AVM ( Arteriovenous malformation )

AAA
Acute COnfusional State / Delirium
ADHD (Attention Deficit Hyperactivity Disorder)
ALI
APS (antiphospholipid Syndrome)
ARDS (SAcute Respiratory Distress Syndrome)
ARMD (Age-related macular degeneration.)
ASD ( Autism Spectrum Disorder)
Asidosis Metabolic
Batu KE
BRVO (branch retinal vein occlusion)
Buka T Tube
CAA
Capsulitis Adhesive
CBT (cognitive behavioral therapy)
CEK LABOR
CLI (Critical limb ischemia)
COVID -19
COVID -19 KONFIRMASI
CRAO (Central retinal artery occlusion)
CRVO (Central retinal vein occlusion)
CSCR ( Central serous chorioretinopathy )
CSR
DDH (Development Dysplasia of hip)
Defec cranium
DIC
DILI
DV (Polycythemia Vera)
ESS (Endometrial Stromal sarcoma)
Feeding difficulties ( Susah makan)
Ganguan Efective Bipolar
Gangguan campuran cemas dan depresi
Ganguan Prilaku
Gastritis erosive
Pendarahan salauran cerna (gastrointestinal)
GBE (Ganguan Bahasa expresiv)
GBER (Ganguan Bahasa expresiv receptive)
GBS (guillain barre syndrome)
Hamil IUFD
Hamil letak Lintang
Hamil Letak Sungsang
Hamil Panggul Sempit
Hamil Placenta letak Rendah
Hamil Dengan lilitaTali Pusat
Hemorrhage vitreous
Hipertrofi konka
HMD (Hyaline membrane disease)
HSP (Henoch(-Schönlein) disease or syndrome purpura
Hypoglycemia neonatal (transitory)
Hypothermia neonatal
Hypothermia neonatal
ICH
ICH Traumatic
Imunisasi gardasil /Cancer Cervix/Rotateg
Imunisasi hexaxim (difteri, tetanus, pertussis, hepatitis B, poliomyelitis)
Imunisasi IMOJEV (Japanese encephalitis)
Imunisasi Prevenar/Pneumucocus
Infeksi Kuku
Infeksi lainnya karena virus corona
IOFB (Intraocular Foreign Bodies)
ITP ( idiopathic thrombocytopenic purpura)
IVH (Intraventricular Hemorhagic)
KIPI (komplikasi ikutan pasca imuisasi).
Kanker Kelenjar getah Bening
Kontak yang terjadi dengan paparan virus menular
LCH (Langerhans-cell histiocytosis)
Lithotripsy
bile duct NEC
Malfungsi CDL
Malfungsi CDL
Mantoux test
MBO
MBO (Mati batang Otak)
Meningitis bateial
MGD (Meibomian Gland Dysfunction)
MODS (Multiple organ dysfunction syndrom)
Muscle Spasm
Myoclonus
Myopic CNV (myopia with choroidal neovascularization)
NAFLD (Nonalcoholic fatty liver disease )
Neovaskularisasi koroid miopia/ Myopic CNV
Nonunion Fracture
NSTEMI
OCD ( Obsessive-compulsive disorder )
OAE (Oto Acoustic Emision)
Olygohidramnion
OPLL (Ossifilation of the Postterior Longitudinal Ligamen)
PAD (Peripheral Artery disease)
Pain Cervical
Panggul sempit
Pasang chemoport
PCO (Posterior Capsular Opacification )
PDR (proliferative diabetic retinopathy )
PED (pigment epithelial defect)
Pelviureteral junction obstruction (PUJO)
Pemeriksaan swab
Pengawasan Kehamilan riw.SC
Pengawasan Kehamilan riw.SC
Penurunan kesadaran
PFO (patent foramen ovale)
PHN (Post Herpetic Neuralgia)
Phytiasis Bulbi
Placenta letak rendah
Placenta Letak Rendah
Placenta Previa Totalis
Pneumonia yang disebabkan oleh virus corona
POAG (Primary Open Angle Glaucoma)
Post explorasi CBD
Polyp Endometrium
PPCM (Peri Partum Myocardiopaty)
PROPABLE COVID 19
PVC (Polypoidal choroidal vasculopathy)
PVNS (Pigmented villonodular synovitis)
Pyonephrosis
Regulasi menstruasi / menunda haid
Renal insuf
Retinal Detacment
RTA (Renal Tubular Asidosis)
SCRENING COVID
Sepsis karena virus corona
Sepsis neonatorum awitan lambat (SNAL)
Shock sepsis
SIADH (secretion. Syndrome of inappropriate antidiuretic hormone secretion)
SNAD
SNAL (sepsis neonatorum awitan lambat)
STEMI
Stricture urethra

suspec covid 19
Syndrome Edward
TB BTA+
TB ON OAT
TB Paru Putus Obat
Transfusion-related acute lung injury (TRALI) ·
TRD (Traction retina detachmen)
Trombolisis
Tuberkulosis paru BTA negatif
Tuberkulosis paru BTA Positif
union, fracture
Vaksin Covid 19
Widrawel Effect Steroid
O13 – Hipertensi dlm kehamilan (HDK)
O14.0 – Preeklamsia Ringan (PER)
O14.1 – Preeklamsia Berat (PEB)
O21.1 – Hiperemesis gravidarum
O23.5 – Infeksi genitalia dlm kehamilan
O24.41 – Diabetes Gestasional (DMG)
O26.0 – Obesitas dlm kehamilan
O26.84 – Diskrepansi Ukuran hamil /PJT
O30.0 - Kehamilan Kembar / Gemelli
O32.0 - Kehamilan Letak Unstable
O32.1 - Kehamilan presentasi bokong
O32.2 - Kehamilan letak lintang oblik
O33.1 - CPD karena panggul sempit
O33.5 - CPD karena bayi besar
O40 - Polihidramnion
O41.0 - Oligohidramnion
O75.82 - Hamil 38-39 mg, renc SC elektif
O44.1 - Plasenta Previa dgn perdarahan
O48.0 - Kehamilan Lewat waktu
O99.0 - Anemia dalam kehamilan
Diabetic Retinopathy (Mata NPDR)
 Q27.3
I47.1
F05.9
F90
M62.2
D68.6
J80
H35.3
F84.0
E87.2
K80
H34.8
Z45.8
E85.4+I68.0
M77.9
R41
Z01.7
I99.8
U07.1
B34.2
H34.1
H34.8
H35.7
H35.7
Q65.8
G52.9
D65
k71.9
D45
C54.1
R63.3
F31.9
F41.2
F98.9
K92.1
K92.2
F80.1
F80.2
G61.0
O36.4
O32.2
032.1
O33.1
O44.0
O69.2
H43.1
J343
P22.0
 D69.0
P70.4
P80.9
P80.9
I62.9
S06.8
Z25.8
Z27.8
Z26.8
Z23.8
L03.0
B34.2
H44.7
D69.3
I61.5
T88.1
C81
Z20.828
C96.0
51.49
T82.4
T85.6
R76.1
G93.9
G93.9
G00.9
H02.8

M62.8
G25.3
H44.2
K76.0
H35.0
M48.1
I21.4
F42.9
Z01.0
O41.0
M48.8
i73.9
M54.2
O65.1
Z45.8
H25.0
H35.2
H35.7
N13.5
Z11.5
 O34.2
O34.2
R40.0
Q21.1
B02.2+G53.0*
H44.5
O44.0
O44.0
O44.1
J12.89 & B97.29
H40.1
Z97.8
N84.0
O90.3
Z20.8
H31.8
M12.2
N13.6
Z30.3
N28.9
H33.5
N25.8
Z11.5
A41.89 & B97.29
P36.1
R57.2
E22.2
P36.9
P36.9
I21.3
N35.9
Z03.8
Q91.3
A15.1
A15.2
A15.0
j95.8
H33.4
9910
A16.0
A15.0
M84.2
Z25.8
E27.3
H36.0
 NAMA TINDAKAN KODE ICD 9
Trabeculectomy 12.64
phacotrabeculectomy + IOL 13.41, 12.64, 13.71
CXL 11.49
AMT 11.62
Resection M. rectus lateral 15.11
Resection M. rectus lateral dan medial 15.3
Vitrectomy DR.DHANA 14.74
Vitrectomy DR. SURYA 14.73
Injeksi vitreous 14.75
ht aff 97.38
IOL 13.71
Aspirati dan irigasi lensa +primary posterior 13.72
Excision pterygium 11.39
Hecting cornea 11.51
Post tindakan MATA H59.8
 TELINGA
Absces Retrouricular H70.0
Anotia Q16.0
Atresia CAE Q16.1
BPPV H81.1
Cerumen Prop H61.2
CHL Bilateral H90.0
CHL Unilateral H90.1
Corpus Alineum T16
Delayed Speech F80.9
Fistel Preacular Q18.1
Herpes Zoster Otika B02.8
Keratosis/Kolesteatoma H60.4
Laserasi Kanal S00.4
Meniere Syndrom H81.0
MHL Bilateral H90.6
MHL unilateral H90.7
Mikrotia Q17.2
Miringitis Bulosa H73.0
NIHL H83.3
OE Difusa H60.3
OE Sirkumkripta H60.0
OMA H66.0
OME H65.3
OMSK Benigna Aktif H66.1
OMSK Benigna Tenang H72.0
OMSK Maligna (Grnuloma) H74.4
OMSK Maligna (Kolesteatoma) H71
OMSK Maligna ( Perforasi Atik) H66.2
OMSK Maligna (Perforasi Marginal) H72.2
OMSK Maligna ( Perforasi Total/Multiple) H72.8
Ot Hematoma H61.1
Otalgia H92.0
Otomycosis B36.9
Post mastoidectomi H95.1
Perforasi MT ec Trauma S09.2
Presbiakusis H91.1
SNHL Bilateral H90.3
SNHL Unilateral H90.4
Sudden Deafness H91.2
Tinnitus H93.1
Tuba Catar H68.1
Vertigi Verifer H81.3

HIDUNG
Corpus Alineum Hidung T17.1
Epistaksis R04.0
Fraktur Nasal S02.0
Hipertropi Konka J34.3
Mukokel Sinus J34.1
Pansinusitis Kronis J32.4
Polip Nasal J33.0
Rhitis Alergi J30.4
Rhinitis Vasomotor J30.0
RSA J01
RSK J32.9
Septum Deviasi J34.2

LARINGS FARING
Abscess Submandibula K12.2
Candidiasis Oral B37.0
Corpus Alineum Esophagus T18.1
Corpus Alineum Faring T17.2
Corpus Alineum laring T17.3
Dysphagia R13
Dysphonia R49.0
Pharyngitis Acut J02.9
Pharyngitis Kronis J31.2
Hypertropi Adenoid J35.2
laryngitis Akut J04.0
Laryngitis Kronis J37.0
Laryngitis TB A15.5
laryngopharyngitis Akut J06.0
Laryngomalasia Q31.5
Lymphadenitis TB A18.2
LPRD K21.9
Nodul Plika Vokalis J38.2
Parese Plika Vocalis J38.0
Parotitis B26
Peritonsiler Absces J36
Polip Plika Vocalis J38.1
Stomatitis Atfosa K12.0
Tonsilitis Akut J30.9
Tonsilitis Kronis J35.0

ONKOLOGI
Ca CAE C4422
CA Cavum Nasi C30.0
Ca Laryng C32.9
Ca Lidah C02.9
Ca Tonsil C10.9
Limfoma Hodgin C81
Limfoma non Hodgin C85
NPC C11.9

Kontrol rawat jalan Z09.8

Kontrol Post Operasi Z09.0
 Arterioplasty 3959
Adhesiolisis tuba dan ovarium 65.89
Baloon Angioplasty 3950
Biopsi cervix (punch) 67.12
Biopsy breast 85.11
Injeksi vitreous 14.75
Vitrectomy DR. SURYA 14.73
ACDF 8051
Adesiolisis 545
AFF T Tube 9755
AMG os + needle diathermy
AMT 11.62
Angkat Jahitan 86.59
Arthroscopy Knee 8026
Aspirati dan irigasi lensa +primary posterior 13.72
        
2. AV SHUNT
        
3942
3. Biopsy cervix (punch)
        
67.12
4. Bonegraft 7800
Bongkar IUD/KB 9771
CABG 3611
        
5. Cek Swab 9033
Closure PDA 3885
        
6. Colpocleisis (complete) (partial)
        
70.8
7. Colpoperineorrhaphy
        
70.71
8. Colporrhaphy anterior
        
70.51
9. Colporrhaphy posterior
      
70.52
11. Conservatif
      
890
12. CTG
      
7535
CTG 75.35
13.
       CVC 38.93
14.
CXL 11.49
      
15. Cystectomy
      
6579
16. DSA
      
8841
17. DSA
      
8841
18. ECHO
      
8872
19. Echocardiography
      
88.72
20. Edmoidectomy
      
2263
21. EEG 8914
EGD 4516
       EKG
89.52
22.
      
23. Ekstraction Kuku
      
8623
24. Electrocaounter
      
863
25. Episiotomy 736
      
26. ERCP (Endoscopic retrograde cholangiopancreatography ) 51.10
Excision pterygium 11.39
      
27. Explorasi batu CBD 5151
      
28. Explorasi CBD 5136
      
29. Explorasi dinding dada 3428
       Explore CBD 5141
30.
FESS 2919
FNAB 9169
Fototerapi 9983
FUNGSI ASITES 54.91
GANTI BALUTAN/DRESSING 93.57
GIPS 93.53
Hecting cornea 11.51
Hecting luka 8659
Hecting Perineum 7171
HEMODIALISA 39.95
Holter Test 8950
ht aff 97.38
HTSOB (Histerektomi Totalis Salpingo Ooforektomi Bilateralis) 6859/6549
Hypoglycemia neonatal P70.4
INCUBATOR 93.35
INFUS 99.18
INFUS PUMP 86.06
INJEKSI ANALGENTIK
INJEKSI ANTI BIOTIK 99.21
Injeksi Avastin 1475
Insersi IUD /Pasang KB 697
INTUBASI 96.02
IOL 13.71
irigasi telinga 9652
KATETERISASI 57.94
KONKOTOMI 211
KONTROL PENDARAHAN 39.98
Koreksi elektrolit 9918
Kromotubasi 661
LABOLATORIUM 90.54
LEEP (loop electrosurgical excision procedure) 6733
Ligasi Esophagus endoscopy 4233
Lithotripsy 51.49
Manual plasenta 75.4
MONITOR EKG 89.54
MPFL (Medial patellofemoral ligament) 8144
MRCP 8897
Myomectomy (uterine) 68.29
NEBULIZER 93.94
NIV (Non Invasif ventilation) 9390
OKSIGEN 93.96
pap Smear 9146
Pasang CDL 3895
Pasang CVP 8962
Pasang kateter urin 57.94
Pasang Khemoport 8607
Pasang laminaria 6993
Pasang NGT 96.34
Pasang NGT 9607
Pasang PPM 3780
Pasang Spalak 93.53
Pasang T Tube 5143
PASANG TAMPON ANTERIOR HIDUNG 21.01
PASANG TAMPON POSTERIOR HIDUNG 21.02
PCNL 5504
PCI 1 BMS 3606
PCI 1 DES 3607
PELD 8059
Periksa dalam 96.44
phacotrabeculectomy + IOL 13.41, 12.64, 13.71
Phlebectomy 38.60
PHOTO CERVICAL 87.22
PHOTO PELVIS 87.24
PHOTO SCHEDEL (SKULL) 87.17
PHOTO TORAX 87.44
PLIF 8451
Post tindakan MATA H59.8
PTCA Percutaneous transluminal coronary angioplasty 00.66
Pungsi Ascites 5491
Pungsi Lumbal
Punsi Pleura 3393
Release of carpal tunnel 0443
Removal DJ Stent 9769
Repair Luka 8659
Reposisi Fracture Aelbow 7972
Resection M. rectus lateral 15.11
Resection M. rectus lateral dan medial 15.3
RJP 99.60
RND (rcdical neck dissection) 4040
ROSC (Return of spontaneous circulation)
Salpingectom 6561
Salpingo-oophorectomy 6549
STERILIZATION FEMALE 6639
Striping Vena 385
STSG (Full-thickness skin graft) 86.63
SUCTIONING 96.04
SUTURE KAKI 83.89
SUTURE KEPALA 86.59
SUTURE TANGAN 82.46
SYIRING PUMP 9:43
TESI ( Transforaminal Epidural injection) 0392
TEVAR Endovascular implantation of graft in thoracic aorta 3973
Thrombectomy 38.00
Tindakan Kode ICD-9
TKR Total Hip replacement 8151
TKR Total knee replacement 8154
Total abdominal hysrterectomy 6859
Total vaginal Hysterectomy 6859
Trabeculectomy 12.64
Trabeculotomy ab externo 12.54
Transcateter closure Of PDA (dr Fuad) 3885
Transcateter closure Of ASD (dr Shirley) 3552
TEE PDA (dr Shirley) 3979
TEE (Transeshopahgeal Echocardiography) 8872
Transfusi Albumin 9907
TRANSFUSI FFP 9907
TRANSFUSI TC 9903
TVH (Total vaginal Hysterectomy) 6859
Ureteroscopy 5631
URS 5631
USG ABDOMEN 88.76
Vitrectomy 1474
Vitrectomy DR.DHANA 14.74
WPW (Wolff Parkinson White Syndrome) I45.6
WSD 3404
Uvulopalatopharyngoplasty (UPPP) 2769
CPAP (Continuous Positive Airway Pressure ) 939
No Diagnosa Utama Kode ICD 10 Diaganosa sekunder

1 UAP (Unstable angina) I20.0: Unstable Angina recent inferior MCI

Hipertesi terkontrol

DM tipe 2 dengan komplikasi

2 unstable Angina I20.0: Unstable Angina kardiovaskular (GDS>200, ada
OAD)

HHD tanpa CHF (ada obat

hipertensi)

Acute anterior transmural I21.0 Acute transmural myocardial DM tipe 2 dengan komplikasi
3 kardiovaskular (GDS>200, ada
miocardial infarction infarction of anterior wall
OAD)

hipertensi + dengan low EF,

acute heart failure

VES (ada bukti di EKG dan obat

anti aritmia seperti cordaron,
bisoprolol)

4 unstable Angina I20.0: Unstable Angina

Acute Lung oedema + hipertensi

5 I50.1: left ventricular failure DM tipe 2
+ CHF

6 CHF I50.0 congestive heart failure

7 CHF ec CAD, acute pulmonary I50.1: left ventricular failure acute transmural MI
edema

8 CHF I50.0 congestive heart failure pleural efusi (pungsi pleura)

hipokalemia (Kcl)

DM tipe 2 dengan komplikasi

I25.1: atherosclerotic heart
9 CAD kardiovaskular (GDS>200, ada
disease
OAD)

DM tipe 2 dengan komplikasi

10 unstable Angina I20.0: Unstable Angina kardiovaskular (GDS>200, ada
OAD)

VES (ada bukti di EKG dan obat

11 unstable Angina I20.0: Unstable Angina anti aritmia seperti cordaron,
bisoprolol)

12 unstable Angina I20.0: Unstable Angina

 DM tipe 2 dengan komplikasi
13 unstable Angina I20.0: Unstable Angina kardiovaskular (GDS>200, ada
OAD)

14 Epistaxis (on simarc) R04.0 Epistaxis CHF

I21.9 Acute myocardial infarction,

15 NSTEMI unspecified Hyperlipidemia

DM tipe 2 dengan komplikasi

16 acute stemi anteroseptal I21.9 Acute myocardial infarction, kardiovaskular (GDS>200, ada
unspecified
OAD)

I21.4 acute subendocardial

17 Acute subendocardial infarction CHF ec CAD, HHD
myocardial infarction

acute lung oedema +acute

18 I50.1: left ventricular failure Ventricular tachycardia
anterior STEMI

T82.6 infection and inflammatory

19 endokarditis, prostetic valve due to cardiac valve prosthesis sepsis (kultur darah +)

acute lung oedema, CHF Z03.9 observation for suspected

20
(observasi kelas 3) diseasea or condtion, unspecified

DM tipe 2 dengan komplikasi

kardiovaskular (GDS>200, ada
OAD)

21 acute lung oedema I50.1 left ventricular failure unstable angina

stroke infark

22 AF I48 atrial fibrilation and flutter hipokalsemia

 Kode ICD 10
tidak diinput karena terapi sama
dengan UAP
tidak diinput karena terkontrol
E11.8: Non-Insulin Dependent
Diabetes Mellitus with Unspecified
Complications
I11.9: Hypertensive heart disease
without (congestive) heart failure
E11.8: Non-Insulin Dependent
Diabetes Mellitus with Unspecified
Complications
I11.0: Hypertensive heart disease
with (congestive) heart failure
I49.3 Ventricular premature
depolarization
E11.9: Non-Insulin Dependent
Diabetes Mellitus without
Complications
I21.0 acute transmuar myocardial
infarction of anterior wall
J91.0 Pleural effusion in conditions
classified elsewhere
E87.6 Hypokalaemia
tidak diinput, GDS normal
E11.8: Non-Insulin Dependent
Diabetes Mellitus with Unspecified
Complications
I49.3 Ventricular premature
depolarization
Tindakan Kode ICD 9 Grouper
I-1-40-I: Prosedur
PCI 1 BMS 36.06: insertion of non drug- Kardiovaskular Perkutan
eluting coronary artery stents
(Ringan)
tidak diinput karena termasuk
koronari arteriografi tindakan PCI
36.07: insertion of Drug I-1-40-II: Prosedur
PCI 1 DES Eluting Coronary artery Stent Kardiovaskular Perkutan
(s) (Sedang) (karena E11.8)
00.66: Percutaneous
transluminal coronary
POBA
angioplasty (PTCA) of
coronary atherectomy
36,07: insertion of Drug I-1-40-III: Prosedur
PCI 1 des Eluting Coronary artery Stent Kardiovaskular Perkutan
(s) (Berat) (karena I11.0)
00.66 percutaneous
PTCA tanpa stent
atherectomy
I-4-12-I kegagalan jantung
(ringan)
I-4-12-I kegagalan jantung
(ringan)
I-4-12-III kegagalan jantung
(berat)
I-4-12-III Kegagalan jantung
Pungsi pleura 34.91 thoracentesis
(berat)
88.55: coronary arteriography I-1-15-I: Kateterisasi jantung
Coronary arteriografi
using single cathether (ringan)
88.55: coronary arteriography I-1-15-II: Kateterisasi jantung
Kateterisasi jantung
using single cathether (sedang)
88.55: coronary arteriography I-1-15-III: Kateterisasi
Kateterisasi jantung
using single cathether jantung (berat)
I-4-20-I Angina Pektoris dan
Nyeri Dada (Ringan)
 E11.8: Non-Insulin Dependent I-4-20-II Angina Pektoris dan
Diabetes Mellitus with Unspecified
Nyeri Dada (Sedang)
Complications

U-4-12-I
tidak diinput karena terapi sama Epistaxis/perdarahan hidung
dengan rawat jalan
(ringan)
I-4-10-I infark miokard akut
E78.5 Hyperlipidaemia, unspecified (ringan)
E11.8: Non-Insulin Dependent
Diabetes Mellitus with Unspecified I-4-10-II infark miokard akut
(sedang)
Complications

I11.0 hypertensive heart disease I-4-10-III infark myokard akut

with (congestive) heart failure (berat)

96.71 continuous mechanical J-1-20-III prosedur sistem

I47.2 ventricular tachycardia ventilator 1 hari ventilator for less than 96 pernapasan non-kompleks
consequtive hours (berat) (karena I47.2)

99.62 other electric

cardioversi
countershock of heart

96.04 insertion of J-1-20-III prosedur sistem

A41.8 other specified septicaemia intubasi endotracheal tube pernapasan non-kompleks
(berat) (karena A41.8)

Z-4-12-I faktor-faktor yang

mempengaruhi status
kesehatan lain-lain (ringan)

E11.8: Non-Insulin Dependent

Diabetes Mellitus with Unspecified
Complications

G-1-12-III Prosedur
I20.0 unstable angina DSA 88.41 arteriography of pembuluh darah
cerebral arteries ekstrakranial (berat)
I63.9 cerebral Infarction,
unspecified

E83.5 disorder of calcium I-4-19-II gangguan konduksi

metabolism dan aritmia jantung (ringan)
 Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas

25,973,600 23,809,100 21,644,600 19,265,500 Kelas 1

47,155,200 41,964,800 36,774,400 118,787,760 DS

59,350,700 52,418,100 45,485,500 58,166,687 kelas 3

Kelas 3
5,051,000 4,329,400 3,607,800 7,200,331
(observasi)

5,051,000 4,329,400 3,607,800 3,632,941 kelas 1

7,025,800 6,022,100 5,018,400 8,751,826 Kelas 2

7,025,800 6,022,100 5,018,400 9,132,707

6,414,500 5,498,100 4,581,800 22,306,427 KELAS3

8,957,700 7,678,000 6,398,400 14,750,020 kelas 1

17,249,000 14,784,900 12,320,700 18,443,154 kelas 1

5,936,600 5,088,500 4,240,400 10,747,381 kelas 1

6,856,800 5,877,200 4,897,700 3,851,031 kelas 1

3,580,100 3,068,700 2,557,200 2,426,056 Kelas 1

5,771,100 4,895,300 4,079,400 8,629,405

10,197,900 8,741,100 7,284,200 18,521,042 kelas 3

14,693,800 12,594,700 10,495,500 9,898,450 VIP

41,157,200 35,227,600 29,398,000 17,185,508 kelas 2

41,157,200 35,227,600 29,398,000 31,450,115 kelas 3

kelas 3
2,651,000 2,272,300 1,893,500 3,512,310
observasi

18,358,900 15,736,200 13,113,500 37,516,298 kelas 3

8,632,800 11,241,043 kelas 1

 Diaganosa
No Diagnosa Utama Kode ICD 10 Kode ICD 10 Tindakan
sekunder

J22 Unspecified
acute convesional tidak diinput
acute lower
state ec hiponatremia karena tidak ada
respiratory
pneumonia terapi NaCl 3%
infection

J20.9 acute
Hipoalbuminemi R77.0 Abnormality
bronchitis bronchitis, a of albumin
unspecified

L89.0 Stage I
ulcus decubitus
decubitus ulcer
grade 1
and pressure area

J22 Unspecified
Pneumonia
acute lower E87.6
(rontgen thorax Hipokalemia
respiratory hypokalaemia
bronchitis)
infection

J22 Unspecified D63.8 Anaemia in

Pneumonia
acute lower other chronic
(rontgen thorax Anemia
respiratory diseases classified
normal)
infection elsewhere

hiperkalemia (K
E87.5
6.0, terapi ca
hyperkalaemia
gluconas IV)
 penurunan
kesadaran ec
sepsis ec
pneumonia
(sepsis tidak ada E11.9: Non-Insulin
J22 Unspecified
hasil kultur Dependent
acute lower
darah/PCT/CRP, DM tipe 2 Diabetes Mellitus
respiratory
pneumonia tidak without
infection
bisa diinputkan Complications
karena rontgen
thorax paru
normal tidak ada
infiltrat)

Candidiasis oral B37.0 Candidal

(terapi candistin) stomatitis

I12.0:
CKD stage V + hypertensive
hipertensi renal disease with
renal failure

I12.0:
CKD stage V + hypertensive Ascites R18: Ascites Pungsi ascites
hipertensi renal disease with
renal failure

D63.8 Anaemia in
other chronic
Anemia
diseases classified
elsewhere
 I12.0: D63.8 Anaemia in
anemia ec CKD + hypertensive other chronic
Pungsi pleura
hipertensi renal disease with diseases classified
renal failure elsewhere

J91 Pleural
Effusion in
effusi pleura conditions
classified
elsewhere

tidak diinput
A91: Dengue
karena gejala
DHF haemorrhagic gastritis
dimungkinkan
fever
karena DHF juga

A90 Dengue
Demam dengue
Fever

D69.6
A90 Dengue trombositopenia thrombocyopenia,
Demam dengue transfusi TC
Fever (transfusi TC)
unspecified

A91: Dengue B02.9 zoster

herpes zoster
DHF haemorrhagic without
(valacyclovir)
fever complication

diare cair akut

dengan dehidrasi A09.0: other and
unspecified
ringan sedang
gastroenteritis an
atau GE akut
colitis of
dengan dehidrasi
infectious origin
ringan sedang
 R10.1: Pain A15.0 Tb lung
TB paru sputum confirm sputum
Dispepsia Localized to
upper abdomen + microscopy with
or without culture

vomitus pada R11 Nausea and I10: esential

hipertensi (primary)
dispepsia vomiting hypertension

E58 dietary
R14 flatulence calcium deficiency
Meteorismus and related hipokalsemia (tidak
conditions mempengaruhi
coding)

A09.0: other and

unspecified
Hipokalemia E87.6:
GEA gastroenteritis an
(terapi KCl) hypokalaemia
colitis of
infectious origin

A09.9
abdominal pain
gastroenteritis
ec colitis (USG: and colitis of DF A90 dengue fever
colitis)
unspecifeid origin

E87.1 hypo-
hiponatremia osmolality and
hyponatraemia

Irritable bowel K58.9: Irritable

bowel syndrome colonoscopy
syndrome
without diarrhoea

D37.4 neoplasm
uncertain or
tumor sigmoid unknown colonoscopy
behaviour of
colon
 biopsi per
endoskopi

D62 acute post

Melaena K92.1 melaena anemia haemorrhagic
anaemia

K81.9
cholecystitis cholecystitis,
unspecifeid

E87.1 hypo-
hiponatremia osmolality and
hyponatraemia

K29.7 Gastritis,
gastritis esofagitis K20 Oesophagitis EGD tanpa biopsi
unspecified

tidak dikode
karena riwayat
AIHA
dan tidak ada
(Autoimune
Febris R50.9 Fever terapi spesifik
Hemolytic
walaupun
Anaemia)
merupakan
diagnosa utama

N39.0 Urinary
ISK tract infection,
site not specified

Hipoglikemia E11.0: Non-

pada DM tipe 2 Insulin I10: esential
(dengan Dependent hipertensi (primary)
penurunan Diabetes Mellitus hypertension
kesadaran) with Coma

E11.9: Non-
Insulin
E87.1 hypo-
Dependent
DM tipe 2 hiponatremia osmolality and
Diabetes Mellitus
hyponatraemia
without
Complications
 J02.9 acute R10.1 pain
akut faringitis pharyngitis, dispepsia localized to upper
unspecified abdomen

J06.0 acute upper E87.1 hypo-

respiratory
URTI hiponatremia osmolality and
infection,
hyponatraemia
unspecified

B34.9 Viral
Viral infection infection,
unspecified

E05.0 Z53.8 procedure

hipertiroid Throtoxicosis, batal operasi not carried out for
unsppecified other reasons

E05.0 D64.9 Anaemia,

hypertiroid Throtoxicosis, Anemia
unspecified
unsppecified

A41.9
Syok sepsis ec J18.9 Pneumonia,
Septicaemia,
pneumonia unspecified
unspecified

N17.9 Acute renal

AKI failure,
unspecified

K80.1 Calculus of
cholecystitis,
gallbladder with CDL
cholelitiasis
other cholecystitis
 K35.8 Acute
appendicitis,
appendicitis ventilator > 96 jam
other and
unspecified

R57.2 Septic shock appendectomi

I11.9 hypertensive
heart disease
reseksi jejunum
HHD without
dan anastomosis
(congestive) heart
failure

sepsis pneumonia
dengan A41.9 E87.1 hypo-
impending gagal septicaemia, hiponatremia osmolality and intubasi
napas (kultur unspecified hyponatraemia
darah +)

E87.6
hipokalemia
hypokalaemia

K92.0
hematemesis
Haematemesis

I10: esential
A01.0 Typhoid
demam tifoid hipertensi (primary)
fever
hypertension

I10: esential I20.9 angina

hipertensi (primary) angina pektoris pectoris,
hypertension unspecified

N39.0 Urinary
ISK tract infection,
site not specified
 I84.2 internal
hemoroid haemorrhoids colonoscopy
without
complication

scleroterapi
hemoroid

K44.9
diaphargmatic
hiatal hernia hernia without EGD dengan biopsy
obstruction or
gangrene

D37.7 neoplasm
uncertain or
unknown
massa anal colonoscopy
behaviour of
other digestive
organs

penurunan E87.1 hypo-

kesadaran ec osmolality and
hiponatremia hyponatraemia

penurunan R40.0
kesadaran somnolence

I12.0 D63.8 Anaemia in

hypertensive other chronic
hipertensi + CKD renal disease with anemia
diseases classified
renal failure elsewhere

G93.4
uremik
encephalopathy,
encephalopaty
unspecified
 E16.2
hipoglikemia hypoglycaemia,
unspecified

E11.9: Non-
Insulin E87.1 hypo-
Dependent
DM tipe 2 hiponatremia osmolality and
Diabetes Mellitus
hyponatraemia
without
Complications

L21.9 seborrhoeic
dermatitis
dermatitis,
seboroik
unspecified

I11.9 hypertensive
heart disease
HHD without
(congestive) heart
failure

E11.9: Non-
Insulin
E87.1 hypo-
Dependent
DM tipe 2 hiponatremia osmolality and
Diabetes Mellitus
hyponatraemia
without
Complications

pneumonia
(rontgen thorax
pneumonia, J18.9 Pneumonia,
unspecified
terapi antibiotik
+)

J18.9 pneumonia, E87.6

pneumonia hipokalemia
unspecified hypokalaemia
parese inferior ec E87.6
hypokalemia (KCl) hypokalaemia

K25.7 gastric
venektasi oesophageal ulkus di antrum ulcer, chronic
without EGD + biospi
esofagus obstruction gaster haemorrhage or
perforation

oesophagitis k20 oesophagitis

K80.5 calculus of
bile duct without K85.9 acute
Batu CBD
cholangitis or pankreatitis akut
pancreatitis, ERCP
unspecified
cholecystitis

K81.0 acute
cholecistitis akut cholecystitis

h81.1 BENIGN
BPPV PAROXYSMAL
VERTIGO

K29.0 acutr D62 acute post

gastritis erosif hemoragic anemia haemorrhagic
gastritis anaemia

N04.9 nepthrotic
nephrotic
syndrome,
syndrome
unspecified

N30.9 cystitis,
cystitis unspecified
 blood streak R04.2 haemotysis

Hernia Esofagus Q40.1 Congenital Gastroentritis K29.7 Gastritis, EGD Endoscopy

hiatus hernia unspecified

E11.5 DM tipe 2
with peripheral
Gangrene DM debridement
circulatory
complications

amputasi great toe

I85.9
oesophageal
Varises esofagus ligasi per endoskopi
varices without
bleeding

Febris ec infeksi
jamur pada
vagina N39.0 Urinary
N76.0 acute
ISK tract infection,
vaginitis
site not specified

K72.9 hepatic
hepatic failure failure,
unspecified

A15.0 Tb lung
D62 acute post
confirm sputum anemia
TB lung sputum + microscopy wit or haemorrhagic
perdarahan
anaemia
without culture
 hiponatremia E87.1 hypo-
(ada terapi NaCl osmolality and
3%) hyponatraemia

D68.9 coagulation
pemanjangan 99.07 transfusion
defect, transfusi FFP
APPT of other serum
unspecified
Kode ICD 9 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas

J-4-21-I GEJALA,
TANDA DAN
DIAGNOSIS
SISTEM 3,953,200 3,388,400 2,823,200 34,539,941 DS
PERNAFASAN
LAIN-LAIN
(RINGAN)

J-4-21-II GEJALA,
TANDA DAN
DIAGNOSIS
SISTEM 6,368,500 5,458,700 4,548,900 11,841,357 DS
PERNAFASAN
LAIN-LAIN
(SEDANG)
 J-4-21-II GEJALA,
TANDA DAN
DIAGNOSIS
SISTEM
PERNAFASAN 6,368,500 5,458,700 4,548,900 18,997,380 DS
LAIN-LAIN
(SEDANG)
(karena
candidiasis oral)

N-4-10-I:
TUMOR GINJAL
& SALURAN Kelas 3
4,681,100 4,012,400 3,343,700 3,047,213
URIN & GAGAL (observasi)
GINJAL
(RINGAN)

N-4-10-II:
54.91: TUMOR GINJAL
Percutaneous & SALURAN 5,837,000 5,003,100 4,169,300 1,469,894 Kelas 3
abdomnial URIN & GAGAL (observasi)
drainage GINJAL
(SEDANG)
 N-4-10-III:
TUMOR GINJAL
34.91
& SALURAN 8,585,400 7,358,900 6,132,400 10,066,460 kelas 2
Thoracentesis
URIN & GAGAL
GINJAL (BERAT)

A-4-13-I:
INFEKSI VIRAL &
2,952,300 2,530,500 2,108,800 13,802,401 kelas 1
NON-BAKTERIAL
LAIN (RINGAN)

A-4-13-I:
INFEKSI VIRAL & 2,952,300
2,530,500 2,108,800
NON-BAKTERIAL
LAIN (RINGAN)

A-4-13-II:
99.05 Transfusion INFEKSI VIRAL & 3,768,000
3,229,700 2,691,400 15,372,969 DS
platelet NON-BAKTERIAL
LAIN (SEDANG)

A-4-13-II:
INFEKSI VIRAL & 3,768,000
3,229,700 2,691,400
NON-BAKTERIAL
LAIN (SEDANG)

K-4-17-I: NYERI
ABDOMEN &
GASTROENTERIT 2,426,800 2,080,100 1,733,400 2,346,274 kelas 2
IS LAIN-LAIN
(RINGAN)
 K-4-17-I NYERI
ABDOMEN &
GASTROENTERIT 2,426,800 2,080,100 1,733,400 4,914,125 Kelas 1
IS LAIN-LAIN
(RINGAN)

K-4-17-I NYERI
ABDOMEN &
GASTROENTERIT 2,426,800 2,080,100 1,733,400 5,059,252 DS
IS LAIN-LAIN
(RINGAN)

K-4-17-II NYERI
ABDOMEN &
kelas 3
GASTROENTERIT 2,988,500 2,561,600 2,134,700 2,033,926
observasi
IS LAIN-LAIN
(Sedang)

K-4-17-II nyeri
abdomen dan
gastroenteritis 2,988,500 2,561,600 2,134,700 6,472,788 kelas 2
lain-lain (sedang
(karena DF)

K-4-18-I:
GANGGUAN
45.23: SISTEM Kelas 3
2,052,200 1,759,000 1,465,900 4,612,805
Colonoscopy PENCERNAAN (observasi)
LAIN-LAIN
(RINGAN)

K-4-18-I:
GANGGUAN
45.23: SISTEM Kelas 3
2,052,200 1,759,000 1,465,900 4,731,115
Colonoscopy PENCERNAAN (observasi)
LAIN-LAIN
(RINGAN)
 45.25 closed
(endoscopy)
biopsy of large
intestine

K-4-18-II:
GANGGUAN
SISTEM
3,463,100 2,968,300 2,473,600 11,496,008 Kelas 1
PENCERNAAN
LAIN-LAIN
(SEDANG)

K-4-11-I Gastritis
45.13 Other
dan ulkus
endoscopy of 3,276,700 2,808,600 2,340,500 8,545,906 DS
peptikum
small intestine
(ringan)

A-4-12-I
DEMAM YANG
TIDAK 3,728,300 3,195,600 2,663,000 9,485,108 DS
DITENTUKAN
(RINGAN)

E-4-10-I
penyakit
kencing manis
4,948,000 4,241,100 3,534,300 4,826,953 DS
dan gangguan
nutrisi/metaboli
k (ringan)

E-4-10-II
penyakit
kencing manis
dan gangguan 6,913,900 5,926,200 4,938,500 7,481,503 kelas 1
nutrisi/metaboli
k (Sedang)
(karena E87.1)
 U-4-13-I
peradangan
epigoltis, telinga
2,797,200 2,397,600 1,998,000 3,437,119
tegah, ispa dan
laringotrakeitis
(ringan)

U-4-13-II
peradangan
epigoltis, telinga
3,297,600 9,769,451
tegah, ispa dan
laringotrakeitis
(sedang)

A-4-13-I:
INFEKSI VIRAL &
2,952,300 2,530,500 2,108,800 3,966,887 kelas 3
NON-BAKTERIAL
LAIN (RINGAN)

E-4-13-I
Gangguan
Kelenjar 5,222,500 4,746,500 3,730,400 4,367,789 kelas 1
Endokrin Lain-
lain (ringan)

E-4-13-II
Gangguan
Kelenjar 7,650,100 6,557,200 5,464,400 9,014,649 kelas 3
Endokrin Lain-
lain (sedang)

J-1-20-III
proseur sistem
pernapasan non 93,700,000 35,277,600 29,398,000 231,750,226 Kelas 1
kompleks
(berat)

38.95 venous
catheterization
for renal dialysis
96.72 continuous
invasive
mechanical
ventilation for 96
consecutive hours
or more

47.09 other
appendectomy

45.93 other smal-

to-smal intestine

J-1-20-II
96.04 insertion of prosedur sistem
endotracheal pernapasan non 26,653,400 22,845,800 19,038,200 37,302,450 kelas 2
tube kompleks
(sedang)

K-4-18-I
Gangguan
kelas 3
sistem 2,052,200 1,759,000 1,465,900 3,344,857
observasi
pencernaan
lain-lain (ringan)

A-4-14-I
Penyakit infeksi
bakteri dan 3,204,800 2,747,000 2,289,100 8,241,171 DS
parasit lain-lain
(ringan)

I-4-17-II
Hipertensi
(sedang) 3,135,600 2,687,700 2,239,700 6,667,180 DS
(karena ISK, ada
terapi quinolon)
 K-4-18-I
Gangguan
45.23 sistem 2,052,200 1,759,000 1,465,900 6,070,597 kelas 3
colonoscopy
pencernaan
lain-lain (ringan)

49.42 injection of
hemorrhoids

45.16 K-4-18-I
esophagogastrod Gangguan
uodenoscopy sistem 2,052,200 1,759,000 1,465,900 3,963,314 kelas 3
(EGD) with closed pencernaan
biopsy lain-lain (ringan)

K-4-18-I
Gangguan
45.23
sistem 2,052,200 1,759,000 1,465,900 kelas 3
colonoscopy pencernaan
lain-lain (ringan)

E-4-11-I
hipovolemia dan
kelas 3
gangguan 4,174,000 3,577,700 2,981,400 6,549,014
elektrolit observasi
(ringan)

G-4-21-I koma
kelas 3
dan stupor non 3,259,600 2,716,500 2,761,300 6,261,901
observasi
trauma (ringan)

N-4-10-II:
TUMOR GINJAL
& SALURAN 5,837,000 5,003,100 4,169,300 11,062,277 kelas 1
URIN & GAGAL
GINJAL (BERAT)
 E-4-10-I
penyakit
kencing manis 4,948,000 4,241,100 3,534,300 3,587,993 kelas 3
dan gangguan observasi
nutrisi/metaboli
k (ringan)

E-4-10-II
penyakit
kencing manis
6,913,900 5,926,200 4,938,500 8,276,530 kelas 1
dan gangguan
nutrisi/metaboli
k (sedang)

E-4-10-III
penyakit
kencing manis
8,846,900 7,583,100 6,319,200 5,958,590 kelas 1
dan gangguan
nutrisi/metaboli
k (berat)

J-4-16-II Simple
pneumonia dan 7,172,500
6,147,900 5,123,200 6,452,174 kelas 1
whooping cough
(sedang)
 E-4-11-I
hipovolemia dan
kelas 3
gangguan 4,174,000 3,577,700 2,981,400 2,813,958
elektrolit observasi
(ringan)

45.16
K-4-12-I
esophagogastrod gangguan kelas 3
uodenoscopy 4,174,000 3,577,700 2,981,400 3,993,356
(EGD) with closed esofagus observasi
(ringan)
biopsy

K-4-12-I
gangguan kelas 3
esofagus 4,174,000 3,577,700 2,981,400 3,570,000 observasi
(ringan)

51.10 Endoscopic B-4-14-I

retrograde Gangguan
5,932,700 5,085,100 4,237,600 45,883,062 kelas 1
cholangiopancrea Saluran Empedu
tography (ERCP) lain-lain (ringan)

B-4-14-I
Gangguan
Saluran Empedu 5,932,700 5,085,100 4,237,600 5,981,624 kelas 2
lain-lain (ringan)

U-4-11-I
disequilrium 2,143,700 1,837,400 1,531,200 2,904,346 kelas 3
(ringan)

K-4-11-I Gastritis
dan ulkus 3,276,700 2,808,600 2,340,500 12,585,554
peptikum
(ringan)

N-4-11-I
peradangan 3,704,700 3,175,400 2,646,200 2,645,889 kelas 3
ginjal (ringan)

N-4-12-I infeksi
ginjal dan
saluran urin 2,414,200 7,115,874 kelas 3
(ringan)
 J-4-21-I gejala,
tanda, dan
diagnosis sistem 3,953,200 3,388,400 2,823,700 15,539,167 DS
pernapasan lain-
lain (ringan)

K-4-18-I
GANGGUAN
45.13 Other
endoscopy of SISTEM 2,052,200 1,759,000 1,465,900 4,076,987 Kelas 3
PENCERNAAN
small intestine
LAIN-LAIN
(RINGAN)

86.22 excisional M-1-30-I

debriement of
prosedur kaki 8,818,900 13,485,656 kelas 1
wound, infection,
(ringan)
or burn

84.11 amputation
of toe

43.41 endoscopic
K-4-12-I
excision or
gangguan
destruction of 2,981,400 4,567,668 kelas 3
esofagus
lesion or tissue of
stomach (ringan)

W-4-11-II infeksi
sistem
4,842,500 6,354,947 kelas 3
reproduksi
wanita (sedang)

J-1-20-I
prosedur sistem
pernapasan 21,161,500 16,265,223 kelas 1
non-kompleks
(ringan)

J-4-15-II
peradangan dan
infeksi 7,318,500 12,600,964 kelas 1
pernapasan
(ringan)
 D-4-11-I
gangguan
4,079,200 3,576,848 kelas 3
pembekuan
darah (ringan)
Keterangan
 Sesuai
keputusan
BPJS
walaupun
diagnosa
utama
adalah
ascites tapi
tetap CKD
yang menjadi
diagnosa
utama yang
diinput
 Diagnosa Diaganosa
No Kode ICD 10 Kode ICD 10 Tindakan Kode ICD 9
Utama sekunder

N13.2:
Hydronephrosis
HN (D) ec Batu I10: esential
with calculus 98.51: ESWL
Ureter Hipertensi (primary) ESWL
ureteral and Kidney, ureter
Proximal hypertension
kidney
obstruction

N20.0 Calculus 98.51: ESWL

Batu ginjal ESWL
of Kidney Kidney, ureter

N13.2:
hidronefrosis Hydronephrosis
ec batu ureter with calculus ureteral 56.1: ureteral
ureteral and meatotomy meatotomy
dextra
kidney
obstruction

transurethral 56.0:
removal of transurethral
obstruction removal of
from ureter obstruction
and renal from ureter and
pelvis renal pelvis

pasang DJ 59.8: ureteral

stent catheterization

N13.1
hydronephtosis
hidronefrosis with ureteral 55.51
ec stricture neferektomi nephroureterec
ureter dextra stricture not tomy
elswhere
classified
 D64.9
Btu pielum N20.0 calculus anemia anaemia, pielotomi 55.11
of kidney pyelotomy
unspecified

S31.3: Open
open wound
wound of 62.69: other
scrotum and repair testis
testis scrotum and repair of testis
testes

61.49: other
reapir of
repair scrotum
scrotum and
tunica vaginalis

63.1 excision of
I86.1 scrotal varicocelectom varicocele and
varicocele
varices i hydrocele of
spermatic cord

56.0:
transurethral
N20.1 Calculus litotripsi removal of
Batu ureter
of ureter pneumatik obstruction
from ureter and
renal pelvis

N35.9 urethral internal 58.5 release

urethral
stricture, urethral urethral
stricture
unspecified meatotomy stricture

T83.5 infection
and
inflammatory
97.64 removal
reaction due to remove DJ
infeksi DJ stent of other urinary
prosthesis stent
drainage device
devices, implant
and graft
urinary sytem
 57.0
transurethral
clearance of transurethral
clearance of
bladder
bladder

N35.9 57.0
N21.0 calculus meatal urethral transurethral
batu buli vesicolitotripsi
in bladder stenosis sricture, clearance of
unspecified bladder

urethral 58.47 urethral

meatoplasty meatoplasty

57.49 other
N32.0 bladder- transurethral
bladder neck bladder neck excision or
neck
stenosis incision destruction of
obstruction
lesion or tissue
of bladder

Kalibrasi dan
N34.2 Other 58.6 Dilation
meatitis dilatasi urethra
urethritis urethra
anterior

peyronies N48.6 Induratio

disease penis plastica

N40 hyperplasia
PH retensi
prostate

Z46.6 fitting and 97.64 removal

DJ stent in situ adjustment of aff DJ stent of other urinary
urinary device drainage device
 60.29 other
BPH N40 hyperplasia TUR-P transurethral
prostate
prostatectomy

retensi urin ec R31 unspecified

hematuria haematuria

N21.0 60.29 other

N40 hyperplasia
BPH retensi batu buli calculus in TUR-P transurethral
prostate
bladder prostatectomy

57.0
cystitis N30.9 cystitis, vesicolitotripsi transurethral
unspecified clearance of
bladder

N13.2
hydronephrosis
hidronephrosis with renal and
karena batu
ureteral
ginjal
calculus
obstruction

fistula N99.9 repair fistul 58.43 closure of

urethrocutan postprocedural urethracutan other fistula
post disorder of urethra
hipospadia genitourinary
system,
unspecifeid

calculus N21.1 calculus litotripsi batu 57.0

urethra in urethra yang transurethral
sebelumnya di clearance of
dorong ke bladder
bladder
 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keterangan

N-1-20-I
Prosedur
13,820,200 11,845,900 9,871,600 12,979,252 kelas 2
Saluran Urin
Atas [Ringan)

N-1-20-I
Prosedur
Saluran Urin 13,820,200 11,845,900 9,871,600
12,979,252 kelas 2
Atas [Ringan)

N-1-20-I
Prosedur 13,820,200 11,845,900 9,871,600 23,961,906 DS
Saluran Urin
Atas [Ringan]

N-1-20-I
Prosedur
13,820,200 11,845,900 9,871,600 19,751,053 kelas 3
Saluran Urin
Atas [Ringan]
 N-1-20-II
Prosedur 19,340,700 16,577,700 13,814,800 28,102,750 kelas 2
Saluran Urin
Atas [Sedang]

V-1-12-I:
prosedur pada
skrotum dan
12,205,200 10,461,600 8,718,000 7,701,050 kelas 3
prostat komplek
moderat
(ringan)

V-1-12-I:
prosedur pada
skrotum dan
12,205,200 10,461,600 8,718,000 8,571,121 kelas 2
prostat komplek
moderat
(ringan)

N-1-40-I
Prosedur pada
uretra dan 11,358,800 9,736,100 8,113,400 18,819,886 kelas 1
transuretra
(ringan)

N-1-40-I
Prosedur pada
uretra dan 11,358,800 9,736,100 8,113,400 14,107,686 kelas 1
transuretra
(ringan)

N-1-40-I
Prosedur pada
uretra dan 11,358,800 9,736,100 8,113,400 13,528,788 kelas 2
transuretra
(ringan)
 N-1-40-I
Prosedur pada
uretra dan 11,358,800 9,736,100 8,113,400 17,004,452 kelas 1
transuretra
(ringan)

N-1-40-I
Prosedur pada
uretra dan 11,358,800 9,736,100 8,113,400 21,178,133 kelas 1
transuretra
(ringan)

N-4-12-I Infeksi
Ginjal dan
3,379,700 2,897,100 2,414,200 7,627,561 Kelas 3
Saluran Urin
(ringan)

V-4-11-I
penyakit sistem
reproduksi laki- 5,216,600 4,471,300 3,726,100 7,270,567 kelas 1
laki selain
tumor (ringan)

V-4-11-I
penyakit sistem
reproduksi laki- 5,216,600 4,471,300 3,726,100 3,433,741 kelas 1
laki selain
tumor (ringan)

N-4-16-I
penyakit ginjal
5,220,800 4,475,000 3,729,200 6,486,784 Kelas 2
dan saluran urin
lain-lain (ringan)
 V-1-14-I
pengangkatan 12,484,400 10,700,900 8,917,400 16,781,400 kelas 3
Prostat melalui
uretra (ringan)

N-4-15-I gejala,
tanda gangguan
ginjal dan 3,045,500 3,654,600 2,577,900 2,392,523 kelas 2
saluran urin
(ringan)

V-1-14-II
pengangkatan
Prostat melalui
uretra (sedang); 18,139,500 15,548,100 12,956,800 15,812,796 kelas 3
sevel 2 karena
cystitis atau
batu buli

N-4-13-I batu
4,827,700 4,138,000 3,448,400 8,020,895 kelas 1
urin (ringan)

N-1-40-I 11,358,800 16,338,262 kelas 1

Prosedur pada
uretra dan
transuretra
(ringan)

N-1-40-I 11,358,800 15,095,522 kelas 1

Prosedur pada
uretra dan
transuretra
(ringan)
 Diaganosa
No Diagnosa Utama Kode ICD 10 Kode ICD 10 Tindakan
sekunder

I67.9:
Hemipares ec E78.5:
Cerebrovascular
CVD iskemik (CT hiperlipidemia Hyperlipidaemia,
disease,
scan normal) unspecified
unspecified

D43.2 neoplasm
uncertain or
SOL susp
unknown
astrocytoma
behaviour of brain,
unspecified

I67.9:
Stroke berulang
(CT scan tidak Cerebrovascular Hipokalemia E87.6:
disease, (terapi KCl) hypokalaemia
dilakukan)
unspecified

E11.9: Non-Insulin
Stroke infark I63.9 Cerebral Dependent
(CT scan kepala: infarction, DM Diabetes Mellitus DSA
infark +) unspecified without
Complications

hemiparese
I63.9 Cerebral
sinistra ec CVD
infarction,
(CT scan kepala unspecified
infark +)

Epilepsy G40.9 Epilepsy

Z54.9
R56.8 other and SOL (sudah convalescence
kejang +SOL unspecified pernah following
convulsions ditegakkan) unspecified
tratment

cephalgia kronis R51 headache

 migraine G43.9 migraine,
chronic unspecified

G62.9
neuropati
Polyneuropathy,
perifer
unspecified

M51.1 lumbar and

other
LBP intervertebral disc facet blok
disorders with
radiculopathy

M51.2 other
specifieid
LBP ex HNP
intervertberal disc
displacement

S33.5 sprain and

lumbar sprain strain of lumbar
spine

H81.4 vertigo of
vertigo central
central origin

G45.0 vertebro-
dolichoechtasia
basilar artery DSA
arteri cerebral
syndrome

D48.0 neoplasm
uncertain or
unknown
tumor tulang
behaviour of bone
and articular
cartilage
 I10 Essential
(primary)
Hematemesis I63.9 Cerebral HT st II, DM hypertension, E11.9
dextra ec CVD infarction, tipe II, Non Insulin
berulang unspecified Hiponatremi dependent diabetes
mellitus without
complications

myofascial pain M79.15 myalgia,

syndrome pelvic, thigh

observasi petit Z03.9 observation

mal dor suspected
disease or
condition

CKR S00.9 Superficial

injury of head, part
unspecified

stenosis arteri I65.2 occlusion and I49.3 ventricular

stenosis of carotid VES premature DSA
carotis
artery depolarization

I11.0 hypertensive
HHD with CHF heart diseas with
congestive heart
failure
 Kode ICD 9 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas

G-4-26-I:
GANGGUAN -
PENYAKIT SISTEM 5,067,400 4,343,500 3,619,600 7,553,623 kelas 2
SARAF LAIN-LAIN
(RINGAN)

G-4-26-I gangguan
penyakit sistem
5,067,400 4,343,500 3,619,600 16,304,222 kelas 1
saraf lain-lain
(ringan)

G-4-26-II
GANGGUAN -
PENYAKIT SISTEM 6,077,300 5,209,100 4,340,900 11,556,085 kelas 1
SARAF LAIN-LAIN
(SEDANG)

G-1-12-I
PROSEDUR
88.41 Arteriography of PEMBULUH DARAH 6,970,900 5,975,000 4,979,200 59,834,502 kelas 1
cerebral arteries
EXTRA KRANIAL
(RINGAN)

G-4-14-I
Kecederaan
pembuluh darah 7,081,500 6,069,900 5,058,200 7,104,219 Kelas 1
otak dengan infark
(ringan)

G-4-22-I Serangan
3,751,700 3,215,700 2,679,800 1,875,446 kelas 2
Kejang (ringan)

G-4-22-I Serangan
Kejang (ringan) 3,751,700 3,215,700 2,679,800 13,754,611 Kelas 1

G-4-23-I migren
dan sakit kepala 3,743,600 2,647,000 1,694,762 kelas 3
(ringan)
 G-4-23-I migren
dan sakit kepala 3,743,600 2,647,000 4,009,809 kelas 1
(ringan)

G-4-17-I Gangguan
Saraf Kranial dan 6,353,300 5,445,700 4,538,100 2,940,283
Perifer

G-3-12-0 prosedur
03.96 percutaneous rawat
pemeriksaan 548,500 5,897,305
denervation of facet jalan
neurologis lain

M-4-17-I Masalah
punggung/pinggal 5,209,400 4,465,200 3,721,000 6,062,493 kelas 1
belakang (ringan)

M-4-17-I Masalah
punggung/pinggal 5,209,400 4,465,200 3,721,000 4,472,346 DS
belakang (ringan)

U-4-11-I
dysequilibrium 2,143,700 1,837,400 1,531,200 3,684,971 Kelas 1
(ringan)

G-1-12-I
PROSEDUR
88.41 Arteriography of PEMBULUH DARAH 6,970,900
5,979,500 4,979,200 12,262,398 kelas 3
cerebral arteries
EXTRA KRANIAL
(RINGAN)

M-4-21-I gangguan
sistem
muskuloskeletal
4,170,700 3,574,900 2,979,100 11,444,461 kelas 3
dan jaringan
penghubung lain-
lain (ringan)
 87.44 Routine chest x-
ray, so described,
87.03 computiresed G-4-14-I
axial tomography of KECEDERAAN
head, PEMBULUH DARAH 7,081,500 6,069,900 5,058,200 6,561,479 Kelas 3
89.52 OTAK DENGAN
Electrocardiogram, INFARK (RINGAN)
93.96 Other oxygen
enrichment

M-4-20-I tanda
gejala dan
peradarangan 4,142,000 3,550,300 2,958,600 4,908,144 kelas 1
muskuloskeletal
(ringan)
Z-4-12-I faktor- 2,272,300 2,849,959 kelas 2
faktor yang
mempengaruhi
status kesehatan
lain-lain (ringan)

L-4-13-I trauma 3,367,300 4,769,622 kelas 1

pada kulit, jaringan
bawah kulit dan
payudara (ringan)

G-1-12-III
88.41 Arteriography of PROSEDUR
PEMBULUH DARAH 18,358,900 16,054,572 kelas 1
cerebral arteries
EXTRA KRANIAL
(BERAT)
Keteranga
n
 Diaganosa
No Diagnosa Utama Kode ICD 10 Kode ICD 10 Tindakan Kode ICD 9
sekunder

P03.4: Fetus and

newborn affected
BBL-SC
by caesarean
delivery

hiperibilirubinemia p59.9 neonatal 99.83 other

jaundice, LT phototherap
pada BBL
unspecified y

tidak diinput
karena tidak
D69.3: Idiopathic
Demam ada terapi
ITP akut thrombocytopenic
purpura dengue spesifik
(pemeriksaan
labor Cuma 1x)

A09.0: other and

unspecified L30.9
GEA gastroenteritis an Dermatitis Dermatitis,
colitis of infectious unspecified
origin

vomitus dengan
R11 Nausea and
dehidrasi ringan
vomiting
sedang

p59.9 neonatal 99.83 other

Hiperbilirubinemia jaundice, LT phototherap
unspecified y

G40.9 Epilepsy,
Epilepsi
unspecified

R56.0 febrile
KDS
convulsions
 R11 Nausea and
vomitus profus
vomiting

B85.9 measles
Morbili without
complication

A09.0 other
and
J18.0 unspecifeid
Bronkopneumonia bronchopneumoni diare gastroenteritis
a, unspecified and colitis of
infectious
origin

J03.9 acute
tonsilitis
tonsilltis

J02.9 acute
faringitis akut pharingitis,
unspecified

J06.9 Acute upper

respiratory
rinofaringitis
infection,
unspecified

P25.1 93.90 non-

Pneumothorax pada Pneumothorax invasive
Cpap
bayi baru lahir originating in mechanical
perinatal period ventilation
 P22.1 transient
TTN tachypnea of
newborn

A01.3 paratyphoid
paratifoid fever C
fever C

J45.9 Asthma,
Asthma
unspecified

R10.4 Other and

Abdominal paint unspecified
abdominal pain

J00 Acute
Nasopharyngitis nasopharyngitis

A49.9 bacterial
bactrial infection infection,
unspecified
 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keterangan

P-8-17-I:
NEONATAL, BBL >
2499 GR TANPA 5,164,100 4,426,300 3,688,600 1,975,313 kelas 1
PROSEDUR
MAYOR (RINGAN)

P-8-13-I neonatal,
BBL 2000-2499 gr
7,746,100 6,639,500 5,532,900 2,417,887 kelas 2
tanpa prosedur
mayor (ringan)

D-4-11-I:
GANGGUAN
5,710,900 4,895,100 4,079,200 12,670,724 DS
PEMBEKUAN
DARAH (RINGAN)

K-4-17-I: NYERI
ABDOMEN &
GASTROENTERITI 2,426,800 2,080,100 1,733,400 1,778,599 Kelas 2
S LAIN-LAIN
(RINGAN)

K-4-17-I: NYERI
ABDOMEN &
GASTROENTERITI 2,426,800 2,080,100 1,733,400 2,466,316 kelas 1
S LAIN-LAIN
(RINGAN)

B-4-13-I
gangguan hati 5,939,000 5,090,600 4,242,200 1,967,539 kelas 2
lain-lain (ringan)

G-4-22-I serangan
3,751,700 3,215,700 2,679,800 2,083,321 kelas 1
kejang (ringan)

G-4-22-I serangan
3,751,700 3,215,700 2,679,800 5,158,005 DS
kejang (ringan)
 K-4-17-I: NYERI
ABDOMEN &
kelas 3
GASTROENTERITI 2,426,800 2,080,100 1,733,400 2,299,189
S LAIN-LAIN observasi
(RINGAN)

A-4-13-I infeksi
viral dan non 2,952,300 2,530,500 2,108,800 2,382,596 Kelas 1
bakterial (ringan)

J-4-16-I simple
pneumonia dan
5,104,000 4,374,900 3,645,700 2,096,000 kelas 3
whooping coug
(ringan)

U-4-13-I
Peradangan
epiglotis, telinga
2,797,200 2,397,600 1,998,000 2,008,278 kelas 2
tegah, ISPA dan
Laringotrakeitis
(ringan)

U-4-13-I
Peradangan
epiglotis, telinga
2,797,200 2,397,600 1,998,000 1,587,647 kelas 1
tegah, ISPA dan
Laringotrakeitis
(ringan)

U-4-13-I
Peradangan
epiglotis, telinga
tegah, ISPA dan 2,797,200 2,397,600 1,998,000 1,714,671
Kelas 2
Laringotrakeitis
(ringan)

P-8-08-I nonatal,
berat badan lahir
group 5 dengan
sindroma distres 5,963,900 5,111,900 4,260,000 12,441,123
kelas 2
pernapasan
(ringan)
A-4-14-I penyakit
infeksi bakteri
3,204,800 2,747,000 2,289,100 2,575,905 kelas 1
dan parasit lain-
lain (ringan)

J-4-18-I ASTHMA
& BRONKIOLITIS 3,144,300 2,695,100 2,245,900 1,279,322 Kelas 3
(RINGAN)

K-4-17-I NYERI
ABDOMEN &
GASTROENTERITI 2,426,800 2,080,100 1,733,400 1,807,753 Kelas 2
S LAIN-LAIN
(RINGAN)

U-4-13-I
PERADANGAN
EPIGLOTIS,
TELINGA
TENGAH, ISPA 2,797,200 2,397,600 1,998,000 1,570,428 Kelas 2
DAN
LARINGOTRAKEITI
S (RINGAN)

A-4-14-I penyakit
infeksi bakteri
2,747,000 1,302,980 kelas 2
dan parasit lain-
lain (ringan)
 Diaganosa
No Diagnosa Utama Kode ICD 10 Kode ICD 10 Tindakan
sekunder

O34.2: Maternal
care due to O82.0: Delivery by
Post SC (bekas SC) uterine scar elective caesarean SC
from previous section
surgery

O32.2: Maternal
care for
Letak lintang
transverse and
oblique lie

O34.2: Maternal
O99.0 anaemia
care due to complicating
Post SC (bekas SC) uterine scar anaemia SC
pregnancy, childbirth
from previous
surgery and the puerperium

D64.9 Anaemia,
unspecifeid

Z53.2 Procedure
not carried out
Kista ovarium because N83.0 Follicular cyst
(menolak patient's
of ovary
tindakan) decision for
other unspefied
reasons

O99.0 Anaemia
complicating
D64.9 Anaemia,
hamil + anemia pregnancy, transfusi PRC
unspecifeid
chidlbirth and
the puerperium

O21.0 mild
HEG hyperemesis
gravidarum
 N83.2 other and
Kista ovarium unspecified kistektomi
bilateral
ovarian cysts

N93.9 abnormal
uterine and
perdarahan
vaginal kuretage
uterus abnormal
bleeding,
unspecified

O05.4 other
abortion,
abortus
Incomplete, kuretage
inkomplete
without
complication

O21.1 missed
missed abortion kuretage
abortion

polip N84.0 polyp of

endometrium corpus uteri

N93.9 abnormal
uterine and d62 acute
perdarahan
vaginal anemia posthaemorragic kuretage
uterus abnormal
bleeding, anaemia
unspecified
 N83.2 Other
Kista Ovarium and unspecified Transfusi FFP
ovarian cysts

N83.1 other and salpingo-

kista ovarium unspecified oophorectomi
ovarian cysts unilateral

total abdominal
histerektomi

D39.0 neoplasm
Uterus
uncertain or subtotal
miomatosus + unknown anemia
D63.0 anaemia in neoplastic disease
abdomina
hiperplasia
behaviour of histerektomi
endometrium
uterus

salpingo-
oophorektomi
bilateral
bekas sc O34.2: Maternal endometriosis O99.8 Other sc
care due to skin specified diseases
uterine scar and conditions
from previous complicating
surgery pregnancy, childbirth
and the puerperium

eksisi
endometriosis
skin

kista N80.9 appendicitis K35.8 acute eksisi

endometriosis endometriosis, appendicitis endometriosis di
unspecified ovarium

appendectomy
kista N80.9 eksisi
endometriosis endometriosis, endometriosis di
unspecified ovarium
 Kode ICD 9 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas

O-6-10-I:
OPERASI
74.1: Low cervical cesarean 10758816 kelas 1
PEMBEDAHA 7,044,300 6,038,000 5,031,600
section (10530642) (kelas 2)
N CAESAR
(RINGAN)

O-6-10-I:
OPERASI
PEMBEDAHA 7,044,300 6,038,000 5,031,600
N CAESAR
(RINGAN)

O-6-10-II:
74.1: Low cervical cesarean OPERASI
PEMBEDAHA 7,635,400 6,544,600 5,453,900 13,416,946 kelas 1
section
N CAESAR
(SEDANG)

Z-4-12-I
Faktor-Faktor
yang
mempengaru
2,651,000 2,272,300 1,893,500 7,961,505 kelas 2
hi status
kesehatan
lain-lain
(ringan)

W-4-16-I
99.04 Transfusion packed Gangguan
Antepartum 3,062,900
2,625,300 2,187,800 2,262,257 Kelas 2
cells
(ringan)

W-4-16-I
Gangguan
3,062,900 2,625,300 2,187,800 1,483,094 kelas 3
Antepartum
(ringan)
 W-1-20-I
65.51 other removal of both prosedur
ovaries at same operative pada rahim 11,674,100 10,006,300 8,338,600 14,640,645 kelas 2
episodes dan adneksa
(ringan)

W-1-11-I
prosedur
dilatasi,
69.09 other dilation and
kuret, 3,249,800 2,785,600 2,321,300 5,924,943 DS
currtege of uterus
intrauterin
dan servik
(ringan)

W-1-11-I
prosedur
dilatasi,
69.09 other dilation and
kuret, 3,249,800 2,785,600 2,321,300 5,102,707 Kelas 2
currtege of uterus
intrauterin
dan servik
(ringan)

W-1-11-I
prosedur
dilatasi,
69.09 other dilation and
kuret, 3,249,800 2,785,600 2,321,300 5,989,844 kelas 1
currtege of uterus intrauterin
dan servik
(ringan)

W-1-11-I
prosedur
dilatasi,
kuret, 3,249,800 2,785,600 2,321,300 3,403,859 kelas 2
intrauterin
dan servik
(ringan)

W-1-11-II
prosedur
dilatasi,
69.09 other dilation and
kuret, 3,249,800 3,073,900 2,561,500 6,288,212 kelas 2
currtege of uterus
intrauterin
dan servik
(sedang)
 65.49 Other unilateral
W-1-20-I
salpingo-oophorectomy 91.49 PROSEDUR
Microscopic examination of
PADA RAHIM 11,674,100 10,006,300 8,338,600 14,091,849 Kelas 2
specimen from female genital
& ADNEKSA
tract, Other microscopic
(RINGAN)
examination

W-1-20-I
prosedur
65.49 other unilateral pada rahim 11,674,100 10,006,300 8,338,600 17,184,746 kelas 3
salpingo-oophorectomy
dan adneksa
(ringan)

68.49 other and unsepcified

total abdominal hysterectomy

W-1-20-II
68.39 other and unspecifed prosedur
subtotal abdominal pada rahim 14,586,800 12,503,000 10,419,200 36,362,163 DS
hysterectomy dan adneksa
(sedang)

65.61 other removal of both

ovaries and tubes at same
operative episode
74.1: Low cervical cesarean L-1-40-II 14,105,900 19,390,587 DS
section prosedur
pada kulit,
jaringan
bawah kulit
dan payudara
sedang)

86.3 Other local excision or

destruction of lesion or tissue
of skin and subkutaneus

65.29 other local excison or W-1-20-II 14,586,800 40,648,839 kelas 1

destruction og ovary prosedur
pada rahim
dan adneksa
(sedang)

47.19 other incidental

appendectomy
65.29 other local excison or W-1-20-I
destruction og ovary prosedur
pada rahim
dan adneksa 8,338,600 11,380,964 kelas 3
(RINGAN)
Keteranga
n
 Diagnosa Diaganosa
No Kode ICD 10 Kode ICD 10 Tindakan
Utama sekunder

K40.3 Unilateral or
unspecified inguinal
Right hernia
hernia, with herniorafi + mesh
inguinal lateralis
obstruction, without
gangrene

K40.4 unilateral or
hernia
unspecified inguinal
inguinalis +
hernia, with
infeksi
gangrene

K40.3 Unilateral or
unspecified inguinal D63.8 anaemi in other
Right hernia
hernia, with anemia chronic disease herniorafi + mesh
inguinal lateralis obstruction, without classified elsewhere
gangrene

N18.5 chronic kidney

CKD
disease, stage 5

N45.9 Orchitis
epididymitis and
Orchitis epididymo-orchitis
without abscess

N43.3 Hydrocele,
Hidrocele hidrocolectomy
unspecified

K35.3 acute
appendisitis
appendicitis with appendektomi
infiltrat
localized peritonitis
 adhesiolisis

K35.3 acute
Appendisitis appendcitis, other appendektomi
kronik
and unspecified

K35.2 acute
appendisitis appendicitis with appendektomi
perforasi generalized
peritonitis

D48.6 neoplasm
uncertain or
tumor mamae excisi +PA
unknown behaviour
of breast

D48.5 neoplasm
benjola pada uncertain or
eksisi + PA
gluteus unknown behaviour
of skin

D48.6 neoplasm
tumor mammae N61 inflammatory
uncertain or unknown excisi +PA
terinfeksi disorders of breast
behaviour of breast

debridement

S70.9 superficial
vulnus punctum injury of hip and
thigh, unspecified

E11.5 non-insulin
dependent diabetes
gangren mellitus with D64.9 anaemi,
Anaemi
diabetik peripheral unspecified
circulatory
complications
 I11.0 hypertensive
HHD + CHF heart disease with
(congestive) heart
failure

D48.7 neoplasm
uncertain or
Limfadenopati unknown behaviour eksisi + PA
coli
of other specified
sites

D48.7 neoplasm
uncertain or
tumor limfe
unknown behaviour radikal eksisi
node
of other specified
sites

E11.5 non-insulin
dependent diabetes
DM Tipe 2 + mellitus with D64.9 anaemi,
anemia debridement
abses gluteal peripheral unspecified
circulatory
complications

Z03.9 observation
tersengat listrik, for suspected Z32.1 pregnancy
keluhan - disease or condition, hamil confirmed
unspecified

K42.9 umbilical
Hernia umbilikal hernia without
herniorafi + mesh
rekuren obstruction or
gangrene
hemoroid I84.0 internal
internal thrombosed anal fissure K60.2 anal fisure, hemoroidektomi
unspecified
trombosis haemorrhoids

repair anal

K43.9 ventral hernia

hernia incisional without obstruction herniorafi + mesh
or gangrene

K35.2 Acute
appendistis appendicitis with adhesi K66.0 Peritoneal
appendektomi
akut perforasi generalized pertoneal adhesions
peritonitis

adhesiolisis

M60.05 infective
cold abscess
myositis, pelvic
psoas
region and thigh

S99.9 unspecified
luka bakar listrik injur of ankle and debridement
foot

K93.0 Tuberculous
disorders of intestines,
A18.3 Tuberculosis psitometri
peritoneum and
of intestines, premier,TBC Laparotomy,
Appendicitis mesenteric glands
peritoneum and Usus, TBC Biopsi
A15.3 Tuberculosis of
mesenteric glands paru
lung, confirmed by
unspecified means
STT di knee

D48.1 neoplasm
uncertain or
unknown behaviour eksisi + PA
of connective tissue
and other soft tissue

D48.1 neoplasm
uncertain or
Recurent soft Wedge Excisi,
unknown behaviour
tissue Rekontruksi
of connective tissue
and other soft tissue

K35.8 Acute
Appendisitis
appendicitis, other Appendiktomy
kronik
and unspecified

fimosis N47 redundant sirumkumsis

prepuce, phimosis
and paraphimosis
Kode ICD 9 Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas

K-1-14-I
PROSEDUR
53.05 Repair of inguinal hernia HERNIA 12997962
kelas 1
with graft or prosthesis, not INGUINAL 7,753,700 6,646,000 5,538,400 (12.309.750
(kelas 2)
otherwise specified DAN )
FEMORAL
(RINGAN)

K-1-14-II
PROSEDUR
53.05 Repair of inguinal hernia HERNIA
with graft or prosthesis, not INGUINAL 7,789,000 24,098,552 kelas 2
otherwise specified DAN
FEMORAL
(SEDANG)

V-4-11-I
Penyakit
Sistem
Reproduksi 4,471,300 2,731,796 Kelas 2
Laki-Laki
Selain Tumor
(ringan)

V-1-12-I
Prosedur
pada
63.1 Excision of varicocele and Skrotum dan
12,205,200 8,910,399 DS
hydrocele of spermatic cord Prostat
Komplek
Moderat
(ringan)

K-1-11-I
Adhesiolisi kelas 1
47.09 other appendectomy 10,013,900 17,980,680 (kelas 2)
peritoneal
(rigan)
54.59 other lysis of peritoneal
adhesions

K-1-13-I
47.09 other appendectomy prosedur 5,473,000 4,691,100 3,909,300 10,165,497 kelas 1
appendik
(ringan)

K-1-13-I
47.09 other appendectomy prosedur 5,473,000 4,691,100 3,909,300 11,576,074 kelas 3
appendik
(ringan)

L-1-50-I
85.20 excision or destruction of prosedur
breast tissue, not otherwised pada 9,232,400 7,913,500 6,594,600 9,740,634 kelas 3
specified payudara
(ringan)

L-1-40-I
prosedur
86.3 other local excision or pada kulit,
destruction of lesion or tissue of jaringan, 7,032,600 6,027,900 5,023,300 8,965,546 kelas 3
skin and subkutaneous tissue bawah kulit
dan payudara
(ringan)

L-1-50-I
85.20 excision or destruction of prosedur
breast tissue, not otherwised pada 9,232,400 7,913,500 6,594,600 9,601,169 Kelas 2
specified payudara
(ringan)

86.22 excisional debridement of

wound, infection, or burn

L-4-13-I
trauma pad
kulit, jaringan 3,367,300 2,886,300 2,405,200 2,472,762 kelas 3
bawah kulit,
dan payudara
(ringan)

M-1-30-III
prosedur kaki 28,607,100 33,069,727 kelas 1
(berat)
 D-1-20-I
prosedur
pada darah
40.29 simple excision of other dan organ 7,294,900 10,241,695
lymphatic structure
pembentuk
darah lain-
lain (ringan)

D-1-20-I
prosedur
pada darah
40.59 radical excision of other
dan organ 6,252,800 11,143,360 kelas 2
lymph nodes
pembentuk
darah lain-
lain (ringan)

I-4-15-II
penyakit
86.22 excisional debridement of pembuluh
7,383,400 17,017,099 kelas 2
wound, infection, or burn darah perifer
dan lain-lain
(sedang)

Z-4-12-I
faktor-faktor
yang
mempengaru
2,272,300 1,893,500 2,177,054 kelas 2
hi status
kesehatan
lain-lain
(ringan)

K-1-12-I
prosedur
53.42 other and open repair of hernia tidak
umbilical hernia with graft or termasuk 4,852,800 3,466,300 14,718,878 kelas 1
prostehesis inguinal dan
femoral
(ringan)
 K-1-50-I
49.46 excision of hemorrhoids prosedur anal 7,209,400 11,844,005 kelas 2
(ringan)

49.71 suture laceration of anus

K-1-12-I
prosedur
hernia tidak
53.61 other open incisional repair termasuk 4,852,800 3,466,300 11,921,057 kelas 3
with graft or prosthesis
inguinal dan
femoral
(ringan)

K-1-11-I
Adhesiolisi
47.09 other appendectomy 10,013,900 19,051,774 kelas 2
peritoneal
(rigan)

54.59 other lysis of peritoneal

adhesions

M-4-21-I
gangguan
sistem
muskuloskele
tal dan 4,170,700 10,686,417 kelas 1
jaringan
penghubung
lain-lain
(ringan)

M-4-21-I
gangguan
sistem
86.22 excisional debridement of muskuloskele
tal dan 4,170,700 8,805,183 kelas 1
wound, infection, or burn
jaringan
penghubung
lain-lain
(ringan)

K-1-10-II
54.59 Other lysis of peritoneal
PROSEDUR
adhesions 90.89 Microscopic
NON
examination of specimen from
KOMPLEKS
upper gastrointestinal tract and 14,534,800 12,458,400 10,382,000 20,892,719 Kelas 2
USUS HALUS
vomitus, Other microscopic
& USUS
examination 45.15 Open biopsy of
BESAR
small intestine
(SEDANG)
 K-1-10-II
PROSEDUR
NON
83.39 excisision of lesion of other KOMPLEKS 7,531,400 8,730,203 kelas 1
soft tissue USUS HALUS
& USUS
BESAR
(SEDANG)

83.39 excisision of lesion of other

M-1-50-I
soft tissue
PROSEDUR
91.69 Microscopic examination of
JARINGAN 7,531,400 6,455,400 5,379,500 12,763,515 Kelas 2
specimen from skin and other
LUNAK
integument, Other microscopic
(RINGAN)
examination

K-1-13-I
prosedur
47.09 other appendectomy 3,909,300 4,691,100 3,909,300 10,477,218 Kelas 2
appendik
(ringan)
64.0 circumsision V-1-15-I 2,072,800 9,083,204 kelas 1
sirkumsis
dengan
kondisi
tertentu
Keteranga
n
No Diagnosa Kode ICD 10 Diaganosa Kode ICD Tindakan Kode ICD 9 Grouper
Utama sekunder 10
traumatic S68.1: debridement 86.22: L-1-30-I:
amputasi Traumatic Excisional PEMINDAHA
phalang amputation debridement of N KULIT
distal of other wound, TANPA LUKA
manus single finger infection, or BAKAR
dextra (complete) burn (RINGAN)
(partial)

v-y Flap 86.71: Cutting

advancement and
preparation of
pedicle grafts
or flaps

pulled S53.0 reposisi 79.72 closed M-4-12-I

elbow Dislocation of tertutup reduction of FRAKTUR/DIS
sinistra radial head dislocation of LOKASI
elbow SELAIN
FEMUR DAN
PELVIS
(RINGAN)

union z96.7 remov implant 78.61 Removal J-1-30-I

lateral Presence of of implanted Prosedur
calvicula other b one device from sistem
dextra and tendon scapula, pernapasan
implants clavicle, and kompleks
thorax (ribs and (ringan)
sternum)

neglected S93.0 ORIF 79.37 open M-1-30-I

dislocation Dislocation of reduction of Prosedur
of left other and fracture with Kaki (ringan)
subtalar unspecified internal
joint parts of foot fixation, tarslas
and
metatarsals
fraktur S62.1 debridement 86.22: M-1-80-I
terbuka fracture of Excisional Prosedur
phalanx other finger, debridement of angoota
media dan open wound, tubuh atas
dislokasi infection, or (ringan)
DIP digiti IV burn
manus
dextra

reposisi 79.24 open

terbuka reduction of
fracture
without
internal
fixation,
phalanges of
hand

fraktur S92.51 ORIF 79.33 open M-1-80-I

terbuka fracture of reduction of Prosedur
phaleng other toe, fracture with angoota
media digiti open internal tubuh atas
III pedis fization, carplas (ringan)
dekstra + and
avulsi skin metacarpals

repai avulsi skin 86.89 other

repair and
reconstruction
of skin and
subkutaneous
tissue

infeksi post T79.3 post- debridement 86.22: A-4-11-I

trauma traumatic Excisional infeksi
wound debridement of sesudah
infection, not wound, operasi dan
elsewhere infection, or trauma
cllassified burn (ringan)

Dislokasi S03.0 reposisi 76.93 closed U-4-14-I

TMJ islocation of tertutup reduction of penyakit
jaw dislokasi TMJ temporomandi mulut dan
bular gigi (ringan)
dislocation
osteomieliti M86.65 other anaemia D64.9 M-4-14-II
s chronic anaemi osteomielitis
osteomyelitis, unspecifie (sedang)
pelvic and d
thigh

dislokasi hip Q65.2 reposisi 79.75 closed M-4-21-I

(anak) congenital tertutup reduction of gangguan
dislocation of dislocation of sistem
hip, hip muskuloskele
unspecified tal dan
jaringan
penghubung
lain-lain
(ringan)

Osteoarthri M17.9 eksisi kapsul 80.16 other M-1-70-I

tis knee dan gonarthrosis, sendi arthoromy of prosedur
bursitis unspecified knee lutut dan
tungkai
bawah selain
kaki (ringan)

debridement 86.22:
Excisional
debridement of
wound,
infection, or
burn

fractur S42.20 ORIF 79.31 ORIF, G-1-20-I

condylus fracture of humerus prosedur
lateral upper end of S54.2 saraf kranial
humerus humerus, injury of dan perifer
sininstra closed radial (ringan)
entrapmen nerve at
t nervus forearm
radialis level
transposisi 04.49 other
nervus radialis peripheral
nerve or
ganglion
decompression
or lysis of
adhesions
Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
12,548,800 10,756,100 8,963,400 17,373,798 DS

4,163,400 3,568,700 2,973,900 9,947,933 kelas 2

10,327,300 8,852,000 7,376,600 12,565,543 kelas 1

12,346,400 10,582,600 8,818,900 22,380,546 kelas 2

12,250,000 10,500,000 8,750,000 10,903,619

12,250,000 10,500,000 8,750,000 33,119,777 DS

4,652,700 3,988,000 3,323,400 14,201,037 kelas 2

3,721,400 1,899,735 kelas 3

 9,751,300 39,753,934 kelas 1

4,170,700 16,250,087 kelas 1

18,471,100 11,814,104 2

kelas 2

10,666,200 21,693,807
No Diagnosa Utama Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9
sekunder
cholecystitis + K80.1 Calculus
cholelitiasis of gallbladder
with other
cholecystitis

cholecystitis + K80.1 Calculus Laparoskopi 51.23 Laparoscopic

cholelitiasis of gallbladder cholecystectomy cholecystectomy
with other
cholecystitis

ileus obstruksi K91.9

ec adhesiolisis postprocedur
post al disorder of
appendectomi digestive
system,
unspecified

cholecystitis + K80.1 Calculus cholecystectomy 51.22

cholelitiasis of gallbladder open cholecystectomy
with other
cholecystitis

Fistula ani residif K60.3 anal fistulectomi 49.12 anal

fistula fistulectomy
Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
B-4-14-I 5,932,700 5,085,100 4,237,600 8,554,026 DS
GANGGUAN
SALURAN EMPEDU
LAIN-LAIN
(RINGAN)

B-1-14-I 10,882,800 9,328,100 7,102,700 29,029,842 DS

Cholesistektomi
dengan
laparoskopik
(ringan)

K-4-18-I gangguan 2,052,200 1,759,000 1,465,900 11,971,245 kelas 1

sistem pencernaan
lain-lain (ringan)

B-1-12-I 9,943,700 8,523,200 7,102,700 15,138,012 kelas 2

cholesistektomi
tanpa laparostkopik
(ringan)

K-1-50-I prosedur 7,209,400 11,048,513 kelas 2

anal (ringan)
No Diagnosa Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9
Utama sekunder
Fraktur S02.40 Fracture fraktur radius S52.6 Fracture rekonstruksi 76.72 Open
zygoma of malar and dan ulna of lower end zygomatikum reduction of
maxillary bones, distal of both ulna (reduksi dan malar and
closed and radius pasang plate zygomatic
and screw) fracture

avulsi/skin S01.5 open rekonstruksi 27.59 other

loss bibir wound of lip bibir plastic repair
atas and oral cavity of mouth

Hipospadia Q54.9 repair 58.45 repair

Hypospadias, hipospadia of
unspecified hypospadias
or epispadias

Kontraktur M62.44 release 86.84

tangan contracture of kontraktur relaxatiob of
muscle, hand scar or web
contracture of
skin

STSG 86.62 other

skin graft to
hand

post op Z98.8 other GV 93.57

release specified application of
kontraktur postsurgical other wound
state dressing
Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
M-1-6-I PROSEDUR 8,059,000 32,844,695 kelas 3 +
SISTEM jasa
MUSKULOSKLETAL raharja
& JARINGAN
PENGHUBUNG
LAIN-LAIN
(RINGAN)

U-1-30-I Prosedur 7,498,600 18,118,028 VIP

Mulut (ringan)

N-1-40-I prosedur 9,736,100 20,559,684 kelas 1

pada uretra dan
transuretra
(ringan)

L-1-30-I 12,548,800 8,963,400 24,976,266 kelas 1

pemindahan kulit
tanpa luka bakar
(ringan)

Z-4-22-I faktor- 1,893,500 3,940,573

faktor yang
mempengaruhi
status kesehatan
lain-lain (ringan)
No Diagnosa Kode ICD 10 Diaganos Kode ICD Tindakan Kode ICD Grouper Kelas 1
Utama a 10 9
sekunder
SOPT J98.4 Other colitis A09.9 Colonosco 45.23 J-4-21-II 6,368,500
disorders of Gastroent Colonosc GEJALA,
lung eritis and opy TANDA DAN
colitis of DIAGNOSIS
unspecifie SISTEM
d origin PERNAFASAN
LAIN-LAIN
(SEDANG)
(karena AF)

AF I48 Atrial
fibrillation
and
flutter

DM E11.9:
Non-
Insulin
Depende
nt
Diabetes
Mellitus
without
Complica
tions

Syok sepsis R57.9 shock, I-4-14-I

ec unspecified Cardiac
pneumonia arrest, tidak
dengan diketahui
retensi (ringan)
sputum, post
cardiac arrest

Asma J45.9 Asthma, J-4-18-I Asma 3,144,300

unspecified dan
bronkiolitis
(ringan)
PPOK J44.9 chronic J-4-17-I 5,210,800
obstructive penyakit
pulmonary paru
disease, obstruktif
unspecified kronis
(ringan)

PPOK J44.1 chronic J-4-17-I 5,210,800

eksaserbasi obstructive penyakit
akut pulmonary paru
disease with obstruktif
acute kronis
exacerbation, (ringan)
unspecified

Pneumonia J44.0 chronic J-4-17-I 5,210,800

pada PPOK obstructive penyakit
pulmonary paru
disease with obstruktif
acute lower kronis
respiratory (ringan)
ifection
Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
53,394,638 DS

3,363,000 4,746,688 kelas 3

observasi

9,006,562 Kelas 1
4,466,400 3,722,400 8,658,000 Kelas 1

4,466,400 3,722,400 10,555,356 DS

4,466,400 3,722,400 4,246,259 kelas 1

No Diagnosa Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9 Grouper
Utama sekunder
aneurisma I72.1 Aneurysm hipertensi I12.0 repair 39.52 Other I-1-20-III
arteri of artery of +CKD Hypertensive aneurisma repair of PROSEDUR
brachialis upper extremity renal disease arteri brachialis aneurysm SISTIM
kiri with renal kiri PEREDARAN
failure DARAH LAIN-
LAIN (BERAT)

Anemia D63.8 Anaemia transfusi PRC 99.04

in other Transfusion
chronic of packed
diseases cells
classified
elsewhere

DM E11.9: Non-
Insulin
Dependent
Diabetes
Mellitus
without
Complications

pneumonia J18.9
Pneumonia,
unspecified

CKD on HD Z49.0 AV shunt 39.27 N-1-12-I

preparotory brachialis arterioveno membuat
care for dialysis stomy for baru,
renal merevisi
dialysis danmeminda
hkan alat
dialisis
(ringan)

pemasanga Z49.0 CDL 3895 N-1-12-I

n CDL preparotory venous membuat
care for dialysis catheteriza baru,
tion for merevisi
renal danmeminda
dialysis hkan alat
dialisis
(ringan)
CKD on HD I12.0 anemia D63.8 Anaemia AV shunt 39.27 N-1-12-II
hypertensive kronik in other brachialis arterioveno membuat
renal disease chronic stomy for baru,
with renal diseases renal merevisi
failure classified dialysis danmeminda
elsewhere hkan alat
dialisis
(sedang)

CDL T82.7 infection

terinfeksi and
inflammatory
reaction due to
other cardiac
and vascular
device, implant
and grafts

varises I83.9 varicose ligasi dan 38.59 I-1-17-I ligasi

veins lower stripping ligation and dan striping
extremities stripping of pembuluh
without ulcer or varicose darah vena
inflammation veins, lower (ringan)
limb
varicose
veins

multiple 38.69 other

phelebectomy excision of
vessels,
lower limbs
hipertensi I12.0 pemasangan 38.95 N-1-12-II
dan CKD hypertensive CDL venous membuat
renal disease catheteriza baru,
with renal tion for merevisi dan
failure renal memindahka
dialysis n alat dialisis
(sedang)
Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
28,501,500 24,429,900 20,358,200 42,886,446 kelas 1

6,131,400 5,255,500 4,379,600 7,290,301 kelas 1

6,131,400 5,255,500 4,379,600 4,716,656 kelas 3

12,584,500 8,210,712 kelas 1

19,254,500 21,184,755 kelas 1

12,584,500 11,859,390 kelas 1
No Diagnosa Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9
Utama sekunder
corpus T17.1 ekstraksi corpus 98.12 Removal of
alienum di Foreign alienum intraluminal
KNS body in foreign bpdy from
nostril nose without
incision

debridement 86.28
nonexcisional
debridement of
wound, Infection,
or burn

tonsilitis J35.0 tonsillektomi 28.2 tonsillectomy

kronis chronic without
tonsillitis adenoidectomy

septum J34.2 hipertrofi J34.3 hyperthrophy septoplasty 21.88 other

deviasi deviated konka of nasal turbinates septoplasty
nasal
septum

konkotomi 21.69 other

turbinectomy
tonislitis dan J35.9 hipertrofi J34.3 hyperthrophy konkotomi 21.69 other
adenoiditis chronic konka of nasal turbinates turbinectomy
kronis disease of
tonsils and
adenoids,
unspecified

tonsilektomi dan 28.3 tonsilectomy

adenoidektomi with
adenoidectomy
tumor D48.5 epistaxis R04.0 epistaxis ekstirpasi tumor 21.31 local
intranasal neoplasm excision or
uncertain or destruction of
unkown intransal lesion
behaviour
of skin

polip nasi J33.0 polyp polipektomi 21.31 local

of nasal excision or
cavity destruction of
intransal lesion

tumor D37.0 biopsi nasofaring 29.12 pharyngeal

nasofaring neoplasm biopsy
uncertain or
unknown
behaviour
lip, oral
cavity, dan
pharynx

Sudden H91.2 Tinitus, DM E11.9 Non insulin 95.41 Audiometry

deaffnes Sudden tipe 2, dpendent diabetes
idiopathic dislipidemia mellitus without
hearing loss complications,
E78.5
Hyperlipidaemia,
unspecified

epistaxis R04.0 nasal packing 21.01 control of

epistaxis epistaxis by
anterior nasal
packing
Grouper Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
U-4-15-I 4,183,500 3,585,800 2,988,200 8,060,886 Kelas 2
Penyakit
telinga,
hidung, mulut,
dan
tenggorokan
lain-lain
(ringan)

U-1-15-I 5,510,100 4,723,000 3,935,800 7,917,495 Kelas 1

prosedur
tonsil dan
adenoid
(ringan)

U-1-20-I 7,494,500 15,006,985 kelas 2

prosedur
tenggorokan,
mulut, hidung,
dan telinga
lain-lain
(ringan)

U-1-20-I 8,743,600 12,052,149 DS

prosedur
tenggorokan,
mulut, hidung,
dan telinga
lain-lain
(ringan)
L-4-14-II 5,354,200 13,068,881 kelas 2
gangguan
pada kulit dan
oayudara lain-
lain (sedang)

U-4-15-I 3,585,800 9,810,629 kelas 2

Penyakit
telinga,
hidung, mulut,
dan
tenggorokan
lain-lain
(ringan)

U-4-15-I kelas 3
Penyakit
telinga,
hidung, mulut,
dan
tenggorokan
lain-lain
(ringan)

2,998,200 9,471,922
U-4-15-I
Penyakit
telinga,
hidung, mulut,
dan
tenggorokan
lain-lain
(ringan)

4,183,500 3,585,800 2,988,200 4,328,603

U-4-12-I kelas 2
epistaksi/perd
arahan hidung
(ringan)

3,068,700 3,088,512
No Diagnosa Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9 Grouper Kelas 1
Utama sekunder
1 katarak H26.9 hipertensi I10 essential fako 13.41 H-1-30-I 10,530,000
Cataract, (primary) phacoemulsi prosedur
unspecified hypertension fication and lensa dan
aspiration of intra okuler
cataract (ringan)

DM tipe 2 E11.9 non-

insulin
Dependent DM
without
complications

2 pseudofa H26.4 after hecting 11.52 repair H-1-30-I 10,530,000

kia cataract kornea of prosedur
postoperativ lensa dan
e wound intra okuler
dehiscence (ringan)
of cornea

3 katarak H26.9 fako 13.41 h-2-36-0

Cataract, phacoemulsi Prosedur
unspecified fication and operasi
aspiration of katarak (rawat
cataract jalan)
Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n
9,025,700 7,521,400 22,136,592 kelas 1

9,025,700 7,521,400

8,009,400 11,155,465 rajal

No Diagnosa Kode ICD Diaganosa Kode ICD Tindakan Kode ICD Grouper Kelas 1
Utama 10 sekunder 10 9

Z98.8 02.06
other other G-1-10-I
post specified cranial kranioto
cranioto postsurgic cranioplas osteoplas mi
1 mi al state ty ty (ringan) 24,570,200
Kelas 2 Kelas 3 Tarif RS Kelas Keteranga
n

49,939,211 DS
No Diagnosa Utama Kode ICD 10 Diaganosa Kode ICD 10 Tindakan Kode ICD 9 Grouper
sekunder
1 erithroderma L53.9 L-4-14-I
Erythematous GANGGUAN
condition, PADA KULIT &
unspecified PAYUDARA
LAIN-LAIN
(RINGAN)
Kelas 1 Kelas 2 Kelas 3 Tarif RS Kelas Keterangan

4,158,700 8,001,761 DS