TARIF PASIEN BPJS BEDAH SARAF

Diagnosis / ICD X Tindakan / ICD IX Tarif

No
Primer Sekunder Primer Sekunder Kelas 1 kelas 2 Kelas 3
1 Epidural Hematom
Acute post haemorragic anemia / Control of hemorrage not
Epidural hemorrage / S 06.4
D 62 otherwise specified / 39.98
Other Craniotomy / 01.24 23,691,400 20,308,900 16,922,400
Compression of Brain / G 93.5 Transfusion of packed cells /
99.04
2 Subdural Hematom

Subdural haemorrage (acut) Compression of Brain / G 93.5 Other Craniotomy / 01.24

(nontraumatic) / I 62.0

Traumatic Subdural
haemorrage, without open
intracranial wound / S 06.50
Traumatic Subdural
haemorrage, with open
intracranial wound / S 06.51
Compression of Brain / G 93.5 Control of hemorrage not
otherwise specified / 39.98 23,691,400 20,308,900 16,922,400
Other Craniectomy / 01.25
Acute post haemorragic anemia / Transfusion of packed cells /
D 62 99.04

3 Fraktur Impresi
Fractur of skull and facial Other Cranial osteoplasti / 02.06
bones, part unspecified, closed dan Repair of brain / 02.92 20.520.100 17.586.900 14.655.800
/ S02.90

Fractur of skull and facial

Other reconstruction of other
bones, part unspecified, facial bone / 76.46 26.033.200 22.316.400 18.595.200
open / S02.91
Acute post haemorragic anemia / Other reconstruction of other Control of hemorrage not
D 62 facial bone / 76.46 otherwise specified / 39.98
62,250,600 53,352,400 44,460,300
Transfusion of packed cells /
99.04
4 Kontusio Cerebri
Intracranial injury, Compression of Brain / G 93.5 Other Craniotomy / 01.24 23,691,400 20,308,900 16,922,400
unspecified / S 06.9
5 Stroke Hemorragic
Essential(primary) Hipertensi / Intracerebral hemorrage Other Craniotomy / 01.24 25.680.200 22.009.400 18.341.200
I 10 nontraumatic / I 62.9
6 Intra Ventrikular Hemorrage
Essential(primary) Hipertensi / Intracerebral haemorrhage, Ventriculostomy 02.2 25.680.200 22.009.400 18.341.200
I 10 intraventricular / I 61.5
7 Hidrosefalus

Anemia, unspecified / D 64.9 14.796.400 12.682.600 10.567.800

Hidrosefalus, unspecified / G Ventricular shunt to abdominal
91.9 Marasmic Kwashiorkor / E 42 cavity and organs / 02.34 26.944.100 23.097.300 19.245.800
Unspecified Protein-energy
56.505.700 48.438.300 40.361.200
malnutrition / E 46
8 Osteoma/Skull tumor
Benign neoplasm of bones of Other Craniectomy / 01.25 20.520.100 17.586.900 14.655.800
skull and face / D 16.4
9 Defek Kranium
Post procedural disorder of
nervous system, unspecified / Hemiplegi, unspecified / G 81.9 Other cranialosteoplasti / 02.06 23,691,400 20,308,900 16,922,400
G 97.9
10 Tumor Cerebri

Neoplasm of uncertain or
unknown behaviour of brain, Compression of Brain / G 93.5
supratentorial / D 43.0

Neoplasm of uncertain or Hidrocephalus in neoplastic Other Craniotomy / 01.24 Ventricular shunt to abdominal 23,691,400 20,308,900 16,922,400
unknown behaviour of brain,
disease / G 94.1 cavity and organs / 02.34
infratentorial / D 43.1

Neoplasm of uncertain or
unknown behaviour of
cerebral meninges / D 42.0
11 Abses Cerebri
Intracranial abscess and
granuloma / G 06.0
Other Craniotomy / 01.24 20.520.100 17.586.900 14.655.800
Extradural and subdural
abscess, unspecified / G 06.2

12 Carpal Tunnel Syndrome

 Carpal Tunnel Syndrome / G Other peripheral nerve or ganglion
decompression or lysis of 15.768.800 13.517.400 11.263.400
56.0
adhesion / 04.49

14 Hernia Nucleus Pulposus

Lumbar and other Other exploration and

intervertebral disc disorder Cord compression , unspecified / decompression of spinal canal / 31,822,600 27,276,500 22,730,400
G 95.2
with radiculopathy / M 51.1 03.09

15 Tumor Spinal
Neoplasm of uncertain or
Cord compression , unspecified /
unknown behaviour of spinal G 95.2
cord / D 43.4
Removal of foreign body from 31,822,600 27,276,500 22,730,400
spinal cord / 03.01
Neoplasm of uncertain or
unknown behaviour of spinal Paraplegi / G82.2
meninges / D 42.1

16 Spina Bifida
Spina Bifida, unspecified / Q Repair of spinal
Paraplegi / G82.2 31,822,600 27,276,500 22,730,400
05.9 myelomeningocele / 03.52
17 Meningoencephalocele
Nasofrontal encephalocele / Q Other reconstruction of other
01.1 facial bone / 76.46 26.033.200 22.316.400 18,595,200

Occipital encephalocele / Q Other operations on skull, brain 20.520.100 17.586.900 14.655.800

01.2 and cerebral meninges / 02.99
 DIAGNOSIS ICD X TINDAKAN ICD IX
Other dorsalgia M54.8 Destruction of cranial and peripheral nerves 04.2
Nerve root and plexus compressions in intervertebral disc disorders G55.1 Injection of anesthetic into peripheral nerve for analgesia 04.81
Intervertebral disc stenosis of neural canal M99.5
Lumbar and other intervertebral disc disorders with radiculopathy M51.1
Neoplasm of uncertain or unknown behavior of brain, supratentorial D43.0 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Injection of antibiotic 99.21
H54.4 Computerized axial tomography of head 87.03
Cerebral aneurysm, nonruptured I67.1 Arteriography of cerebral arteries 88.41
Compression of brain G93.5 Other puncture of artery 38.98
Ptosis of eyelid H02.4 Control of hemorrhage, not otherwise specified 39.98
Hemiplegia, unspecified G81.9
Essential (primary) hypertension I10
Neoplasm of uncertain or unknown behavior of pituitary gland D44.3 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Computerized axial tomography of head 87.03
Visual field defects H53.4
Hypothyroidism, unspecified E03.9
Epidural haemorrhage, without open intracranial wound S06.40 Other craniotomy 01.24
Pneumonia due to other specified infectious organism J16.8 Cerebral scan 92.11

Neoplasm of uncertain or unknown behavior of brain, infratentorial D43.1 Other craniotomy 01.24
Compression of brain G93.5 Computerized axial tomography of head 87.03
Headache R51 Injection of antibiotic 99.21

Hydrocephalus, unspecified G91.9 Replacement of ventricular shunt 02.42

Compression of brain G93.5
Marasmic kwashiorkor E42
Bacterial meningoencephalitis and meningomyelitis, not elsewhere classified G04.2
Neoplasm of uncertain or unknown behavior of cerebral meninges D42.0 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Computerized axial tomography of head 87.03
Hemiplegia, unspecified G81.9 Injection of antibiotic 99.21
Headache R51
Epidural haemorrhage S06.4 Other craniotomy 01.24
Restlessness and agitation R45.1 Continous mechanical ventilation for less than 96 consecutive hours 96.71
Fever, unspecified R50.9
 Anaemia, unspecified D64.9
Epidural haemorrhage S06.4 Application of external fixation device, femur 78.15
Fracture of shaft of femur, closed S72.30 Continous mechanical ventilation for 96 consecutive hours or more 96.72

Hydrocephalus, unspecified G91.9 Ventricular shunt to abdominal cavity and organs 02.34
Compression of brain G93.5
Frontal encephalocele Q01.0
Congenital malformation of brain, unspecified Q04.9
Benign neoplasm of spinal cord D33.4 Other exploration and decompression of spinal canal 03.09
Cord compression, unspecified G95.2
Radiculopathy, lumbosacral region M54.17
Low back pain, lumbosacral region M54.57
Other specified cardiac arrhythmias I49.8
Traumatic subarachnoid haemorrhage S06.6 Arteriorgraphy of cerebral arteries 88.41
Injury of carotid artery S15.0 Arteriorgraphy of other specified sites 88.49
Blindness, both eyes H54.0
Driver injured in collision with other and unspecified motor vehicles in traffic accident V29.4
Nasofrontal encephalocele Q01.1 Other operations on skull, brain and cerebral meninges 02.99
Compression of brain G93.5
Anaemia, unspecified D64.9
Epidural haemorrhage S06.4 Other craniotomy 01.24
Compression of brain G93.5 Computerized axial tomography of head 87.03

Lumbar spina bifida with hydrocephalus Q05.2 Other repair and reconstruction of skin and subcutaneous tissue 86.89
Compression of brain G93.5 Other exploration and decompression of spinal canal 03.09
Bacterial sepsis of newborn, unspecified P36.9 Repair of spinal myelomeningocele 03.52
Anaemia, unspecified D64.9 Removal of ventricular shunt 02.43
Encephalitis,myelitis, and encephalomyelitis, unspecified G04.9
Lumbar spina bifida without hydrocephalus Q05.7 Other repair and plastic operations on spinal cord structures 03.59
Paraplegia, unspecified G82.2
Unspecified urinary incontinence R32
Faecal incontinence R15
Fracture of skill and facial bones, part unspecified, closed S02.90 Other reconstruction of other facial bone 76.46
Compression of brain G93.5

Hydrocephalus, unspecified G91.9 Arteriography of cerebral arteries 88.41

Other congenital malformations of great veins Q26.8 Control of hemorrhage, not otherwise specified 39.98
Cerebral aneurysm, nonruptured I67.1 Other puncture of artery 38.98
 Neoplasm of uncertain or unknown behavior of pineal gland D44.5 Other craniotomy 01.24
Compression of brain G93.5

Congenital malformation syndromes predominantly affecting facial appearance Q87.0 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Transfusion of packed cells 99.04
Haemorrhage, not elsewhere specified R58
Acute posthaemorrhagic anaemia D62
Neoplasm of uncertain or unknown behavior of pituitary gland D44.3 Other reconstruction of other facial bone 76.46
Compression of brain G93.5
Visual field defects H53.4
Hyperprolactinemia E22.1
Blindness, one eye H54.4
Hypothyroidism, unspecified E03.9
Mechanical complication of internal fixation device of other bones T84.2 Revision of pedicle-based dynamic stabilization (s) 84.83
Other specified intervertebral disc degeneration M51.3 Dorsal and dorsolumbar fusion, posterior technique 81.05
Radiculopathy, lumbar region M54.16
Aneurysm of carotid artery I72.0 Clipping of aneurysm 39.51
Compression of brain G93.5
Hemiplegia, unspecified G81.9
Disorder of facial nerve, unspecified G51.9
Neoplasm of uncertain or unknown behavior of brain, supratentorial D43.0 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Injection of antibiotic 99.21
Blindness, one eye H54.4 Computerized axial tomography of head 87.03
Neoplasm of uncertain or unknown behavior of brain, supratentorial D43.0 Other reconstruction of other facial bone 76.46
Compression of brain G93.5 Injection of antibiotic 99.21
Decubitus ulcer L89 Computerized axial tomography of head 87.03
Extradural and subdural abscess, unspecified G06.2 Excisional debridement of wound, infection or burn 86.22
Urinary tract infection, site not specified N39.0 Graft of muscle or fascia 83.82
Craniosynostosis Q75.0 Other craniectomy 01.25
Congenital malformation syndromes predominantly affecting facial appearance Q87.0 Transfusion of packed cells 99.04
Acute posthaemorrhagic anaemia D62
Cerebral aneurysm, nonruptured I67.1 Arteriography of cerebral arteries 88.41
Compression of brain G93.5 Control of hemorrhage following vascular surgery 39.41
Other puncture of artery 38.98
Unspecified or unknown behavior neoplasm of brain, supratentorial D32.0 Replacement of v entricular shunt 2.42

Hydrocephalus, unspecified G91.9 Other Craniotomy 01.24

Neoplasm of uncertain or unknown behavior of pituitary gland D44.3 Injection of antibiotic 99.21
 Low Vision, Both Eyes Computerized axial tomography of head 82.03

Neoplasm of uncertain or unknown behavior of spinal cord D43.4 Ventricular shunt to abdominal cavity and organs 2.34
Paraplegia, unspecified G82.2 Computerized axial tomography of head 82.03
Discitis G91.9 Other reconstruction of other facial bone 76.46
Low Vision, Both Eyes Computerized axial tomography of head 87.03
Lumbar and other intervertebral disc disorders with radiculopathy M51.1 Excision or destruction of lesion of spinal cord or spinal meninges 3.4
Essential (primary) hypertension I10 Other cranial nerve decompression 4.42

Benign neoplasm of cerebral meninges D32.0 Arteriography of cerebral arteries 88.41

Other aqcuired deformity of head M95.2 Arteriography using contrast material 88.4
Exophthalmic condition H05.2 Other puncture of artery 38.98

Hyperostosis of skull Control of haemorrhage, not otherwise specified 39.98

Carotid Cavernous Fistule I67.1 Injection of steroid 99.23
Excision or destruction of lesion of spinal cord or spinal meninges 3.4

Continuous mechanical ventilation for 96 consecutive hours or more 96.72

Temporary tracheostomy 31.1
Other Craniotomy 01.24
Replacement of v entricular shunt 2.42
Other Craniotomy 01.24
Injection of antibiotic 99.21
Canal Stenosis G51.3 Computerized axial tomography of head 82.03
Benign neoplasm of bones of skull and face D16.4 Total excision of pituitary gland, transspenoidal approach 7.65
Other aqcuired deformity of head M95.2 Injection of antibiotic 99.21

Lumbar and Other intervertebral disc disorders with radiculopathy M51.1 Repair of spinal myelomeningocele 3.52
Paraplegia, unspecified G82.2 Revision of ventricular shunt 76.46
Other aqcuired deformity of head M95.2

Neoplasm of uncertain or unknown behavior of pituitary gland D44.3

Low Vision, Both Eyes
Neoplasm of uncertain or unknown behavior of pituitary gland D44.3
Low Vision, Both Eyes
Hydrocephalus, unspecified G91.9
 Paraplegia, unspecified G82.2
Dissocoative anaesthesia and sensory loss F44.6
Arnold Chiari syndrome Q07.0
Pneumonia in bacterial disease classified elsewhere J17.0
Adult respiratory distress syndrome J80
Hydrocephalus, unspecified G91.9
Unspecified or unknown behavior neoplasm of brain, supratentorial D32.0
Fracture of skull and facial bones, part unspecified S02.9
Fracture of vault of skull S02.0

Focal brain injury S06.3

Traumtic cerebral oedema S06.1

Subdural haemorrhage (acute) (nontraumatic) I62.9
Anaemia, unspecified D64.9
Benign neoplasm of cerebral meninges D32.0
Other aqcuired deformity of head M95.2
Exophthalmic condition H05.2
Hyperostosis of skull

Hydrocephalus, unspecified G91.9

Hyperostosis of skull
Benign neoplasm of cerebral meninges D32.0
Other aqcuired deformity of head M95.2
Exophthalmic condition H05.2

Hyperostosis of skull
Neoplasm of uncertain or unknown behavior of pituitary gland D44.3
Blindness, one eye H54.4
Compression of brain G93.5
Hypo-osmolality and hyponatremia E87.1
Anaemia, unspecified D64.9
Neoplasm of uncertain or unknown behavior of pituitary gland D44.3
Low vision, one eye H53.4