2

Tata Cara Pengisian ICD

1. ICD ditulis dengan huruf cetak setelah
tindakan/ resume pasien keluar dari VK
dan IGD
2. Lembar rangkuman pulang wajib diisi
lengkap H-1 pasien pulang.
3. Dokter Penanggung Jawab Pelayanan wajib
menandatangani di lembar rangkuman,
tindakan dan laporan tindakan saat H-1.
4. Untuk kasus campuran (mixed case). kode
ICD dapat ditanyakan /dilaporkan langsung
ke dokter residen stase medrek atau
konsulen penanggung jawab Medical
Record.
5. Urutan pengisian ICD:
a. Maternal condition
b. Methods of delivery
c. Outcome

3
Partus Spontan (LOS 1 hari)

Diagnosa O80. Spontaneous vertex

Utama : 0 delivery

Diagnosa Z37. Single live birth

Sekunder : 0

Tindakan utama 73.5 Manually assisted delivery

: 9

T i n d a k a n 73.6 Episiotomy
tambahan :

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

INA-CBG O-6-1 PERSALINAN VAGINAL

: 3-I (RINGAN)
LOS = Length of Stay (Lama hari rawat)


4
Augmentasi drip (LOS 1 hari)

Diagnosa O62. Secondary uterine inertia

Utama : 1

Diagnosa Z37. Single live birth

Sekunder : 0

O80. Spontaneous vertex

0 delivery

Tindakan utama 73.5 Manually assisted delivery

: 9

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.6 Episiotomy

73.0 Induction of labor by

1 artificial rupture of
membranes

5
 INA- O-6- PERSALINAN VAGINAL
CBG : 12-I DENGAN PROSEDUR
SELAIN STERILISASI &/
DILATASI &KURET
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

6
Misoprostol (LOS 1 hari)

Diagnosa O62 Other uterine inertia

Utama : .2

Diagnosa O80 Spontaneous vertex

Sekunder : .0 delivery

Z37. Single live birth

0

Tindakan utama 73.5 Manually assisted delivery

: 9

T i n d a k a n 73.4 Medical induction of labor

tambahan :

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.6 Episiotomy

73.0 Induction of labor by

1 artificial rupture of
membranes

7
 INA-CBG O-6-1 PERSALINAN VAGINAL
: 2-I DENGAN PROSEDUR
SELAIN STERILISASI &/
DILATASI &KURET
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

8
Spontan Bracht (LOS 1 hari)

Diagnosa O62 Other uterine inertia

Utama : .2

Diagnosa O80 Spontaneous breech

Sekunder : .1 delivery

Z37. Single live birth

0

Tindakan utama 73.5 Manually assisted delivery

: 9

Ti n d a k a n Microscopic examination
tambahan : 90.5 of blood, Other
9 microscopic examination

75.3 Other fetal monitoring

4

73.4 Medical induction of labor

73.0 Induction of labor by

1 artificial rupture of
membranes

9
 INA-CBG O-6-1 PERSALINAN VAGINAL
: 2-I DENGAN PROSEDUR
SELAIN STERILISASI &/
DILATASI &KURET
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

10
Spontan Gemeli (LOS 1 hari)

Diagnosa O84. Multiple delivery, all

Utama : 0 spontaneous

Diagnosa Z37. Twins, both liveborn

Sekunder : 2

O30. Twin pregnancy

0

Tindakan utama 73.5 Manually Assisted delivery

: 9

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.0 Induction of labor by

1 artificial rupture of
membranes

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

11
 INA-CBG O-6-13 PERSALINAN VAGINAL
: -II (SEDANG)

LOS = Length of Stay (Lama hari rawat)

12
Spontan Preterm (LOS 1 hari)

Diagnosa O60. Preterm labour with

Utama : 1 preterm delivery

Diagnosa O80. Spontaneous vertex

Sekunder : 0 delivery

Z37. Single live birth

0

Tindakan utama 73.5 Manually assisted delivery

: 9

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.0 Induction of labor by

1 artificial rupture of
membranes

73.6 Episiotomy

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

13
INA-CBG O-6-12 PERSALINAN VAGINAL
: -I DENGAN PROSEDUR
SELAIN STERILISASI &/
DILATASI &KURET
(RINGAN)

14
Spontan KPD (LOS 1 hari)

Diagnosa Z37. Single live birth

Utama : 0

Diagnosa O80. Spontaneous vertex

Sekunder : 0 delivery

O42. Premature rupture of

9 membranes, unspecified

Tindakan utama 73.5 Manually assisted delivery

: 9

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.0 Induction of labor by

1 artificial rupture of
membranes

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

15
 99.2 Injection of antibiotic
1

73.6 Episiotomy

INA- Z-4-1 FAKTOR-FAKTOR YANG

CBG : 2-II MEMPENGARUHI
STATUS KESEHATAN
LAIN-LAIN (SEDANG)

16
Sungsang Manual aid (LOS 1 hari)

Diagnosa O83. Other assisted breech

Utama : 1 delivery

Diagnosa Z37. Single live birth

Sekunder : 0

O32. Maternal care for breech

1 presentation

O62. Other uterine inertia

2

Tindakan utama 72.5 Other partial breech

: 2 extraction

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.0 Induction of labor by

1 artificial rupture of
membranes

73.6 Episiotomy

17
 INA- O-6-13 PERSALINAN VAGINAL
CBG : -I (RINGAN)

LOS = Length of Stay (Lama hari rawat)

18
Forceps kala II Lama Gawat janin (LOS 1 hari)

Diagnosa O63. Prolonged second stage of

Utama : 1 labour

Diagnosa P03. Fetus and newborn affected

Sekunder : 2 by forceps delivery

Z37. Single live birth

0

O68. Labour and delivery

9 complicated by fetal stress,
unspecified

Tindakan utama 72.1 Low forceps operation with

: episiotomy

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

73.0 Induction of labor by

1 artificial rupture of
membranes

73.6 Episiotomy

19
INA-CBG O-6-13 PERSALINAN
: -I VAGINAL (RINGAN)

20
Shoulder dystocia (LOS 1 hari)

Diagnosa O66. Prolonged second stage of

Utama : 0 labour

Diagnosa Z37. Single live birth

Sekunder : 0

Tindakan utama 73.5 Other manually assisted

: 9 delivery

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

INA-CBG O-6-13 PERSALINAN VAGINAL

: -I (RINGAN)

LOS = Length of Stay (Lama hari rawat)


21
Vakum Kala II Lama Gawat Janin (LOS 1 hari)

Diagnosa O63. Prolonged second stage of

Utama : 1 labour

Diagnosa Z37. Single live birth

Sekunder : 0

O68. Labour and delivery

9 complicated by fetal stress,
unspecified

O81. Vacuum extractor delivery

4

Tindakan utama 72.7 Vacuum extraction with

: 1 episiotomy

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

22
 INA- O-6-1 PERSALINAN VAGINAL
CBG : 2-I DENGAN PROSEDUR
SELAIN STERILISASI &/
DILATASI &KURET
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

23
Forceps PEB (LOS 1 hari)

Diagnosa O14. Severe pre-eclampsia

Utama : 1

Diagnosa P03. Fetus and newborn affected

Sekunder : 2 by forceps delivery

Z37. Single live birth

0

O81. Vacuum extractor delivery

4

Tindakan utama 72.1 Low forceps operation with

: episiotomy

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

73.6 Episiotomy

72.7 Vacuum extraction with

1 episiotomy

57.9 Insertion of indwelling

4 urinary catheter

24
 99.2 Injection or infusion of
9 other therapeutic or
prophylactic substance

INA- O-6-13 PERSALINAN VAGINAL

CBG : -II (SEDANG)

LOS = Length of Stay (Lama hari rawat)

25
Forceps Superimposed PEB (LOS 2 hari)

Diagnosa O10. Pre-existing essential

Utama : 0 hypertension complicating
pregnancy, childbirth and
the puerperium

Diagnosa O14. Severe pre-eclampsia

Sekunder : 1

Z37. Single live birth

0

Tindakan utama : 72.1 Low forceps operation

with episiotomy

T i n d a k a n 99.18 Injection or infusion of

tambahan : electrolytes

75.34 Other fetal monitoring

73.6 Episiotomy

57.94 Insertion of indwelling

urinary catheter

99.29 Injection or infusion of

other therapeutic or
prophylactic substance

26
 INA-CBG O-6-13- PERSALINAN
: II VAGINAL (SEDANG)

LOS = Length of Stay (Lama hari rawat)

27
Forceps PEB Edema Paru (LOS 2 hari)

Diagnosa O99. Diseases of the respiratory

Utama : 5 system complicating
pregnancy, childbirth and
the puerperium

Diagnosa J81 Pulmonary oedema

Sekunder :

O14. Severe pre-eclampsia

1

P03. Fetus and newborn affected

2 by forceps delivery

Z37. Single live birth

0

Tindakan utama 72.1 Low forceps operation with

: episiotomy

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

73.6 Episiotomy

28
 57.9 Insertion of indwelling
4 urinary catheter

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

89.6 Monitoring of cardiac

8 output by other technique

INA- O-6-13 PERSALINAN VAGINAL

CBG : -II (SEDANG)

LOS = Length of Stay (Lama hari rawat)

29
Forceps PEB Cardiomiopati (LOS 2 hari)

Diagnosa O99. Diseases of the circulatory

Utama : 4 system complicating
pregnancy, childbirth and
the puerperium

Diagnosa I42.0 Dilated cardiomyopathy

Sekunder :

O14. Severe pre-eclampsia

1

Z37. Single live birth

0

O81. Low forceps delivery

0

Tindakan utama 72.1 Low forceps operation with

: episiotomy

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

30
 89.6 Monitoring of cardiac
8 output by other technique

INA- O-6-1 OPERASI PEMBEDAHAN

CBG : 0-II CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

31
SC Sungsang Cord Prolaps (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa O69. Labour and delivery

Sekunder : 0 complicated by prolapse of
cord

O32. Maternal care for breech

1 presentation

Z37. Single live birth

0

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

75.3 Other fetal monitoring

4

32
 99.2 Injection of antibiotic
1

INA- O-6-10 OPERASI

CBG : -I PEMBEDAHAN CAESAR
(SEDANG)

LOS = Length of Stay (Lama hari rawat)

33
SC KPD Gawat Janin (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa Z37. Single live birth

Sekunder : 0

O42. Premature rupture of

0 membranes, onset of
labour within 24 hours

P01. Fetus and newborn affected

1 by premature rupture of
membranes

P20. Intrauterine hypoxia first

1 noted during labour and
delivery

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination of

9 blood, Other microscopic
examination

75.3 Other fetal monitoring

4

34
 99.2 Injection of antibiotic
1

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

INA-CBG O-6-10 OPERASI

: -II PEMBEDAHAN
CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

35
SC Gemeli (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa O30. Twin pregnancy

Sekunder : 0

O42. Premature rupture of

0 membranes, onset of
labour within 24 hours

P01. Fetus and newborn affected

1 by premature rupture of
membranes

P20. Intrauterine hypoxia first

1 noted during labour and
delivery

Tindakan utama 74.1 Low cervical cesarean

: section

Ti n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination of

9 blood, Other microscopic
examination

75.3 Other fetal monitoring

4

36
 99.2 Injection of antibiotic
1

99.2 Injection or infusion of other

9 therapeutic or prophylactic
substance

INA- O-6-1 OPERASI PEMBEDAHAN

CBG : 0-II CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

37
SC PEB (LOS 3 hari)

Diagnosa Utama O15. Eclampsia in pregnancy

: 0

Diagnosa O14. Severe pre-eclampsia

Sekunder : 1

Z37. Single live birth

0

Tindakan utama : 74.1 Low cervical cesarean

section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

99.2 Injection of antibiotic

1

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

38
 INA-CBG O-6-1 OPERASI PEMBEDAHAN
: 0-II CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

39
SC PEB Gawat Janin (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa Z37. Single live birth

Sekunder : 0

O42. Premature rupture of

0 membranes, onset of
labour within 24 hours

P01. Fetus and newborn affected

1 by premature rupture of
membranes

P20. Intrauterine hypoxia first

1 noted during labour and
delivery

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination of

9 blood, Other microscopic
examination

75.3 Other fetal monitoring

4

40
 99.2 Injection of antibiotic
1

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

INA-CBG O-6-10 OPERASI

: -II PEMBEDAHAN
CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

41
SC PEB Gawat Janin (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa Z37. Single live birth

Sekunder : 0

O42. Premature rupture of

0 membranes, onset of
labour within 24 hours

P01. Fetus and newborn affected

1 by premature rupture of
membranes

P20. Intrauterine hypoxia first

1 noted during labour and
delivery

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination of

9 blood, Other microscopic
examination

75.3 Other fetal monitoring

4

42
 99.2 Injection of antibiotic
1

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

INA-CBG O-6-10 OPERASI

: -II PEMBEDAHAN
CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

43
SC PEB Solutio Placenta (LOS 3 hari)

Diagnosa O45. Premature separation of

Utama : 0 placenta with coagulation
defect

Diagnosa O14. Severe pre-eclampsia

Sekunder : 1

O82. Delivery by elective

0 caesarean section

Z37. Single live birth

0

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

75.3 Other fetal monitoring

4

99.2 Injection of antibiotic

1

44
 99.2 Injection or infusion of
9 other therapeutic or
prophylactic substance

88.7 Other diagnostic ultrasound

9

INA-CBG O-6-10 OPERASI

: -II PEMBEDAHAN
CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

45
SC PEB Edema Paru (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa O99. Diseases of the respiratory

Sekunder : 5 system complicating
pregnancy, childbirth and
the puerperium

J81 Pulmonary oedema

O14. Severe pre-eclampsia

1

O68. Labour and delivery

8 complicated by other
evidence of fetal stress

Z37. Single live birth

0

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

46
 75.3 Other fetal monitoring
4

99.2 Injection of antibiotic

1

99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

88.6 Monitoring of cardiac

8 output by other technique

INA-CBG O-6-10 OPERASI

: -II PEMBEDAHAN
CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

47
SC PEB Cardiomiopati (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa O99. Diseases of the circulatory

Sekunder : 4 system complicating
pregnancy, childbirth and
the puerperium

I42.0 Dilated cardiomyopathy

O14. Severe pre-eclampsia

1

Z37. Single live birth

0

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.2 Injection of antibiotic

1

48
 99.2 Injection or infusion of
9 other therapeutic or
prophylactic substance

88.6 Monitoring of cardiac

8 output by other technique

INA- O-6-1 OPERASI PEMBEDAHAN

CBG : 0-II CAESAR (SEDANG)

LOS = Length of Stay (Lama hari rawat)

49
SC Bekas SC Inersia uteri (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa Z37. Single live birth

Sekunder : 0

O34. Maternal care due to

2 uterine scar from previous
surgery

O62. Secondary uterine inertia

1

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

50
 75.3 Other fetal monitoring
4

99.2 Injection of antibiotic

1

INA-CBG O-6-10 OPERASI

: -I PEMBEDAHAN
CAESAR (RINGAN)

LOS = Length of Stay (Lama hari rawat)

51
SC Placenta Previa Totalis (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa Z37. Single live birth

Sekunder : 0

O46. Antepartum haemorrhage,

9 unspecified

O44. Placenta praevia specified

0 as without haemorrhage

Tindakan utama 74.1 Low cervical cesarean

: section

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination of

9 blood, Other microscopic
examination

88.7 Other diagnostic ultrasound

9

52
 75.3 Other fetal monitoring
4

99.2 Injection of antibiotic

1

INA- O-6-10 OPERASI

CBG : -II PEMBEDAHAN CAESAR
(SEDANG)

LOS = Length of Stay (Lama hari rawat)

53
SC Atonia Histerektomi (LOS 3 hari)

Diagnosa O82. Delivery by caesarean

Utama : 2 hysterectomy

Diagnosa O62. Secondary uterine inertia

Sekunder : 1

Z37. Single live birth

0

Tindakan utama 68.3 Other and unspecified

: 9 subtotal abdominal
hysterectomy

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

74.1 Low cervical cesarean

section

99.2 Injection of antibiotic

1

75.3 Other fetal monitoring

4

54
 INA-CBG W-1-20 PROSEDUR PADA
: -II RAHIM & ADNEKSA
(SEDANG)

LOS = Length of Stay (Lama hari rawat)

55
SC Atonia B-Lynch Suture (LOS 3 hari)

Diagnosa O82. Delivery by emergency

Utama : 1 caesarean section

Diagnosa O62. Secondary uterine inertia

Sekunder : 1

Z37. Single live birth

0

T i n d a k a n 75.5 Repair of current obstetric

utama : 2 laceration of corpus uteri

T i n d a k a n 74.1 Low cervical cesarean

tambahan : section

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

75.3 Other fetal monitoring

4

56
INA- W-1-2 PROSEDUR PADA
CBG : 0-II RAHIM & ADNEKSA
(SEDANG)

57
SC Placenta Akreta Histerektomi (LOS 3 hari)

Diagnosa O82. Delivery by caesarean

Utama : 2 hysterectomy

Diagnosa O43. Morbidly adherent placenta

Sekunder : 2

Z37. Single live birth

0

Tindakan utama 68.9 Other and unspecified

: hysterectomy

T i n d a k a n 74.1 Low cervical cesarean

tambahan : section

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

75.3 Other fetal monitoring

4

58
INA-CBG W-1-2 PROSEDUR PADA
: 0-II RAHIM & ADNEKSA
(SEDANG)

59
SC Placenta Akreta Histerektomi (LOS 3 hari)

Diagnosa O82. Delivery by caesarean

Utama : 2 hysterectomy

Diagnosa O43. Morbidly adherent placenta

Sekunder : 2

Z37. Single live birth

0

T i n d a k a n 68.9 Other and unspecified

utama : hysterectomy

T i n d a k a n 74.1 Low cervical cesarean

tambahan : section

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

75.3 Other fetal monitoring

4

60
 INA-CBG W-1-20 PROSEDUR PADA
: -II RAHIM & ADNEKSA
(SEDANG)

LOS = Length of Stay (Lama hari rawat)

61
Kuretase Sisa Placenta (LOS 1 hari)

Diagnosa O72. Delayed and secondary

Utama : 2 postpartum haemorrhage

Diagnosa O73. Retained placenta without

Sekunder : 0 haemorrhage

Tindakan utama 69.0 Dilation and curettage

: 2 following delivery or
abortion

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

62
 99.0 Transfusion of blood
8 expander

INA-CBG W-1-1 PROSEDUR ABORSI

: 0-II (SEDANG)

LOS = Length of Stay (Lama hari rawat)

63
Abortus Incomplete (LOS 1 hari)

Diagnosa O03 Spontaneous abortion,

Utama : .4 incomplete, without
complication

Diagnosa
Sekunder :

T i n d a k a n 69.0 Dilation and curettage

utama : 2 following delivery or
abortion

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

64
 INA-CBG W-1-10 PROSEDUR ABORSI
: -II (SEDANG)

LOS = Length of Stay (Lama hari rawat)

65
Kuretase Mola hidatidosa (LOS 1 hari)

Diagnosa Utama O01 Hydatidiform mole,

: .9 unspecified

Diagnosa
Sekunder :

Tindakan utama : 69.0 Other dilation and

9 curettage of uterus

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic

9 ultrasound

99.0 Transfusion of blood

8 expander

66
INA-CBG W-1a-1 PROSEDUR DILATASI,
: 1-II KURET, INTRAUTERIN
& SERVIK (SEDANG)

67
Kuretase PA (DUB) (LOS 1 hari)

Diagnosa N93. Other specified abnormal

Utama : 8 uterine and vaginal
bleeding

Diagnosa
Sekunder :

T i n d a k a n 69.0 Other dilation and

utama : 9 curettage of uterus

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic

9 ultrasound

68
INA-CBG W-1-11 PROSEDUR DILATASI,
: -I KURET, INTRAUTERIN
& SERVIK (RINGAN)

69
Kuretase PA (Mioma) (LOS 1 hari)

Diagnosa Utama D25. Leiomyoma of uterus,

: 9 unspecified

Diagnosa
Sekunder :

Tindakan utama : 69.0 Other dilation and

9 curettage of uterus

Tindakan tambahan 99.1 Injection or infusion of

: 8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic
9 examination of blood,
Other microscopic
examination

88.7 Other diagnostic

9 ultrasound

INA-CBG W-1-11 PROSEDUR DILATASI,

: -I KURET, INTRAUTERIN
& SERVIK (RINGAN)

70
LOS = Length of Stay (Lama hari rawat)

71
Konservatif Abortus Eminen (LOS 2 hari)

Diagnosa Utama O20 Threatened abortion

: .0

Diagnosa
Sekunder :

Tindakan utama : 99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

Tindakan tambahan 99.1 Injection or infusion of

: 8 electrolytes

88.7 Diagnostic ultrasound

8 of gravid uterus

INA-CBG W-4-14 ABORTUS

: -I MENGANCAM
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

72
Konservatif Hyperemesis Gravidarum (LOS 2
hari)

Diagnosa Utama O21. Hyperemesis

: 1 gravidarum with
metabolic disturbance

Diagnosa
Sekunder :

Tindakan utama : 99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

Tindakan tambahan 99.1 Injection or infusion of

: 8 electrolytes

88.7 Diagnostic ultrasound of

8 gravid uterus

INA-CBG W-4-16 GANGGUAN

: -I ANTEPARTUM
(RINGAN)

73
LOS = Length of Stay (Lama hari rawat)

74
Konservatif PEB (LOS 2 hari)

Diagnosa O14. Severe pre-eclampsia

Utama : 1

Diagnosa
Sekunder :

T i n d a k a n 99.2 Injection or infusion of

utama : 9 other therapeutic or
prophylactic substance

T i n d a k a n 75.3 Other fetal monitoring

tambahan : 4

88.7 Diagnostic ultrasound of

8 gravid uterus

99.1 Injection or infusion of

8 electrolytes

75
 INA-CBG W-4-16 GANGGUAN
: -I ANTEPARTUM
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

76
Konservatif Superimposed PEB (LOS 2 hari)

Diagnosa O10. Pre-existing essential

Utama : 0 hypertension complicating
pregnancy, childbirth and
the puerperium

Diagnosa O14. Severe pre-eclampsia

Sekunder : 1

T i n d a k a n 99.2 Injection or infusion of

utama : 9 other therapeutic or
prophylactic substance

T i n d a k a n 75.3 Other fetal monitoring

tambahan : 4

88.7 Diagnostic ultrasound of

8 gravid uterus

99.1 Injection or infusion of

8 electrolytes

INA-CBG W-4-16 GANGGUAN

: -I ANTEPARTUM
(RINGAN)

77
LOS = Length of Stay (Lama hari rawat)

78
Konservatif Placenta Previa (LOS 2 hari)

Diagnosa Utama O46. Antepartum

: 9 haemorrhage, unspecified

Diagnosa O44. Placenta praevia specified

Sekunder : 0 as without haemorrhage

Tindakan utama : 99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

T i n d a k a n 75.3 Other fetal monitoring

tambahan : 4

88.7 Diagnostic ultrasound of

8 gravid uterus

99.1 Injection or infusion of

8 electrolytes

INA-CBG W-4-1 GANGGUAN

: 6-I ANTEPARTUM
(RINGAN)

79
LOS = Length of Stay (Lama hari rawat)

80
Konservatif Ketuban Pecah Dini (LOS 2 hari)

Diagnosa Utama O42. Premature rupture of

: 9 membranes, unspecified

Diagnosa
Sekunder :

Tindakan utama : 99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

Tindakan tambahan 99.2 Injection of antibiotic

: 1

88.7 Diagnostic ultrasound of

8 gravid uterus

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

INA-CBG W-4-16 GANGGUAN

: -I ANTEPARTUM
(RINGAN)

81
LOS = Length of Stay (Lama hari rawat)

82
Konservatif Prematur Kontraksi (LOS 2 hari)

Diagnosa Utama O60. Preterm labour without

: 0 delivery

Diagnosa
Sekunder :

Tindakan utama : 99.2 Injection or infusion of

9 other therapeutic or
prophylactic substance

Tindakan tambahan 88.7 Diagnostic ultrasound of

: 8 gravid uterus

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

INA-CBG W-4-15 PERSALINAN PALSU

: -I (RINGAN)

LOS = Length of Stay (Lama hari rawat)

83
UROGINEKOLOGI

84
Abses Bartholin Rawat Jalan

Diagnosa N75. Abscess of Bartholin's

Utama : 1 gland

Diagnosa
Sekunder :

Tindakan utama 71.2 Marsupialization of

: 3 Bartholin's gland (cyst)

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

99.2 Injection of antibiotic

1

85
INA-CBG W-2-3 PROSEDUR KECIL
: 3-0 VULVOVAGINAL

86
Adhesi Labia

Diagnosa Q52. Fusion of labia

Utama : 5

Diagnosa R33 Retention of urine

Sekunder :

N99. Postoperative adhesions

2 of vagina

Tindakan utama 71.0 Lysis of vulvar adhesions

: 1

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

99.2 Injection of antibiotic

1

87
INA-CBG W-1-3 PROSEDUR PADA
: 0-II VAGINA, SERVIK &
VULVA (SEDANG)

88
MRKH

Diagnosa Q51. Agenesis and aplasia of

Utama : 0 uterus

Diagnosa
Sekunder :

Tindakan utama 70.6 Vaginal reconstruction

: 2

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

89
INA-CBG W-1-3 PROSEDUR PADA
: 0-I VAGINA, SERVIK &
VULVA (RINGAN)

90
Prolaps Uteri Rectokel Sistokel

Diagnosa N81. Incomplete uterovaginal

Utama : 2 prolapse

Diagnosa N81. Rectocele

Sekunder : 6

N81. Cystocele
1

Tindakan utama 68.5 Other and unspecified

: 9 vaginal hysterectomy

Ti n d a k a n 70.5 Repair of cystocele with

tambahan : 4 graft or prosthesis

99.1 Injection or infusion of

8 electrolytes

99.2 Injection of antibiotic

1

INA- W-1-3 PROSEDUR PADA

CBG : 0-I VAGINA, SERVIK &
VULVA (RINGAN)

91
Rektovaginal Fistule

Diagnosa N82. Other female intestinal-

Utama : 4 genital tract fistulae

Diagnosa
Sekunder :

T i n d a k a n 99.2 Injection of antibiotic

utama : 1

T i n d a k a n 99.1 Injection or infusion of

tambahan : 8 electrolytes

70.7 Repair of rectovaginal

3 fistula

INA-CBG K-1-50 PROSEDUR ANAL

: -I (RINGAN)

92
Inkontinensia Alvi

Diagnosa R15 Faecal incontinence

Utama :

Diagnosa
Sekunder :

P r o s e d u r 49.7 Other repair of anal

: 9 sphincter

71.7 Other repair of vulva and

9 perineum

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

93
INA-CBG W-1-3 PROSEDUR PADA
: 0-I VAGINA, SERVIK &
VULVA (RINGAN)

94
Ruptur perineum gr 4

Diagnosa O70. Fourth degree perineal

Utama : 3 laceration during delivery

Diagnosa
Sekunder :

Tindakan utama 75.6 Repair of current obstetric

: 2 laceration of rectum and
sphincter ani

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

95
INA-CBG W-4-1 GANGGUAN
: 7-I POSTPARTUM
(RINGAN)

96
Vesicovaginal Fistula

Diagnosa N82. Vesicovaginal fistula

Utama : 0

Diagnosa
Sekunder :

Tindakan utama 57.8 Repair of other fistula of

: 4 bladder

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

97
INA-CBG N-1-11 PROSEDUR KANDUNG
: -I KEMIH KOMPLEK
(RINGAN)

98
GINEKOLOGI

99
Endometriosis dengan salpingoovarektomi

Diagnosa N80. Endometriosis of ovary

Utama : 1

Diagnosa
Sekunder :

Tindakan utama 65.6 Other removal of both

: 1 ovaries and tubes at same
operative episode

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

INA-CBG PROSEDUR PADA RAHIM

: W-1-2 & ADNEKSA (RINGAN)
0-I

100
Kista ovarium dengan salpingoovarektomi

Diagnosa N80. Endometriosis of ovary

Utama : 1

Diagnosa
Sekunder :

Tindakan utama 90.5 Microscopic examination

: 9 of blood, Other
microscopic examination

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

99.1 Injection or infusion of

8 electrolytes

88.7 Other diagnostic ultrasound

9

65.6 Other removal of both

1 ovaries and tubes at same
operative episode

INA-CBG PROSEDUR PADA RAHIM

: W-1-2 & ADNEKSA (RINGAN)
0-I

101
Mioma dengan histerektomi totalis
salpingoovarektomi bilateral

Diagnosa D25. Intramural leiomyoma of

Utama : 1 uterus

Diagnosa N80.
Endometriosis of ovary
Sekunder : 1

Tindakan utama 68.4 Other and unspecified total

: 9 abdominal hysterectomy

T i n d a k a n 65.6 Other removal of both

tambahan : 1 ovaries and tubes at same
operative episode

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

99.2 Injection of antibiotic

1

INA-CBG PROSEDUR PADA RAHIM

: W-1-2 & ADNEKSA (RINGAN)
0-I

102
Rupture perineum grade III

Diagnosa O70. Third degree perineal

Utama : 2 laceration during delivery

Diagnosa O80. Spontaneous vertex

Sekunder : 0 delivery

Single live birth

Z37.
0

Tindakan utama 73.5 Other manually assisted

: 9 delivery

T i n d a k a n 73.4 Medical induction of labor

tambahan :

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

75.3 Other fetal monitoring

4

71.7 Other repair of vulva and

9 perineum

103
 INA-CBG W-1- PROSEDUR PADA VAGINA,
: 30-I SERVIK & VULVA (RINGAN)

Total vagina histerektomi

Diagnosa N81. Complete uterovaginal

Utama : 3 prolapse

Diagnosa
Sekunder :

Tindakan utama 68.5 Other and unspecified

: 9 vaginal hysterectomy

T i n d a k a n 70.5 Repair of cystocele and

tambahan : 0 rectocele

99.2 Injection of antibiotic

1

99.1 Injection or infusion of

8 electrolytes

57.9 Insertion of indwelling

4 urinary catheter

90.5 Microscopic examination

9 of blood, Other
microscopic examination

104
INA-CBG W-1-3 PROSEDUR PADA VAGINA,
: 0-I SERVIK & VULVA
(RINGAN)

105
Karsinoma servik dengan
kemoterapi;haemodialisis

Diagnosa Z51. Chemotherapy session for

Utama : 1 neoplasm

Diagnosa C53. Malignant neoplasm,

Sekunder : 9 cervix uteri, unspecified

Anaemia in neoplastic
D63. disease
0

Chronic kidney disease,

N18. stage 3
3

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

39.9 Hemodialysis
5

106
INA-CBG C-4-13 KEMOTERAPI (SEDANG)
: -II

107
Servik dengan kemoterapi; anemia

Diagnosa Z51. Chemotherapy session for

Utama : 1 neoplasm

Diagnosa C53. Malignant neoplasm,

Sekunder : 9 cervix uteri, unspecified

Anaemia in neoplastic
D63. disease
0

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

108
INA-CBG C-4-1 KEMOTERAPI (SEDANG)
: 3-II

109
Servik dengan histerektomi; radikal

Diagnosa C53. Malignant neoplasm,

Utama : 9 cervix uteri, unspecified

Diagnosa
Sekunder :

Tindakan utama 57.9 Insertion of indwelling

: 4 urinary catheter

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

68.6 Other and unspecified

9 radical abdominal
hysterectomy

110
INA-CBG W-1- PROSEDUR PADA RAHIM &
: 20-I ADNEKSA (RINGAN)

111
Kemoterapi revisi

Diagnosa Z51. Chemotherapy session for

Utama : 1 neoplasm

Diagnosa C56 Malignant neoplasm of

Sekunder : ovary

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

INA-CBG C-4-1 KEMOTERAPI (RINGAN)

: 3-I

112
Karsinoma ovarium dengan kemoterapi

Diagnosa C56 Malignant neoplasm of

Utama : ovary

Diagnosa Z51. Chemotherapy session for

Sekunder : 1 neoplasm

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

INA-CBG W-4-1 TUMOR SISTEM

: 0-II REPRODUKSI WANITA
(SEDANG)

113
Karsinoma ovarium dengan HTSOB

Diagnosa C56 Malignant neoplasm of

Utama : ovary

Diagnosa
Sekunder :

Tindakan utama 99.2 Injection of antibiotic

: 1

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

99.1 Injection or infusion of

8 electrolytes

68.4 Other and unspecified total

9 abdominal hysterectomy

65.6 Other removal of both

1 ovaries and tubes at same
operative episode

114
INA-CBG W-1-20 PROSEDUR PADA RAHIM
: -I & ADNEKSA (RINGAN)

115
Tumor trophoblastic gestasional dengan
kemoterapi

Diagnosa Z51. Chemotherapy session for

Utama : 1 neoplasm

Diagnosa C58 Malignant neoplasm of

Sekunder : placenta

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

57.9 Insertion of indwelling

4 urinary catheter

99.1 Injection or infusion of

8 electrolytes

INA-CBG C-4-13 KEMOTERAPI (RINGAN)

: -I

116
Tumor trophoblastic gestasional anemia

Diagnosa Z51. Chemotherapy session for

Utama : 1 neoplasm

Diagnosa C58 Malignant neoplasm of

Sekunder : placenta

O99. Anaemia complicating

0 pregnancy, childbirth and
the puerperium

Tindakan utama 99.2 Injection or infusion of

: 5 cancer chemotherapeutic
substance

T i n d a k a n 99.2 Injection of antibiotic

tambahan : 1

90.5 Microscopic examination

9 of blood, Other
microscopic examination

57.9 Insertion of indwelling

4 urinary catheter

99.1 Injection or infusion of

8 electrolytes

99.0 Transfusion of blood

8 expander

117
INA-CBG C-4-13 KEMOTERAPI (SEDANG)
: -II

118
Molahidatidosa

Diagnosa O01. Hydatidiform mole,

Utama : 9 unspecified

Diagnosa
Sekunder :

Tindakan utama 99.2 Injection of antibiotic

: 1

T i n d a k a n 57.9 Insertion of indwelling

tambahan : 4 urinary catheter

99.1 Injection or infusion of

8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

69.0 Dilation and curettage for

1 termination of pregnancy

INA-CBG W-1-10- PROSEDUR ABORSI

: I (RINGAN)

119
Molahidatidosa dengan kelainan tiroid

Diagnosa O01. Hydatidiform mole,

Utama : 9 unspecified

Diagnosa O99. Endocrine, nutritional

Sekunder : 2 metabolic diseases
complicating pregnancy,
childbirth and the
puerperium

Tindakan utama 99.2 Injection of antibiotic

: 1

T i n d a k a n 57.9 Insertion of indwelling

tambahan : 4 urinary catheter

99.1 Injection or infusion of

8 electrolytes

90.5 Microscopic examination

9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

69.0 Dilation and curettage for

1 termination of pregnancy

INA-CBG W-1-10- PROSEDUR ABORSI

: II (SEDANG)

120
POLIKLINIK

121
Pemeriksaan Antenatal

Diagnosa Z36. Antenatal screening,

Utama : 9 unspecified

Diagnosa
Sekunder :

Tindakan utama 88.7 Diagnostic ultrasound of

: 8 gravid uterus

T i n d a k a n 75.3 Other fetal monitoring

tambahan : 4

INA-CBG PROSEDUR ULTRASOUND

: Z-3-2 GINEKOLOGIK
5-0

122
Pemeriksaan Antenatal dengan Komplikasi

Diagnosa Z36. Antenatal screening,

Utama : 9 unspecified

Diagnosa Z Supervision of high-risk

Sekunder : 35.9 pregnancy, unspecified

Tindakan utama 88.7 Diagnostic ultrasound of

: 8 gravid uterus

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood

75.3 Other fetal monitoring

4

INA-CBG PROSEDUR ULTRASOUND

: Z-3-2 GINEKOLOGIK
5-0

123
Wound care Pasca Seksio Sesarea

Diagnosa O90. Disruption of caesarean

Utama : 0 section wound

Diagnosa N80.
-
Sekunder : 1

Tindakan utama 91.7 Microscopic examination

: 9 of specimen from operative
wound

T i n d a k a n 93.5 Application of other wound

tambahan : 7 dressing

INA-CBG PERAWATAN LUKA

: Z-3-2
7-0

124
Amniocentesis

Diagnosa Z36. Antenatal screening for

Utama : 0 chromosomal
abnormalities

Diagnosa
-
Sekunder :

Tindakan utama 75.1 Diagnostic amniocentesis

:

T i n d a k a n 88.7 Diagnostic ultrasound of

tambahan : 8 gravid uterus

INA-CBG W-2-34-0 PROSEDUR

: GINEKOLOGI LAIN-
LAIN

125
Amnioinfusion

Diagnosa O41. Other specified disorders

Utama : 8 of amniotic fluid and
membranes

Diagnosa
Sekunder :

Tindakan utama 75.3 Amnioinfusion

: 7

T i n d a k a n 75.3 Other fetal monitoring

tambahan : 4

88.7 Diagnostic ultrasound of

8 gravid uterus

INA-CBG Z-3-2 PROSEDUR ULTRASOUND

: 5-0 GINEKOLOGIK

126
Karsinoma servik

Diagnosa C53. Malignant neoplasm,

Utama : 9 cervix uteri, unspecified

Diagnosa
Sekunder :

T i n d a k a n 67.11 Endocervical biopsy

utama :

T i n d a k a n 89.2 Gynecological
tambahan : 6 examination

INA-CBG W-2-34 PROSEDUR

: -0 GINEKOLOGI LAIN-
LAIN

127
Karsinoma ovarium

Diagnosa Utama C56 Malignant neoplasm of

: ovary

Diagnosa
Sekunder :

Tindakan utama 89.2 Gynecological examination

: 6

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

INA-CBG Z-3-2 PROSEDUR ULTRASOUND

: 3-0 LAIN-LAIN

128
Kista ovarium

Diagnosa D27 Benign neoplasm of ovary

Utama :

Diagnosa
Sekunder :

Tindakan utama 89.2 Gynecological examination

: 6

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

88.7 Other diagnostic ultrasound

9

INA-CBG Z-3-2 PROSEDUR ULTRASOUND

: 3-0 LAIN-LAIN

129
Injeksi Tapros

Diagnosa Utama N80. Endometriosis of ovary

: 1

Diagnosa
Sekunder :

Tindakan utama 99.2 Injection or infusion of

: 5 other theurapeutic or
prophylactic substance

Ti n d a k a n
tambahan :

INA-CBG Q-5- PENYAKIT KRONIS KECIL

: 44-0 LAIN-LAIN

130
Pemeriksaan Duh Tubuh

Diagnosa N76. Acute vulvitis

Utama : 2

Diagnosa Vulvovaginal ulceration

Sekunder : N77. and inflammation in other
8 disease classified
elsewhere

Tindakan utama 91.4 Microscopic examination

: 9 of specimen from genital
tract

T i n d a k a n 89.2 Gynecological examination

tambahan : 6

INA-CBG Q-5-4 PENYAKIT AKUT KECIL

: 2-0 LAIN-LAIN

131
Prolaps Uteri; Cystocele; Rectocele

Diagnosa N81. Incomplete uterovaginal

Utama : 2 prolapse

Diagnosa N81.
Cystocele
Sekunder : 1

N Recocele
81.6

Tindakan utama 89.2 Gynecological examination

: 6

T i n d a k a n 90.5 Microscopic examination

tambahan : 9 of blood, Other
microscopic examination

91.4 Microscopic examination

6 of specimen from female
genital tract, cell block and
papanicolaou smear

132
INA-CBG Q-5-44 PENYAKIT KRONIS KECIL
: -0 LAIN-LAIN

133