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 S52.90 78.69 removal implant 3.765.791
device from the bone

Luka terbuka di tangan, crush S67.8 Crushing injury of other and 84.03 amputation through 14.952.975
injury unspecified parts of wrist and hand hand.
S55.1 injury of radial artery at forearm
level
Luka kotor /infeksi di jaringan M65.8 Synovitis and tenosynovitis 82.04 incision and drainage 8.403.235
lunak of palmar at thenar space,
86.66 homograft to skin
Infeksi jaringan L.02.51 Cutaneus abscess of the hand. 82.04 incision and drainage 8.403.235
of palmar at thenar space,
86.66 homograft to skin
ganglion M67.4 ganglion 82.29 Excision of other lesion 12.485.355
of soft tissue of hand

Fracture pada pergelangan S62.8 fracture at wrist and hand level 79.34 open reduction of 12.485.355
tangan dan tangan fracture with internal fixation
, carpals and metacarpals.

Luka berat pada jari, tangan S68 traumatic amputasion of wrist 84.04 amputation and 14.952.971
(perlu amputasi) and hand level disarticulation of hand
S55.1 injury of radial artery at forearm

Deformitas/ kelainan pada jari
Jepitan pada syaraf/carpal
tunnel syndrome
Syndactili
Dislokasi pada jari
Tumor ganas pada ekstremitas
atas
Infeksi pada sendi
Kerusakan sendi krn rematik
Kerusakan sendi bukan karena
rematik
Deformitas/ kelainan pada jari
level
M20.0 Deformity of finger 84.03 amputation and 9099.408
disarticulation of Hand
S64 injury of nerves at wrist and hand 05.9 other operation on 11.164.055
level nervous system
Q70 Syndactili 86.85 correction of 12.485.355
syndactyly
S63.1 dislocation and sprain of joints 79.84 open reduction of 12.485.355
and ligaments at wrist and hand level dislocation of hand and
finger
C40.1 malignant neoplasm of short 84.03 amputation of through 14.952.975
bones of upper limb hand
S55.1 injury of radial artery at forearm
leve
M00 Pyogenic infection 81.29 arthhrodesis of other 8.404.231
specified joints
86.66 homograft to skin
M05 .38 rheumatoid arthritis with 81.29 arthhrodesis of other 8.403.235
rheumatoid factor specified joints
M65.80 other synovitis and 86.66 homograft to skin
tenosynovitis
M06 other rheumatoid arthritis 81.29 arthhrodesis of other 8.403.235
specified joints
86.72 pedicle or flap graft,
not otherwise specified
M20.0 Deformity of finger 82.8 other plastic operation 12.485.355
 on hand,

kontracture M24.59 contracture unspecified site 82.3 other excision of soft 12.485.355
tissue of hand;

polidactili Q69 polidactyli 84.03 amputation and 8.403.235

disarticulation of finger:
86.66 homograft to skin

Raw surface, defek soft tissue,
sural flap, semua tindakan flap
Traumatic amputasi perlu
replantasi
L98.9 other disorders of skin and 82.8 other plastic operation 8.403.235
subcutaneous tissue, not elsewhere on hand
86.72 pedicle or flap graft,
not otherwise spesified
S68.9 traumatic amputasion of wrist 84.22 finger reattachment 8.403.235
and hand level 86.72 pedicle or flap graft,
S55.1 injury of radial artery at forearm not otherwise spesified
leve

Trauma (Fracture)

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur Plafon

1. Non union perlu bone graft M84.90 disorder of continuity of 78.69 bone graft 8.403.235
bone , unspecified 86.66 homograft to skin
2. Fracture clavikula S42 fracture of shoulder and upper 79.30 ORIF,unspecified site 3.835.376
arm
3. Fracture clavikula dengan S.06.9 intracranial injury 79.30 ORIF,unspecified site 7.691.543
cedera kepala S42 fracture of shoulder and upper
arm
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 Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
7. Fracture radius S52.3 fracture shaft radius 79.32 ORIF , radius and ulna 12.485.355

8. Fracture ulna S52.2 fracture shaft ulna 79.32 ORIF , radius and ulna 12.485.355

9. Fr antebrachii S52.7 fracture shaft forearm 79.32 ORIF , radius and ulna 12.485.355
10. Fracture humerus S42.3 fracture shaft humerus 79.31 ORIF humerus 12.485.355

11. Fracture pada tangan, S62 fracture at wrist and hand level 79.34 ORIF phalank of hand 12.485.355
metacarpal, phalang
12. Fracture subtrochanter femur S72.2 subtrochanteric fracture of 79.35 ORIF , femur Klas 1= 8.898.656
perlu ORIF femur Klas 2 = 7.627.420
Klas 3 = 6 .356.183

Hip implant :
6000.000
13. Fracture intercondylar femur, S72 fracture shaft femur 79.35 ORIF , femur Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183

Knee implant :
6000.000
14. Fracture intertrochanter femur M81.65 Osteoporosis 79.35 ORIF , femur Klas 1= 8.898.656
S72.14 Intertrochanteric fracture of Klas 2 = 7.627.420
femure Klas 3 = 6 .356.183
 Hip implant :
6000.000
15. Fracture galeazi S52.3 fracture shaft radius 79.32 ORIF , radius and ulna ; 12.485.355

16. Fracture montegia S52.2 shaft ulna 79.32 ORIF , radius and ulna 12.485.355
;,

17. Fracture prksimal humerus,neck S42.20 fracture of upper end of 79.31 ORIF humerus 12.485.355
humerus humerus
18. OA Sendi lutut perlu TKR M17.4 other secondary gonarthrosis , 81.54 Total Knee 5.978.592
bilateral Replacement
M19.26 secondary of the joint , lower
leg

19. OA Sendi perlu TKR M17.4 other secondary gonarthrosis , 81.47 other repair of knee Klas 1: 30.748.959
bilateral Klas 2:26.353.251
M19.26 secondary of the joint , lower Klas 3: 21.963.542
leg
Knee replacement
3.000.000
20. OA sendi Hip perlu THR M19.26 secondary of the joint , lower 81.51 Total Hip Replacement 5.978.592
leg

21. OA Sendi perlu THR M19.26 secondary of the joint , lower 81.40 Repair of hip, not Klas 1= 8.898.656
leg elsewhere classified 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

23. Fracture plateau tibia
24. Fracture acetabulum
25. Fracture
pedis,metacarpale,ankle
26. Fracture patella
27. Infeksi pada sendi,
28. Infeksi tulang, tromboemboli
29. Dislokasi pinggul
30. Dislokasi bahu
31. Dislokasi siku
S72.0 fracture of head and neck of elsewhere classified Klas 2 = 7.627.420
femur Klas 3 = 6 .356.183
Hip implant :
3000.000
S82 Fracture of tibia 79.36 ORIF , tibia and fibula 21.963.542
)
S32.4 fracture acetabulum 79.30 ORIF , unspecified site 11.164.055
05.9 other operation on
nervous system Hip implant :
6000.000
S82.90 Fracture of lower leg , 79.37 ORIF tarsal,metatarsal 8.855.736
including ankle
822.1 fracture of patella,open 81.44 patellar stabilization 21.963.542
M01 direct infection of joint in 81.9 other operation on joint
infectious and parasitic disease structure
classified elsewhere 86.66 homograft to skin
M86 Osteomyelitis, 79.6 debridement of open
fracture site ;
86.72 pedicle or flap graft,
not otherwise specified
S73.0 Dislocationand sprain of joint 79.75 closed reduction of 3481.352
and ligament of hip dislocation , hip
S43.0 Dislocation and sprain of joint 79.71 closed reduction of 1.948.000
and ligament of shoulder dislocation shoulder
S53.1 Dislocation and sprain of joint 79.72 closed reduction of 1.948.000
and ligament of elbow dislocation , elbow
 32. Fracture neglected M84.9 disorder of continuity of 78.4 other repair of plastic
bone,unspesified 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 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 1.948.000
ekstremitas atas dengan GA level fracture without internal
fixation

2 Reposisi dan pasang gip S82.7 fracture of lower leg 79.07 closed reduction of 1.948.000
ekstremitas bawah dengan GA fracture without internal
fixation

3 Rekonstruksi ibu jari kaki , halux M20.1 halux valgus/acquired 82.89 other plastic operation 8.855.731
valgus on hand
77.51 other buninectomy

4 Fracture neglected M84.9 disorder of continuity of 78.4 other repair of plastic

bone,unspesified operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
5 Kelainan congenital,CTEV,Blount Q66.3 other congenital varus 78.4 other repair of plastic 12.485.355
 disease deformities of feet, operation of bone

6 Pemanjangan tulang Q66.3 other congenital varus 78.3 limb lengthening 21.953.542
deformities of feet, procedure

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 2.049.737
other soft tissue structure

2 Eksisi tumor
3 Amputasi tumor di atas
lutut(above knee)
4 Amputasi tumor di bawah lutut
(below knee)
5 Eksisi luas (wide eksisi)
6 Fraktur dengan tumor tulang
7. Operasi tumor ganas
C40.9 malignant neoplasm of bone 82.29 excision of other 12.485.355
and articular cartilage of limb,. lesion of hand
C40.9 malignant neoplasm of bone 84.17 amputation above 9.099.400
and articular cartilage of limb,. S85.0 knee/transfemoral
injury of popliteal artery
C40.9 malignant neoplasm of bone 84.15amputation below knee 9.099.400
and articular cartilage of limb,. S85.0
injury of popliteal artery
D49.2 neoplasm of unspecified 77.60 local excision of lesion 12.485.355
behavior of bone , soft tissue , skin or tissue of bone unspecified
S85.0 injury of popliteal artery site
86.66 homograft to skin
C40.9 malignant neoplasm of bone 79.3 ORIF
and articular cartilage of limb,. 86.66 homograft to skin
C40.9 malignant neoplasm of bone 78.4 other repair of plastic 8.403.235
and articular cartilage of limb,. S85.0 operation of bone;
injury of popliteal artery 86.72 pedicle or flap graft,
not otherwise spesified
8 Ganti sendi pada kasus tumor C79.9 secondary malignant neoplasm 81.40 repair of hip 8.403.235
tulang/AMP of unspecified site

Arthroscopy , Shoulder (bahu) dan Knee (lutut)

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur plafon

1. Infeksi sendi lutut, M17.9 Gonarthrosis , unspecified 81.47 other repair of knee 21.000.000
M01.56 arthritis in other bacterial
disease lower leg
M35.4 diffuse fasciitis

2 Bahu kaku/frozen shoulder/ M75.0 adhesive capsulitis of shoulder 80.21 arthroscopy shoulder 7.691.547
adhesive capsulitis M35.4 diffuse fasciitis

3 Mengeluarkan benda asing di M25.68 stiffness of joint 81.47 other repair of knee 21.000.000
lutut/loose bodies M65.26 calcific tendinitis

4
5 Debridement shoulder M25.68 stiffness of joint 80.21 arthroscopy shoulder; Klas 3 = 7.691.547
M65.26 calcific tendinitis M35.4 Klass 2 =9226.000
diffuse fasciitis Klass1: 10.768.160

6
7 Rotator cuff tear M75.1 complete rotator cuff tear or 80.21 arthroscopy shoulder; 9.229.852
rupture not specified as traumatic 80.49 division of joint,
 M35.4 diffuse fascitis ligament or cartilage of other
specified site

8 Rupture meniscus M23.2 dearrangement of meniscus 81.47 other operation of 21.000.000

due to old tear or injury knee

9 Osteoarthritis lutut derajat S83.2 tear of meniscus,current 81.47 other operation of 21.000.000
ringan (1-2)/ artroscopy M35.8 other specified systemic knee
debridement involvement connective tissue

10
11 Ligament ACL/PCL lutut putus M23.61 other spontaneous disruption 81.47 other operation of Klas 3= 21.963.542
of ligament of knee, ACL /Anterior cruciate ligament Klas 2= 26.356.251
horn medial meniscus Klas 1= 30.748.959

Implant knee :
6000.000
12
13 Ganti sendi lutut/ total knee M17 osteoartritis of knee 81.47 other operation of Klas 1: 30.748.959
arthroplasty/osteoarthritis ) knee Klas 2:26.353.251
derajat berat Klas 3: 21.963.542

14 Rematik di lutut derajat berat
perlu ganti sendi
Knee replacement
3.000.000
M05.661 rhaumatoid arthritis of left 81.47 other operation of Klas 1: 30.748.959
knee with involvement of other organ knee Klas 2:26.353.251
and system Klas 3: 21.963.542

Knee replacement
3.000.000
15
 Spine/ Tulang Belakang

No Keterangan ICD 10 Diagnosis ICD 9 Prosedur plafon

1. scoliosis M41.55 scoliosis 81.60 , 360 degree spinal 34.590.151
S25.9 injury of unspecified blood fusion, single incision
vessel of thorax approach
M43.54 vertebral subluxation 83.74 reattachment of
muscle
77.31 other division of
scapula, clavicle,and thorax
(rib and sternum)

2 Spondilolisthesis, canal stenosis M43.15 spondilolisthesis; M48.05 03.09 other exploration and Klass 3= 25.165.278
spinal stenosis decompression of spinal Klass 2= 30.000.000
M48.54 collapse vertebrae canal Klass 1 = 35.231.390
S25.8 injury of other blood vessel of 84.51 insertion of other
thorax spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
3. Tumor tulang belakang C41.2 malignant neoplasm of 03.09 other exploration and Klass 3= 25.165.278
vertebral column ; M48.05 spinal decompression of spinal Klass 2= 30.000.000
stenosis canal Klass 1 = 35.231.390
M48.54 collapse vertebrae 84.51 insertion of other
S25.8 injury of other blood vessel of spinal device;
thorax 81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

4 HNP/canal stenosis di cervical M50.1 cervical disc disorder; 03.09 other exploration and Klass 3= 25.165.278
dengan tetraparese dengan M48.05 spinal stenosis decompression of spinal Klass 2= 30.000.000
implan M48.54 collapse vertebrae canal Klass 1 = 35.231.390

5 HNP/canal stenosis di
thorakal/lumbal dengan implan
G82.4 flaccid tetraplegia 84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
M51.1 thoraxic , thoracolumbal and 03.09 other exploration and Klass 3= 25.165.278
lumbosacral intervertebral disc decompression of spinal Klass 2= 30.000.000
disorder; canal Klass 1 = 35.231.390
M48.05 spinal stenosis 84.51 insertion of other
M48.54 collapse vertebrae spinal device;
S25.8 injury of other blood vessel of 81.62 fusion of 2-3 vertebrae
thorax 81.04 Dorsal fusion

6 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 25.165.278
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

7 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 19.950.055
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion

8 Fraktur tulang belakang dengan
implan
S32.7 fracture of lumbar spine and 03.09 other exploration and Klass 3= 25.165.278
pelvis; decompression of spinal Klass 2= 30.000.000
M48.0 spinal stenosis canal Klass 1 = 35.231.390
M48.54 collapse vertebrae 84.51 insertion of other
S25.8 injury of other blood vessel of spinal device;
thorax 81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion