Other conditions : Acute appendicitis
Procedure : Appendectomy *Berikan kode Tindakan menggunakan ICD 9CM
Reselect acute appendicitis as the “main condition” and code to K35.9.