LAMPIRAN

BPJS KESEHAT
PENYAKIT

ICP

A. KELOMPOK UMUM
1

Tuberkulosis (TB) Paru

A70

Morbili

A71

Varisela

A72

4
5

Malaria
DBD & DHF

A73
A77

Leptospirosis

A78

Infeksi Pada Umbilikus

A78

8
9
10

Kandidiasis Mulut
Lepra
Keracunan Makanan

A78
A78
A86

11
12

Alergi Makanan
Exanthematous Drug Eruption

A92
S07

13

Fixed Drug Eruption (FDE)

A85

14

Reaksi Anafilaktik

A92

15

Syok

K99

B. DARAH, PEMBENTUKAN DARAH, SISTEM IMUN

1
2

Anemia defisiensi besi

HIV/AIDS tanpa komplikasi

B82
B90

Limfadenitis

L04.9

C. DIGESTIVE
1

Refluks Gastroesofageal

D84

2
3
4
5
6

Gastritis
Intoleransi Makanan
Malabsorbsi Makanan
Demam Tifoid
Gastroenteris (termasuk disentri, kolera dan giardiasis)

D07
D29
D29
D70
D73

PENYAKIT
7
8
9

ICP
D70
S87
D14

11
12
13
14
15
16
17

Disentri Basiler dan Disentri Amuba

Apendisitis Akut
Perdarahan Saluran Makan Bagian Atas
Ulkus gaster
Lesi korosif esofagus
Perdarahan Saluran Makan Bagian Bawah
Divertikulosis/divertikulitis
Hemoroid 1-2
Hemoroid 3-4
Kolitis
Hemoroid Grade 1-2
Hepatitis A
Hepatitis B
Parotitis
Askariasis
Cutaneus Larva Migrans
Penyakit cacing tambang

18

Skistosomiasis

D96

19
20
21
22

Strongiloidiasis
Taeniasis
Peritonitis
Kolesistitis

D96
D96
D99
D98

10

D70

D95
D72
D72
D83
D96
D96
D96

D. MATA
1
2
3

Mata Kering/Dry eye

Buta Senja
Hordeolum

F99
F99
F72

4
5
6

Konjungtivitis infeksi
Konjungtivitis alergi
Blefaritis
Perdarahan Subkonjungtiva

F70
F71
F72
F75

Benda asing di konjungtiva

F76

8
9
10
11
12
13

Astigmatism
Hipermetropia
Miopia Ringan
Presbiopia
Katarak pada Pasien Dewasa
Glaukoma Akut

F91
F91
F91
F91
F92
F93

PENYAKIT

ICP

E. TELINGA
1
2
3

Otitis Eksterna
Otitis Media Akut
Serumen Prop

H70
H71
H81

F. HIDUNG
1

Benda Asing di Hidung

R87

G. KARDIOVASKULAR
1
2

Angina Pektoris
Infark Miokard

K74
K75

Takikardia

K79

K77

Gagal Jantung
Akut
Kronik
Cardiorespiratory Arrest

Hipertensi Esensial

K86

Infark Serebral/Stroke

K90

K80

H. MUSKULOSKELETAL
1
2
3
4
5

Fraktur Terbuka
Fraktur Tertutup
Polimialgia Reumatik
Artritis Reumatoid
Lipoma

L76
L76
L99
L99
S78

I. NEUROLOGI
1
2
3
4
5
6
7
8
9
10

Kejang Demam
Vertigo
Delirium
Tetanus
Rabies
Epilepsi
Status Epileptikus
Migren
Bells` Palsy
Tension Headache

N07
N17
P71
N72
A77
N88
N88
N89
N91
N95

PENYAKIT

ICP

J. PSIKOLOGIS
1

Insomnia

P06

Demensia

P70

3
4

Gangguan Campuran Anxietas dan Depresi

Gangguan Pstikotik

P74
P98

K. RESPIRASI
1
2
3
4
5
6
7
8
9
10
11
12
13

Epistaksis
Furunkel Pada Hidung
Faringitis
Rhinitis Akut
Rhinitis Alergik
Rhinitis Vasomotor
Tonsilitis
Laringitis
Bronkitis Akut
Influenza
Pneumonia Aspirasi
Pneumonia dan Bronkopneumonia
Pertusis

R06
R73
R74
R74
R97

14

Asma Bronkial

R96

R76
R77
R78
R80
R99
R81
R71

L. KULIT
1

Miliaria

S02 S29

Veruka Vulgaris

S03

3
4
5

Reaksi Gigitan Serangga

Herpes Zoster tanpa komplikasi

S12
S70

6
7

Herpes Simpleks tanpa komplikasi

Skabies
Pedikulosis Kapitis

S71
S72
S73

Dermatofitosis

S74

PENYAKIT

ICP

9
10

Pitiriasis versikolor / Tinea versikolor

Pioderma

S76
S84
S76

11
12
13
14

Dermatitis Seboroik
Dermatitis Atopik
Dermatitis Numularis
Liken simpleks kronik (neurodermatis sirkumkripta)

S86
S87
S87
S87

15
16
17
18
19
20

Dermatitis Kontak Alergik (DKA)

Dermatitis Kontak Irirtan
Napkin Eczema (Dermatitis popok)
Pitiriasis Rosea
Moluskum Kontagiosum
Urtikaria

S88
S88
S89
S90
S95
S98

21

Filariasis

S99

22

Luka bakar derajat I dan II

S24

M. METABOLIK ENDOKRIN DAN NUTRISI

1

Obesitas

2
3
4

Tiroktoksikosis
Hiperglikemia Hiperosmolar Non Ketotik
Hipoglikemia

T82
T83
T85
A91
T87

Diabetes Melitus

T89

6
7

Diabetes Melitus
Malnutrisi Energi Protein (MEP)
Hiperuricemia-Gout Arthritis

T90
T91
T99

Dislipidemia

T92
T93

N. SALURAN KEMIH
1

Infeksi Saluran Kemih

O. KESEHATAN WANITA

U71

PENYAKIT
1
2
3
4
5

ICP

Hiperemeis Gravidarum
Kehamilan Normal
Pre-eklampsia
Eklampsi
Abortus komplit

W05
W90
W81
W81
W82

Abortus inkomplit

W82

6
7

Anemia Defisiensi Besi pada Kehamilan

Ketuban Pecah Dini (KPD)

B80
W92

Persalinan lama

Perdarahan Post Partum

W92
W93
W17

10

Ruptur Perineum Tingkat 1-2

W92

11

Mastitis

X21

P. PENYAKIT KELAMIN
1

Flour Albus / Vaginal discharge Non Gonore

Sifilis

Gonore

4
5

Vaginitis
Vulvitis

X14
X71
X72
X73
X92
Y70
X70

X71
Y71
X84
X84

Sumber : PMK No. 5 Th. 2014 tentang Panduan Praktik Klinis bagi Dokter di Faskes Primer

LAMPIRAN PEER MENTORING FKTP

BPJS KESEHATAN CABANG PRABUMULIH
ICPCIP

TCDX

Tuberculosis

A15

Measles

B05.9

Chickenpox

B01.9

Malaria
Viral disease other NOS

B54
A90
A91
A27.9

Infection disease other/NOS

Infectious disease other
Infectious desease other
Infectious disease other/NOS
Toxic Effect Non Medical Substance

A37.9
A30
T.62.2

Allergy / allergic reaction NOS

Rash generalized

L27.0

Adverse effect medical agent

L27.0

Allergy / allergic reaction NOS

Cardiovascular disease other

R57.9

Anaemia other/unspecified
HIV - infection/AIDS

D64.9
Z21

SISTEM IMUN

B70
Oesphagus disease

K21.9

Dyspepsia/indigestion
Digestive syndrome/complaint other
Digestive syndrome/complaint other
Gastrointestinal infection
Gastroenteris presumed infection

K29.7

A01.0
A09

ICPCIP
Gastrointestinal infection
(Appendicitis)
Haematemesis/vomiting blood

TCDX
K.35.9
D15

Gastrointestinal infection

Anal fissure/perianal abscess

Viral Hepatitis
Viral Hepatitis
Mouth/tounge/lip disease
Worms/other parasites
Worms/other parasites
Worms/other parasites

Worms/other parasites
Worms/other parasites
Disease digestive system, other
Cholecystitit/cholelithiasis

K11.2
B77.9
B76.9
B76.0
B76.1
B65.9
B65.2
B78.9
B68.9
K65.9
K81.9

Eye/adnexa disease other

Eye/adnexa disease other
Blepharitis/stye/chalazion

H04.1
H53.5
H00.0

Conjungctivitis infectious
Conjungctivitis allergic
Blepharitis/stye/chalazion
Contusion/haemorrhage eye

H10.9
H10.1
H01.0
H57.8

Foreign body in eye

T15.9

Refractive error
Refractive error
Refractive error
Refractive error
Cataract
Glaucoma

H52.2
H52.0
H52.1
H52.4
H26.9
H40.2

Worms/outer parasite

ICPCIP

TCDX

Otitis eksterna
Acute otitis media/myringitis
Excessive ear wax

H60.9
H66.0
H61.2

Foreign body nose/larynx/bronchus

T17.1

Ischaemic heart disease with angina

Acute Myocardial Infarction

I20.9
I21.9

Paroxysmal Tachicardy

R00.0
I47.1
I47.2
I50.9

Heart failure

Cardiac arrhytmia NOS

Hypertension uncomplicated

I10

Stroke/cerebrovascular accident

I63.9

Fracture other
Fracture other
Musculosceletal disease other
Musculosceletal disease other
Lipoma

T14
T14
M53.3
M53.3
D17.9

Convulsion/Seizure
Vertigo/dizziness
Organic psychosis other
Tetanus
Viral disease other/NOS
Epilepsy
Epilepsy
Migraine
Facial paralysis/Bells` palsy
Tension Headache

R56.0
R42
F05.9
A35
A82.9
G40.9
G41.9
G43.9
G51.0
G44.2

ICPCIP

TCDX

Sleep disturbance

G47.0

Dementia

F03

Anxiety Disorder (anxiety state)

Psychosis NOS/other

F41.2
F20#

Nose bleed/epistaxis
Boil/abscess nose
Upper respiratory infection acute
Upper respiratory infection acute
Allergic rhinitis

R04.0
J34.0
J02.9
J00
J30.0

Tonsilitis Acute
Laryngitis / tracheitis acute
Acute bronckitis / bronchiolitis
Influenza
Respitory disease other
Pneumonia
Whooping cough

J04.0
J20.9
J11
J69.0
J18.9
A37.8

Asthma

J45

Sweat gland disease

L74.3

Warts

B07

Insect bite / sting

Herpes Zoster

T63.4
B02.9

Herpes Simplex
Scabies / other acariasis
Pediculosis / skin infestation other

B00.9
B86
B85.0

Dermatophytosis

B35
B.35.0
B.35.1
B.35.2
B.35.3
B.35.4
B.35.5
B.35.6
B.35.8

ICPCIP

TCDX

Skin infection other

Impetigo
Skin infection other

B.36.0
L01
L02

Dermatitis seborrhoeic
Dermatitis / atopic eczema
Dermatitis / atopic eczema
Dermatitis / atopic eczema

L08.0
L21
L20
L20.8
L28.0

Dermatitis contact / allergic

Dermatitis contact / allergic
Diaper rash
Pityriasis rosea
Molluscum contagiosum
Urticaria
Skin infection other

L23
L24
L22
L42
B08.1
L50
L50.9
B74
B74.0
B74.1
B74.2

Burn / Scald

ISI
Obesity
Overweight
Hipertiroidisme /tirotoksikosis
Abnormal result invetigation NOS
Hypoglycaemia

E66.9

Diabetes insulin dependent

E10

Diabetes non-insulin dependent

Vitamin / nutritional deficiency
Endocrin / metabolic / nutrition al disease other

E11
E46
E79.0

Gout
Lipid disorder

M10
E78.5

Cystitis / urinary infection others

N39.0

E05.9
R73.9
E16.2

i Dokter di Faskes Primer

ICPCIP

TCDX

Pregnancy vomiting / nausea

Uncomplicated labour / delivery livebirth
Toxaemia of pregnancy
Toxaemia of pregnancy
Abortion spontaneous

O21.0
O80.9
O14.9
O15.9
O03.9

Abortion spontaneous

O06.4

Irodeficiency anemia
Complicated labour / delivery livebirth

D50
O42.9

life birth
still birth
Post partum bleeding

O63.9

Complicated labour / delivery livebirth

O70.0

Breast symptom / complaint female other

N61

Vaginal discharge

N98.9

Gonore pada perempuan

Urogenital candidiasis pada perempuan
Tikomoniasis urogenital pada perempuan
Klamidia genital pada perempuan
Syphilis male
Syphilis female

Gonorrhoea female
Gonorrhoea male
Vaginitis
Vagintis / Vulvitis

O72.1

A51
A51.0
A52
A53.9
A54.9
N76.0
N76.0

RING FKTP
RABUMULIH
TCDX

TK

Respiratory tuberculosis, bacteriologiccaly and

histologically confirmed

4A

Meales without complication (Measles NOS)

4A

Varicella without complication (Varicella NOS)

4A

Unspecified malaria
Dengue fever
Dengue haemorrhagic fever

4A
4A
4A
4A

Candidiasis unspecified
Leprosy [Hansen disease]
Other Ingested (parts of plants(s) )

4A
4A
4A

Generalized skin eruption due to drugs and

medicaments

4A

Generalized skin eruption due to drugs and

medicaments

4A
4A

Shock, unspecified

3B

Anaemia, unspecified
Asymptomatic human immunodeficiency virus (HIV)
infection status

4A
4A

Lymphadenitis Acute

4A

Gastro-oesophageal reflux disease without

oesophagitis

4A

Gastritis, unspecified

4A
4A
3A
4A
4A

Typhoid fever
Diarrhoea and gastroenteris of presumed infection
origin

TCDX
( Acute appendicitis )
Melaena

TK
4A
3B
3A
3B

Sialoadenitis
Ascariaris unspecified
Hookworm disease unspecified
Ankylostomiasis
Necatoriasis
Skistosomiasisunspecified
Schistomiasis due to S. japonicum
Strongyloidiasis
Taeniasis
Peritonitis, unspecified
Cholecystitis, unspecified

3A
4A
3A
3A
4A
4A
3A
4A
4A
4A
4A
4A
4A
4A
3B
3B

Other disorders of lacrimal gland

Colour vision deficiencies
Hordeolum and other deep inflammation of eyelid

4A
4A
4A

Conjungctivitis, unspecified
Acute atopic conjunctivitis
Blepharitis
Other specified disorders of eye and adnexa

4A
4A
4A
4A

Foreign body on external eye, part unspecified

4A

Astigmatism
Hypermetropia
Myopia
Presbyopia
Cataract, unspecified
Primary angle-closure glaucoma

4A
4A
4A
4A
4A

TCDX

TK

Otitits Externa, Unspecified

Acute suppurative otitis media
Impacted cerumen

4A
4A
4A

Foreign body in nostril

4A

Angina pectoris, unspecified

Acute Myocardial Infarction, Unspecified

3B
3B

Tachicardy Unspecified
Supraventicular Tachicardy
Ventricular Tachicardy

3B

3B
3A
3B
Essential (primary) hypertension

4A

Cerebral infarction, unspecified

3B

Fracture of unspecified body

Fracture of unspecified body
Polymyalgia rheumatica
Polymyalgia rheumatica
Benign lipomatous neoplasm

3B
3B
3A
3A
4A

Febrile convulsions
Dizziness and giddiness
Delirium, unspecified
Othertetanus
Rabies, unspecified
Epilepsy, unspecified
Status epilepticus, unspecified
Migraine, unspecified
Bells` Palsy
Tension-type headache

4A
4A
3A
4A
3B
3A
3B
4A
4A
4A

TCDX

TK

Disorders of initiating and maintaining sleep

(insomnias)

4A

Unspecified dementia

3A

Mixed Anxiety and Depression Disorder

Chronic Psychonic Disorder

3A
3A

Epistaxis
Abscess, furuncle and carbuncle of nose
Acute pharyngitis, unspecified
Acute nasopharingitis
Vasomotor rhinitis
Acute tonsilitis, unspecified
Acute laryngitis
Acute bronchitis, unspecified
Influenza, virus not identified
Pneumonitis due to food and vomit
Pneumonia, unspecified
Whooping cough, Bordetella bronchiseptica

4A
4A
4A
4A
4A
4A
4A
4A
4A
4A
3B
4A
4A

Asthma

4A

Miliaria, unspecified

4A

Viral warts

4A

Venom of other arthropods

Zoster without complication

4A
4A
4A

Herpesviral infection, unspecified

Scabies
Pediculosis due to Pediculus humanus capitis
Dermatophytosis
Tinea barbae and tinea capitis
Tinea unguium
Tinea manuum
Tinea pedis
Tinea corporis
Tinea imbricate
Tinea cruris
Other dermatophytoses

4A
4A
4A

TCDX

TK

Pityriasis versicolor
Impetigo
Cutaneous abscess, furuncle and carbuncle

4A
4A

Pyoderma
Seborrhoeic dermatitis
Atopic dermatitis
Other atopic dermatitis
Lichen simplex chronicus
Allergic contact dermatitis
Irritant contact dermatitis
Diaper (napkin) dermatitis
Pityriasis rosea
Molluscum contagiosum
Urticaria
Urticaria, unspecified
Filariasis
Filariasis due to Wucheraria bancrofti
Filariasis due to Brugia malayi
Filariasis due to Brugia timori

4A
4A
4A
3A
3A
4A
4A
4A
4A
akut 4A
Kronis 3A

4A

4A
Obesity unspecfied
Tirotoksikosis unspecified
Hyperglycaemia unspecified
Hypoglicaemia unspecified
Insulin-dependent diabetes melitus
Non-Insulin-dependent diabetes melitus
Unspecified protein-energy malnutrition
Hyperuricemia without signs of inflammatory
arthritis and tophaceous disease

3A
3B
ringan 4A,
berat 3B
tipe 1/2 4A, tipe
lain 3A
4A
4A

Gout
Hiperlipidemia

4A

Urinary tract infection , site not specified

4A

TCDX

TK

Mild hyperemesis gravidarum

Single spontaneous delivery unspecified
Pre-eclampsia, unspecified
Eclampsia, unspecified as to time period
Unspecified abortion, complete, without comlication

3B
4A
3B
3B
4A

Unspecified abortion, incomplete, without

comlication

3B

Iron deficiency anaemia

Premature rupture of membrance, unspecified

4A
3A

long labour

3B

Other Immediate Postpartum haemorrhage

3B

First degree perineal laceration during delivery

4A

Inflammatory disorders of breast

4A
4A

Early syphilis
Primary genital syphilis
Late syphilis
Syphilis, unspecified
Gonococcal infection, unspecified

3A

Acute Vaginitis
Acute Vaginitis

4A
4A

4A