ICD 10

&

ICD 9 CM

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ICD
10

ICD-10 terdiri dari 3

Volume:
Volume

1, Daftar klasifikasi

Volume

2, Petunjuk

penggunaan
Volume

3, Indek

Tabular List of inclusions and

four-character subcategories
Chapter

Blocks

Title

A00-B99

Certain infectious and parasitic diseases

II

C00-D48

Neoplasms

III

D50-D89

Diseases of the blood and blood-forming organs and certain disorders

IV

E00-E90

involving the immune mechanism

Endocrine, nutritional and metabolic diseases

F00-F99

Mental and behavioural disorders

VI

G00-G99

Diseases of the nervous system

VII

H00-H59

Diseases of the eye and adnexa

VIII

H60-H95

Diseases of the ear and mastoid process

IX

I00-I99

Diseases of the circulatory system

J00-J99

Diseases of the respiratory system

XI

K00-K93

Diseases of the digestive system

Tabular List of inclusions and

four-character subcategories
Chapter

Blocks

Title

XII

L00-L99

Diseases of the skin and subcutaneous tissue

XIII

M00-M99

Diseases of the musculoskeletal system and connective tissue

XIV

N00-N99

Diseases of the genitourinary system

XV

O00-O99

Pregnancy, childbirth and the puerperium

XVI

P00-P96

Certain conditions originating in the perinatal period

XVII

Q00-Q99

Congenital malformations, deformations and chromosomal

R00-R99

abnormalities
Symptoms, signs and abnormal clinical and laboratory findings, not

XIX

S00-T98

elsewhere classified
Injury, poisoning and certain other consequences of external causes

XX

V01-Y98

External causes of morbidity and mortality

XXI

Z00-Z99

Factors influencing health status and contact with health services

XXII

U00-U99

Codes for special purposes

XVIII

VOLUME 3
Dibagi dalam 3 Bagian:
Seksi I, daftar semua
terminologi klasifikasi
Seksi II, Indeks penyebab
luar
Seksi III, Tabel obat

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Jika tidak ada diagnosis yang dibuat maka gejala

utama, temuan abnormal atau problem dapat dipilih.

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Tujuh Langkah Seleksi Data

rekam medik pasien
1. Periksa Riwayat Masuk dan
Keluar
2. Periksa Ringkasan
Medis/resume
3. Periksa Laporan Pembedahan,
PA, Lab & Radiologi
4. Periksa Catatan/follow up
Dokter
5. Periksa Catatan/follow up

Tujuh Langkah Pengkodean

Diagnosis (Buku ICD-10):
1. Pilih diagnosis yg akan dikode
2. Tentukan lead term
3. Lihat lead term dalam
alphabetic index
4. Dapatkan modifiers
5. Periksa kode dlm index di
tabular list
6. Periksa inclusion and
exclusion terms

Lead term
Acut

Ulcer of the
Stomach with
Haemorrhage and
Perforation

Modifier
Ulcer, ulcerated, ulcerating
stomach (eroded)(peptic)(round) K25.9
- with
- - hemorrhage K25.4
- - - and perforation K25.6
- - perforation K25.5
- acut
- - with
- - - hemorrhage K25.5
- - -- and perforation K25.2
- - - perforation K25.1
- chronic
- - with
- - - hemorrhage K25.4
- - - - and perforation K25.6
- - - perforation K25.1

Lihat di tabular list

K25

Gastric ulcer
[See before K25 for subdivisions ]
Includes: erosion (acute) of stomach
ulcer (peptic):
pylorus
stomach
Use additional external cause code (Chapter XX), if desired, to identify
drug, if drug-induced.
Excludes: acute haemorrhagic erosive gastritis ( K29.0 )
peptic ulcer NOS ( K27.- )

Lihat untuk subdivisinya

The following fourth-character subdivisions are for use with categories K25K28:
.0

Acute with haemorrhage

.1

Acute with perforation

.2

Acute with both haemorrhage and perforation

.3

Acute without haemorrhage or perforation

.4

Chronic or unspecified with haemorrhage

.5

Chronic or unspecified with perforation

.6

Chronic or unspecified with both haemorrhage and perforation

.7

Chronic without haemorrhage or perforation

.9

Unspecified as acute or chronic, without haemorrhage or perforation

Panduan memilih
diagnosis dan koding

Coding of combination
categories
Code to:
insulinMain
dependent
condition:
diabetes with
Cataract.
ophthalmic
Insulincomplications
dependent
(E10.3) and
diabetes
diabetic cataract
Other
(H28.0*) as the
conditions:
main
Hypertension

condition.

If

it is not possible to
obtain clarification
from the health care
practitioner, one of the
following rules may be
applied and the main

ICD 9
CM

Definisi
PROSEDUR - Intervensi medis atau bedah
yang dilakukan terhadap pasien dengan
tujuan untuk diagnostik ataupun
terapetik.
Meliputi :
Radiologi eksplorasi fungsional
Intervensi bedah
Prosedur umum untuk tujuan
diagnostik / terapetik

Definisi
Prosedur

Prosedur operasi
didefinisikan
sebagai
prosedur terapetik
Prosedursetiap
Operasi
atau diagnostik utama dengan
menggunakan berbagai instrumen
atau dengan memanipulasi bagian
atau beberapa bagian dari tubuh
dan pada umumnya dilakukan
dengan bantuan anastetik.

Principle Operation:

dilakukan untuk menangani principle diagnosis.

Prosedur non-operasi
Prosedur investigatif dan terapetik
lain yang tidak melibatkan bedah,

misalnya

radiologi;
laboratorium;
fisik;
psikologik;
dan sebagainya.

0 00

Procedures and interventions, not elsewhere classified

1 01-05

Operations on the nervous system

2 06-07

Operations on the endocrine system

3 08-16

Operations on the eye

4 18-20

Operations on the ear

5 21-29

Operations on the nose, mouth, and pharynx

6 30-34

Operations on the respiratory system

7 35-39

Operations on the cardiovascular system

8 40-41

Operations on the hemic and lymphatic system

9 42-54

Operations on the digestive system

10 55-59

Operations on the urinary system

11 60-64

Operations on the male genital organs

12 65-71

Operations on the female genital organs

13 72-75

Obstetrical procedures

14 76-84

Operations on the musculoskeletal system

15 85-86

Operations on the integumentary system

16 87-99

Miscellaneous diagnostic and therapeutic procedures

Chapter I - Operations on the

nervous system (01-05)
(1st
axis)
01

Incision & excision of skull, brain and cerebral

meninges (1st axis)

01.0 Cranial puncture (2nd axis)

01.01

Cisternal puncture (3rd axis)

01.02
Ventriculopuncture thru previously
implanted catheter
(3rd axis)
01.09 Other cranial puncture (3rd axis)

Chapter VI Operations on
the respiratory system (30-34)
(1st axis)
32

Excision of lung and bronchus

(1st axis)

32.0
Local excision or destruction of lesion or tissue
of bronchus
(2nd axis)
32.01 Endoscopic excision or destruction of lesion or
tissue of
bronchus (3rd axis)
32.09 Other local excision or destruction of lesion or
tissue of
bronchus (3rd axis)

Langkah Pengkodean Prosedur

Identifikasi

Konvensi dalam Pengkodean Prosedur

Lead Term:

Menggunakan terminologi
tindakan / kata biasa
contoh: bisa Herniorraphy atau
Repair of Hernia

Konvensi dalam Pengkodean Prosedur

Include
Catatan ini tampil dibawah judul kode 3 digit untuk
mendefinisikan lebih jauh atau untuk memberi
s
contoh dari isi kategori tersebut

81.5 Joint replacement of lower extremity

Includes: arthroplasty of lower
extremity with:

external traction or fixation

graft of bone (chips) or

cartilage

internal fixation device or

prosthesis
Kondisi
yang masuk dalam catatan excludes

Exclude
harus dikode di tempat lain seperti yang
s
ditunjukkan
setiap kasus
81.55 Revisiondalam
of hip replacement

Excludes: arthrodesis of knee (81.22)

Contoh: Appendicitis akut dengan

Appendicectomy
Lead term : Appendicectomy
Alphabetic index : Appendicectomy (with drainage)
47.0
incidental 47.1
Tabular list :
47 Operations on appendix
Includes: appendiceal stump
47.0 Appendectomy
Exclude: incidental
appendectomy,described

laparoscopic (47.11)
other (47.19)
47.1 Incidental appendectomy
47.2 Drainage of appendiceal

Contoh: CRF dengan Hemodialysis

Lead term : Hemodialysis

Alphabetic index: Hemodialysis (extracorporeal) 39.95

Tabular list :

39 Other operations on vessels

39.95 Hemodialysis
Artificial kidney
Hemofiltration
Hemodiafiltration
Renal
dialysis
(54.98)

Excludes: Peritoneal dialysis

Contoh: Lower Segment Cesarean

Section (fetal distress)
Lead term :

Cesarean

Alphabetic index :
74.99

Cesarean section
classical 74.0
fundal 74.0

74.1
Tabular list :
74.0
fetus
section

lower uterine segment

upper uterine
74 Cesarean
sectionsegment
and removal of
74.1 Low cervical cesarean
Lower uterine segment

KONVENSI DALAM PENGKODEAN PROSEDUR

Use

additional code

This instruction is placed in the

Tabular List in those categories

where the user will need to add
further information (by using an
additional code) to give a more
complete picture of the
diagnosis or procedure.

13.1 Intracapsular extraction

of lens
Code

also any synchronous insertion

of pseudophakos (13.71)
13.11 Intracapsular extraction of lens by
temporal inferior route
13.19 Other intracapsular extraction of
lens
Cataract extraction NOS
Cryoextraction of lens
Erysiphake extraction of cataract
Extraction of lens NOS

13.7 Insertion of prosthetic

lens [pseudophakos]
Excludes: implantation of intraocular
telescope prosthesis (13.91)
13.70 Insertion of pseudophakos, not
otherwise specified
13.71 Insertion of intraocular lens prosthesis
at time of cataract extraction, onestage
Code also synchronous extraction of cataract
(13.11-13.69)

13.72 Secondary insertion of intraocular

lens prosthesis

erima kasih