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Pariaman, 23 November 2022

No. : Casemix/RSPr/XI/2022
Attachment :-
Regarding :Pending claim verification
To the Head of Services and Nursing
In
Place

Following up on the results of verification of BPJS pending claims for May – October
2022, we convey with this letter that there are several cases of pending claims that require the
following things to be done:
1 Pneumonia Can be diagnosed whenon the chest x-ray there is a new
infiltrate or progressive infiltrateadded with2or more of the
following symptoms:
1. Coughs increase
2. Changes in the characteristics of sputum / purulent
3. Fever (body temperature> 38 C) / history of fever
4. Physical examination: found signs of consolidation,
bronchial breath sounds and rhonki
5. Leukocytes < 10,000 or < 4500
2 BATTERY Can be diagnosed whenTwo creatinine checks were
performedwith KDIGO criteria where in stage I there is an
increase in serum creatinine of 0.3 mg/dL in 48 hours or
>1.5 -1.9 times the baseline (previous value)or urine output
<0.5 ml/kg/hour in 6 hours.
3 Cardiogenic shock The condition of Cardiogenic Shock can be a secondary
diagnosis, especially in patients with heart disease with
evidence of written clinical criteria in the medical record in
the form of: 1. Blood Pressure Drop. BP < 90 mmHg
without inotrope, or b. BP < 80 mm Hg w/ inotrope 2.
Decreased Ejection Fraction (EF < 50%)(echocardiography)
4 Epilepsy Must includeEEG
5 Anemia of Chronic Indication for Transfusion ifHb < 8 gr/dl
Disease
5 COPD Must includespirometry
6 Gastritis/peptic ulcers Must includeendoscope
7 Typhoid fever Tubex/Typhidot supporting examination or widal
standard(minimum widal O 320)
8 UTI Urinary leukocytes > 10 LPB
9 HHD Make sure the Diagnostic criteria for HHD: 1. Physical
examination: According to JNC VII2 criteria. Photothorax:
Cardiomegaly 3. ECG : LVH4. ABPM,
HBPM5.Echocardiography: LVH, diastolic dysfunction
(PPK Cardiovascular Disease from the Association of
Indonesian Cardiovascular Specialists 2016)
10 Varicocele / scrotal varices There is no medical indicationto perform action on patients
with varicocele / scrotal varicose veins on:
1. Infertility
2. Desire to enter the TNI or other educational
institutions (young age)
11 Acute Respiratory Failure Criteria for acute respiratory failure (J96.0) if one of the
following criteria is met: 1. Blood gas analysis results
showed pO2 <
60 mmHg and/or SaO2 < 91%2. The results of pulse
oximetry showed SpO2 <
91%3. The results of blood gas analysis showed pO2 /
FIO2 (P/F) ratio < 3004. Blood gas analysis results showed
pCO2
> 50 mmHg with a pH < 7.355. The blood gas analysis
results showed
increase in pCO2 = 10 mmHg from baseline (if
prior blood gas analysis results are known)
12 Chronic Respiratory Criterion for chronic respiratory failure (J96.1) if the
Failure following criteria are met:
The results of blood gas analysis showed all of the
following criteria: a. increase in pCO2 > 50 mmHg b.
increased bicarbonate (HCO3) > 24 mmHg c. Normal pH
(7.35 – 7.45) d. pO2 < 60 mmHg and/or SaO2 < 91%
13 STT Indications for soft tissue tumor surgery performed with
general narcotics with one of the following criteria:
1. Deep Soft Tissue tumors
2. Extends to vital structures
3. Dimensions of one > 4 cm,evidenced by clinical
photos pre and post op
4. Malignancy
5. Needs reconstruction
6. Location: head and neck