REKAP BIAYA

NO KELAS KODE DX KODE PROSEDUR BIAYA DLL KODE DLL PROSEDUR

1 Z50.1 OTHER PHYSICAL THERAPY 93.39 OTHER PHYSICAL THERAPY 9334 DIATERMI
93.35 OTHER HEAT THERAPY
93.11 ASSISTING EXERCISE 102,700

2 R50.9 FEVER 175,000

3 L50.9 URTIKARIA 175,000

4 A09.9 GASTROENTERITIS DAN COLITIS 175,000 89.52 EKG

5 S05.8 OTHER INJURIES OF EYE AND ORBIT 277,300

6 J30.4 ALERGIK RINITIS

R51 HEADACHE 177,800

FOLLOW UP EXAM AFTER OTHER

TREATMENT FOR OTHER
7 Z09.8 KONDITION
I69.4 SEQUELE OF STROKE
I10 ESSENTIAL HIPERTENSI
E11.9 NIDDM
G40.9 EPILEPSY 177,800

8 H61.2 IMPECTED CERUMEN 177,800

OTHER CRONIC SUPPURATIVE

9 H66.3 OTITIS MEDIA
J31.0 CHRONIC RHINITIS 177,800
10 E11.4 NIDDM
G63.2 DIABETIC POLYNEUROPHATY
I10 ESSENTIAL HT 177,800

11 J31.0 CHRONIK RINITIS 177,800

12 N18.9 CHRONIK RENAL FAILURE

I10 ESSENTIAL HT 251,000

13 Z09.8 FOLLOW UP EXAM

J06.8 ISPA
B86 SCABIES 177,800

14 J06.9 ISPA
E46 PROTEIN ENERGI MALNUTRISI 175,000

SUPERFISION OF OTHER HIGHT

15 Z35.8 PREGNANCY
GESTASIONAL
O13 HIPERTENSI/PROTEINURIA 284000

16 Z38.0 SINGLETON BORN IN HOSPITAL

P59.9 NEONATAL JOUNDICE 281700

FOLLOW UP EXAM AFTER OTHER

TREATMENT FOR OTHER
17 Z09.8 KONDITION 93.57 WOUND DRESING
O82.0 DELIVERI SC 171700
 FOLLOW UP EXAM AFTER OTHER
TREATMENT FOR OTHER
18 Z09.8 KONDITION
NONINFLAMATORI DISORDER OF
N89.8 VAGINA 512800 88.79 USG

FOLLOW UP EXAM AFTER OTHER

TREATMENT FOR OTHER
19 Z09.8 KONDITION
O03.4 SPONTANEUS ABORTION 284000 88.78 USG

SUPERVISION OF OTHER HIGH RISK

20 Z35.8 PREGNANCY

MATERNAL CARE DUE TO UTERINE

O34.2 SCAR FROM PREVIOUS SURGERY 284000 88.78 USG

21 B18.1 CRONIC VIRAL HEPATITIS 175000

22 K30 DISPEPSIA 231900

23 J46 STATUS ASMATIKUS 295500 9394 NEBULIZER

OTHER OXYGEN
93.96 ENRICHMENT

INJURI OF MUSCLES AND TENDON

24 T14.6 OF UNSPECIFIED BODY REGION 175000

25 H81.3 OTHER PERIPHERAL VERTIGO 177800

 SUPERFISIAL INJURY OF
26 T14.0 UNSPECIFIED REGION 171700 93.57 WOUND DRESSING

27 R10.0 ACUTE ABDOMEN 126600

26 A09.9 GE 175000

27 R10.0 ACUTE ABDOMEN 126600

28 5961
DLL KODE DLL DX

I20.9 ANGINA PECTORIS

R10.0 ACUTE ABDOMEN
ND DRESING
ND DRESSING
 REKAP BIAYA RAWAT INAP

NO KELAS KODE DX UTAMA DX SEKUNDER

1 I kontraksi;
II KPD;kontraksi+breech
O34.2 Bekas SC presentasion; SC
emergensi/SC Poli
III
2 I letak lintang;
II O33.9 CPD (Panggul Sempit) oligohidramnion
III
3 I bekas SC;
II O68.0 Fetal distress (Gawat Janin) malpresentasi
III
4 I bekas SC;CPD;
II malpresentasi; breech
O63.0 Kala I memanjang presentasion; fetal
distress; gagal induksi
III
5 I hamil preterm
II O42.0 Ketuban Pecah Dini 24jam
III
6 I
II O41.0 Oligohidramnion
III
7 I distosia kala 1;
II O48 Prolonged pregnancy (post term) fetal distress
III
8 I
II O14.0 Moderate pre-eclampsia
III
9 I Endocrine,nutrisional metabolik thyrotoxicosis
II O99.2 disease complicating
III pregnancy,childbirth,puerperium
10 I shock following labour
II O72.0 Third stage haemoraghe delivery
III
11 I
Third degree perineal laceration
II O70.2
during delivery
III
12 I
II O20.0 Threatened abortion
III
13 I
Spontaneous abortion,incomplete
II O03.4
without complication
III
14 I
II O80.8 Persalinan normal spontan
III
15 I
II O63.0 Distosia kala I persalinan spontan
III
16 I
O42.0 Ketuban Pecah Dini 24jam persalinan spontan
 II O42.0 Ketuban Pecah Dini 24jam persalinan spontan
III
17 I
persalinan spontan;
II O34.2 Bekas SC
kontraksi
III
18 I
II
III
19 I
II
III
20 I
II
III
21 I
II
III
22 I
II
III
23 I
II
III
24 I
II
III
25 I
II
III
26 I
II
III
27 I
II
III
28 I
II
III
29 I
II
III
30 I
II
III
31 I
II
III
32 I
II
III
33 I
II
III
34 I
II
III
35 I
II
III
36 I
II
III
37 I
II
III
38 I
II
III
39 I
II
III
40 I
II
III
41 I
II
III
42 I
II
III
43 I
II
III
44 I
II
III
45 I
II
III
46 I
II
III
47 I
II
III
48 I
II
III
49 I
II
 III
50 I
II
III
51 I
II
III
52 I
II
III
53 I
II
III
54 I
II
III
55 I
II
III
56 I
II
III
57 I
II
III
58 I
II
III
59 I
II
III
60 I
II
III
61 I
II
III
62 I
II
III
63 I
II
III
64 I
II
III
65 I
II
III
66 I
 II
III
67 I
II
III
68 I
II
III
69 I
II
III
70 I
II
III
71 I
II
III
72 I
II
III
73 I
II
III
74 I
II
III
75 I
II
III
76 I
II
III
77 I
II
III
78 I
II
III
79 I
II
III
80 I
II
III
81 I
II
III
82 I
II
III
83 I
 II
III
84 I
II
III
85 I
II
III
86 I
II
III
87 I
II
III
88 I
II
III
89 I
II
III
90 I
II
III
91 I
II
III
92 I
II
III
93 I
II
III
94 I
II
III
95 I
II
III
96 I
II
III
97 I
II
III
98 I
II
III
99 I
II
III
100 I
 II
III
101 I
II
III
102 I
II
III
103 I
II
III
104 I
II
III
105 I
II
III
106 I
II
III
107 I
II
III
108 I
II
III
109 I
II
III
110 I
II
III
111 I
II
III
112 I
II
III
113 I
II
III
114 I
II
III
115 I
II
III
116 I
II
III
117 I
 II
III
118 I
II
III
119 I
II
III
120 I
II
III
121 I
II
III
122 I
II
III
123 I
II
III
124 I
II
III
125 I
II
III
126 I
II
III
127 I
II
III
128 I
II
III
129 I
II
III
130 I
II
III
131 I
II
III
132 I
II
III
133 I
II
III
134 I
 II
III
135 I
II
III
136 I
II
III
137 I
II
III
138 I
II
III
139 I
II
III
140 I
II
III
141 I
II
III
142 I
II
III
143 I
II
III
144 I
II
III
145 I
II
III
146 I
II
III
147 I
II
III
148 I
II
III
149 I
II
III
150 I
II
III
151 I
 II
III
152 I
II
III
 KODE PROSEDUR (KODE) BIAYA
O47.1; 6,065,100
O42.0 ;
O47.1+O32.1; 5,198,600
SC (74.4)
O82.1/O82.0
4,332,200
O32.2; 6,065,100
O41.0 SC (74.4) 5,198,600
4,332,200
O34.2; 6,065,100
O32.8 SC (74.4) 5,198,600
4,332,200
O34.2;O33.9 6,065,100
O32.8; O32.1; 5,198,600
O68.0; O61.9 SC (74.4)

4,332,200
O60.3 SC (74.4); 6,065,100
Injeksi steroid (99.23) 5,198,600
4,332,200
6,065,100
SC (74.4) 5,198,600
4,332,200
O63.0; 6,065,100
O68.0 SC (74.4) 5,198,600
4,332,200
6,065,100
SC (74.4) 5,198,600
4,332,200
E05.9 6,065,100
SC (74.4) 5,198,600
4,332,200
O75.1 1,980,300
Manual plasenta (75.2);
Transfusi PRC (99.04) 1,697,400
1,414,500
1,980,300
repair other current
obstetric laceration (75.69) 1,697,400
1,414,500
1,521,100
USG gravid (88.78)
Infus(99.18) 1,303,800
1,086,500
2,042,200
Kuretase (69.02) 1,750,400
1,458,700
Induksi (73.4) 2,073,100
Manually assisted 1,777,000
delivery (73.59) 1,480,800
Induksi (73.4) 2,073,100
O80.8 Manually assisted 1,777,000
delivery (73.59) 1,480,800
Induksi (73.4) 2,453,700
O80.8 Manually assisted
delivery (73.59)
 Induksi (73.4)
O80.8 Manually assisted 2,103,200
delivery (73.59) 1,752,700
Induksi (73.4) 2,453,700
O80.8;
Manually assisted 2,103,200
O47.1
delivery (73.59) 1,752,700
6,065,100
5,198,600
4,332,200
4,271,700
3,661,500
3,051,200
4,933,200
4,228,500
3,523,700
6,065,100
5,198,600
4,332,200
3,367,800
2,886,700
2,405,600
6,065,100
5,198,600
4,332,200
1,525,000
1,307,200
1,089,300
2,094,900
1,795,700
1,496,400
2,450,900
2,100,800
1,750,600
6,407,600
5,492,200
4,576,800
2,450,900
2,100,800
1,750,600
2,227,400
1,909,200
1,591,000
1,138,200
975600
813000
2,042,200
1,750,400
1,458,700
2,073,100
1,777,000
1,480,800
6,065,100
5,198,600
4,332,200
1,521,100
1,303,800
1,086,500
2,453,700
2,103,200
1,752,700
2,073,100
1,777,000
1,480,800
5,981,000
5,126,600
4,272,200
2,450,900
2,100,800
1,750,600
1,138,200
975600
813000
6,065,100
5,198,600
4,332,200
4,472,200
3,833,300
3,194,400
1,479,100
1,267,800
1,056,500
1,479,100
1,267,800
1,056,500
1,980,300
1,697,400
1,414,500
5,396,800
4,625,800
3,854,900
4,472,200
3,833,300
3,194,400
1,531,300
1,312,600
1,093,800
6,065,100
5,198,600
4,332,200
4,269,300
3,659,400
3,049,500
1,555,800
1,333,600
1,111,300
2,387,300
2,046,200
1,705,200
2,604,800
2,232,700
1,860,600
7,697,900
6,598,200
5,498,500
3,439,200
2,947,900
2,456,600
2,453,700
2,103,200
1,752,700
4,011,000
3,438,000
2,865,000
2,387,300
2,046,200
1,705,200
6,065,100
5,198,600
4,332,200
4,415,000
3,784,200
3,153,500
2,450,900
2,100,800
1,750,600
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
2,073,100
1,777,000
1,480,800
2,433,200
2,085,600
1,738,000
1,531,300
1,312,600
1,093,800
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
7,697,900
6,598,200
5,498,500
7,000,100
6,000,100
5,000,100
3,588,900
3,076,200
2,563,500
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
1,555,800
1,333,600
1,111,300
4,469,600
3,831,000
3,192,500
2,740,200
2,348,800
1,957,300
1,980,300
1,697,400
1,414,500
2,955,900
2,533,600
2,111,400
1,531,300
1,312,600
1,093,800
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
3,730,500
3,197,600
2,664,700
8,458,000
7,249,700
6,041,400
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
6,065,100
5,198,600
4,332,200
1,479,100
1,267,800
1,056,500
1,525,000
1,307,200
1,089,300
3,847,500
3,297,800
2,748,200
1,479,100
1,267,800
1,056,500
2,453,700
2,103,200
1,752,700
1,531,300
1,312,600
1,093,800
1,531,300
1,312,600
1,093,800
1,479,100
1,267,800
1,056,500
1,479,100
1,267,800
1,056,500
4,933,200
4,228,500
3,523,700
6,065,100
5,198,600
4,332,200
1,555,800
1,333,600
1,111,300
5,981,000
5,126,600
4,272,200
1,479,100
1,267,800
1,056,500
6,065,100
5,198,600
4,332,200
1,479,100
1,267,800
1,056,500
5,367,500
4,600,700
3,833,900
3,679,100
3,153,500
2,627,900
1,479,100
1,267,800
1,056,500
1,479,100
1,267,800
1,056,500
2,042,200
1,750,400
1,458,700
6,065,100
5,198,600
4,332,200
2,176,200
1,865,300
1,554,400
2,453,700
2,103,200
1,752,700
3,388,900
2,904,800
2,420,700
2,453,700
2,103,200
1,752,700
6,065,100
5,198,600
4,332,200
3,588,900
3,076,200
2,563,500
3,588,900
3,076,200
2,563,500
6,407,600
5,492,200
4,576,800
7,562,800
6,482,400
5,402,000
2,227,400
1,909,200
1,591,000
2,073,100
1,777,000
1,480,800
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
6,065,100
5,198,600
4,332,200
6,065,100
5,198,600
4,332,200
4,933,200
4,228,500
3,523,700
1,531,300
1,312,600
1,093,800
2,453,700
2,103,200
1,752,700
2,176,200
1,865,300
1,554,400
6,065,100
5,198,600
4,332,200
2,453,700
2,103,200
1,752,700
4,469,600
3,831,000
3,192,500
1,479,100
1,267,800
1,056,500
1,064,800
912700
760600
6,065,100
5,198,600
4,332,200
2,453,700
2,103,200
1,752,700
4,042,500
3,465,000
2,887,500
6,065,100
5,198,600
4,332,200
3,439,200
2,947,900
2,456,600
1,521,100
1,303,800
1,086,500
6,065,100
5,198,600
4,332,200
1,525,000
1,307,200
1,089,300
2,073,100
1,777,000
1,480,800
6,065,100
5,198,600
4,332,200
2,073,100
1,777,000
1,480,800
1,525,000
1,307,200
1,089,300
6,065,100
5,198,600
4,332,200
3,375,700
2,893,500
2,411,200
2,042,200
1,750,400
1,458,700
 REKAP BIAYA RAWAT INAP

NO KELAS KODE DX UTAMA

1 I
II P22.8 RDS
III
2 I
II P22.8 RDS
III
3 I
II P59.8 Neonatal jaundice from other cause
III
4 I
II P59.8 Neonatal jaundice from other cause
III
5 I
Neonatal jaundice from other cause (BBLR 2400
II P59.8
gram)
III
6 I
II P24.9 Neonatal aspiration syndrome
III
7 I
II P24.9 Neonatal aspiration syndrome BBLR 2200 gram
III
8 I
II P22.8 RDS
III
9 I
II J06.9 ISPA
III
10 I
II R56.0 Febrile convulsion
III
11 I
II J18.0 Bronkopneumonia
III
12 I
II A91 Demam Berdarah (DHF)
III
13 I
II A09.9 GEA
III
14 I
II
III
15 I
II
III
16 I
II O42.0 Ketuban Pecah Dini 24jam
III
17 I
II O34.2 Bekas SC
III
18 I
 DX SEKUNDER KODE PROSEDUR (KODE) BIAYA
Neonatal jaundice P59.9
CPAP (93.90); fototerapi 4,933,200
(99.83); labor (90.59); infus 4,228,500
(99.18);OGT (96.6) 3,523,700
Neonatal jaundice; hipoglikemia P59.9; P70.4
CPAP (93.90); fototerapi 7,000,100
(99.83); labor (90.59); infus 6,000,100
(99.18);OGT (96.6) 5,000,100
4,271,700
fototerapi (99.83); labor
(90.59); infus (99.18) 3,661,500
3,051,200
3,847,500
fototerapi (99.83); labor
(90.59); infus (99.18) 3,297,800
2,748,200
6,407,600
fototerapi (99.83); labor
(90.59); infus (99.18) 5,492,200
4,576,800
Convulsion of newborn P90 CPAP (93.90); rontgen thorax; 8,627,500
labor (90.59); infus 7,395,000
(99.18);OGT (96.6) 6,162,500
5,367,500
CPAP (93.90); labor (90.59);
infus (99.18);OGT (96.6) 4,600,700
3,833,900
Neonatal jaundice with preterm P59.0 CPAP (93.90); fototerapi 8,458,000
(99.83); labor (90.59); infus 7,249,700
(99.18);OGT (96.6) 6,041,400
2,450,900
infus,labor 2,100,800
1,750,600
3,388,900
infus,labor 2,904,800
2,420,700
rontgen thorax (87.49); 4,472,200
oksigen (93.96); 3,833,300
antibiotik,labor,infus 3,194,400
1,479,100
infus,labor 1,267,800
1,056,500
1,525,000
infus,labor 1,307,200
1,089,300
 2,073,100
1,777,000
1,480,800
Induksi (73.4) 2,453,700
persalinan spontan O80.8 Manually assisted delivery 2,103,200
(73.59) 1,752,700
Induksi (73.4) 2,453,700
persalinan spontan; kontraksi O80.8; Manually assisted delivery
O47.1 2,103,200
(73.59) 1,752,700
6,065,100
 REKAP BIAYA RAWAT INAP

NO KELAS KODE DX UTAMA

1 I
II I20.9 Angina Pectoris
III
2 I
II I21.4 Acute subendocardial myocardial infarction
III
3 I
II I21.4 Acute subendocardial myocardial infarction
III
4 I
II I50.0 CHF (Congestive Heart Failure)
III
5 I
II K30 Dyspepsia
III
6 I
II K30 Dyspepsia
III
7 I
II K30 Dyspepsia
III
8 I
II K30 Dyspepsia
III
9 I
II J18.0 Bronkopneumonia
III
10 I
II G62.9 Polineuropati
III
11 I
II E11.9 Diabetes NIDDM tanpa komplikasi
III
12 I
II E11.5 Diabetes NIDDM dengan komplikasi periferal sirkulasi
III
13 I
II A09.9 GEA
III
14 I
Chronic Obstructive Pulmonary Disease with Acute Lower
II J44.0
Respiration Infection
III
15 I
J44.0 Chronic Obstructive Pulmonary Disease with Acute Lower
II Respiration Infection
III
16 I
II A01.0 Thypoid fever
III
17 I
II A91 Demam Berdarah (DHF)
III
18 I
II A90 Demam Dengue
III
 DX SEKUNDER KODE PROSEDUR (KODE) BIAYA
3,730,500
infus,labor 3,197,600
2,664,700
Hipertensi; Old myocardial I10; I25.2 3,588,900
infarction infus,labor,EKG 3,076,200
2,563,500
3,588,900
infus,labor,EKG 3,076,200
2,563,500
Hiponatremia E87.1 3,679,100
infus,labor,EKG 3,153,500
2,627,900
1,531,300
infus,labor 1,312,600
1,093,800
Acute Cystitis; Nausea Vomiting N30.0; 2,176,200
R11 USG Abdomen (88.67), infus, labor 1,865,300
1,554,400
Hipokalemia; Diabetes NIDDM E87.6; 2,176,200
E11.9 infus,labor 1,865,300
1,554,400
ISPA J06.9 1,531,300
infus,labor 1,312,600
1,093,800
4,472,200
infus,labor,rontgen thorax 3,833,300
3,194,400
CKD, hipertensi N18.9; 5,396,800
I10 infus,labor,EKG 4,625,800
3,854,900
Hipertensi I10 4,469,600
labor,infus 3,831,000
3,192,500
Hipertensi; Dislipidemia I10; 7,697,900
E78.9 Amputasi jari ( 84.01); labor,infus 6,598,200
5,498,500
1,525,000
infus,labor darah, labor feses (90.99) 1,307,200
1,089,300
3,375,700
rontgen thorax; nebule (93.94);
infus, labor 2,893,500
2,411,200
Acute Cystitis N30.0 4,042,500
rontgen thorax; nebule (93.94);
infus, labor 3,465,000
2,887,500
2,955,900
infus, labor 2,533,600
2,111,400
ISPA J06.9 1,479,100
infus, labor 1,267,800
1,056,500
ISPA J06.9 1,479,100
infus, labor 1,267,800
1,056,500
 REKAP BIAYA RAWAT INAP

NO KELAS KODE DX UTAMA

1 I
II L03.9 Selulitis
III
2 I
II L03.9 Selulitis
III
3 I
II M67.9 Disorder of synovium tendon
III
4 I
II K35.8 Acute apendisitis
III
5 I
Other infiltrative disorder of skin and
II L98.6
subcutaneous tissue
III
DX SEKUNDER KODE PROSEDUR (KODE) BIAYA
1,555,800
Eksisi debridement
(86.22) 1,333,600
1,111,300
1,555,800
redressing (93.57);
antibiotik (99.21) 1,333,600
1,111,300
7,697,900
excision lession of
tendon of hand (82.21) 6,598,200
5,498,500
3,439,200
apendectomi (47.09) 2,947,900
2,456,600
4,555,900
local excision lession of
skin (86.3) 3,905,100
3,254,200