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LAMPIRAN KESEPAKATAN

DAFTAR NAMA DIAGNOSA PENYAKIT YANG DAPAT TUNTAS DI PUSKESMAS

No. Nama Diagnosa Nama ICD X Kode ICD X

1 Alergi makanan Dermatitis due to ingested food L.27.2

2 Anemia defisiensi pada kehamilan Iron deficiency anaemia D.50

3 Askariasis Ascariaris unspecified B.77.9

4 Asma Bronkial Asthma J.45

5 Bell's Palsy Bells’ palsy G.51.0

6 Benda Asing di Hidung Foreign body in nostril T.17.1

Foreign body on external eye, part


7 Benda Asing di konjungtiva T.15.9
unspecified

8 Blefaritis Blepharitis H.01.0

9 Bronkitis Akut Acute bronchitis, unspecified J.20.9

10 cutaneus larva migran Hookworm disease, unspecified B.76.9

Typhoid fever
11 Demam Tifoid A.01.0

12 Dermatitis atopik (kecuali recalcitrant) Atopic dermatitis L.20

13 Dermatitis kontak iritan Irritant contact dermatitis L.24

Other atopic dermatitis


14 Dermatitis numularis L.20.8

Seborrhoeic dermatitis
15 Dermatitis seboroik L.21

Tinea barbae and tinea capitis


16 Tinea kapitis B.35.0

17 Tinea barbe Tinea barbae and tinea capitis B.35.0

18 Tinea Imbricate Other dermatophytoses B.35.8


No. Nama Diagnosa Nama ICD X Kode ICD X

Tinea corporis
19 Tinea Korporis B.35.4

20 Tinea manum Tinea manuum B.35.2

21 Tinea unguium Tinea unguium B.35.1

Tinea cruris
22 Tinea kruris B.35.6

Tinea pedis
23 Tinea pedis B.35.3

Non-insulin-dependent diabetes mellitus


24 Diabetes mellitus tipe 2 E.11

25 Disentri basiler, disentri amuba Acute amoebic dysentery A.06.0

26 Dislipidemia Hiperlipidemia E.78.5

27 Epistaksis Epistaxis R.04.0

28 Exanthematous drug eruption, fixed drug Generalized skin eruption due to drugs and L.27.0
eruption medicament

Acute pharyngitis, unspecified


29 Faringitis J.02.9

30 Filariasis Filariasis B.74

31 Furunkel pada hidung Abscess, furuncle and carbuncle of nose J.34.0

Gastritis, unspecified
32 Gastritis K.29.7

Diarrhoea and gastroenteritis of presumed A.09


33 Gastroenteritis ( termasuk kolera, giardiasis ) infection origin

34 Gonorhoe Gonococcal infection, unspecified A.54.9

35 Hemoroid grade 1/2 Haemorrhoids I.84

36 Herpes Simpleks tanpa komplikasi Herpesviral infection, unspecified B.09

37 Herpes Zooster tanpa komplikasi Zoster without complication B.02.9

38 Hipermetropia ringan Hypermetropia H.52.0


No. Nama Diagnosa Nama ICD X Kode ICD X

39 Hipertensi essensial Essential (primary) hypertension I.10

40 Hiperurisemia ( Gout ) Gout M.10

hypoglycaemia unspecified
41 Hipoglikemia ringan E.16.2

Hordeolum and other deep inflammation of H.00.0


42 Hordeolum eyelid

Omphalitis of newborn with or without


43 Infeksi pada umbilikus P.38
mild haemorrhage

44 Infeksi saluran kemih Urinary tract infection, site not specified N.39.0

45 Influenza Influenza, virus not identified J.11

46 Insomnia Insomnia non organik pada psikiatri F.51

47 Intoleransi makanan Malabsorption due to intolerance K.90.4

48 Kandidiasis mulut Candidiasis unspecified B.37.9

49 Kehamilan normal Single spontaneous delivery, unspecified O.80.9

50 Kejang Demam Febrile convulsions R.56.0

51 Konjungtivitis Conjunctivitis, unspecified H.10.9

52 Laringitis Acute laryngitis J.04.0

Leprosy [Hansen disease]


53 Lepra A.30

54 Leptospirosis (tanpa komplikasi) Leptospirosis, unspecified A.27.9

55 Limfadenitis Lymphadenitis Acute B.70

56 Lipoma Benign lipomatous neoplasm D.17.9

burn and corrosion, body region


57 Luka bakar derajat 1 dan 2 T.30
unspecified

58 Malnutrisi energi-protein Unspecified protein-energy malnutrition E.46


No. Nama Diagnosa Nama ICD X Kode ICD X

59 Mastitis Inflammatory disorders of breast N.61

Migraine, unspecified
60 Migren G.34.9

61 Miliaria Miliaria, unspecified L.74.3

62 Miopia ringan Myopia H.52.1

63 Moluskum kontagiosum Molluscum contagiosum B.08.1

Measles without complication (Measles


64 Morbili tanpa komplikasi B.05.9
NOS).

Diaper (napkin) dermatitis


65 Napkin eczema L.22

Otitis externa, unspecified


66 Otitis eksterna H.60.9

67 Otitis media akut Acute serous otitis media H.65.0

68 Parotitis Mumps B.29

69 Penyakit cacing tambang Ankylostomiasis B.76.0

Other specified disorders of eye and adnexa


70 Perdarahan sub konjungtiva H.57.8

71 Pertusis *tidak ditemukan Panduan Klinis di KMK

72 Ptiriasis rosea L.42

73 Ptiriasis vasikolor Pityriasis versicolor B.36.0

74 Pneumonia, bronkopneumonia Bronchopneumonia, unspecified J.18.0

75 Reaksi anafilatik Anaphylactic shock, unspecified T.78.2

76 Reaksi gigitan serangga Venom of other arthropods T.63.4

Gastro-oesophageal reflux disease without K.21.9


77 Refluks gastroesofageal oesophagitis

78 Rhinitis akut Acute nasopharyngitis (common cold) J.00


No. Nama Diagnosa Nama ICD X Kode ICD X

79 Rhinitis alergika Allergic rhinitis, unspecified J.30.4

80 Rhinitis Vasomotor Vasomotor rhinitis J.30.0

First degree perineal laceration during


81 Ruptur perineum tingkat 1-2 O.70.0
delivery

82 Serumen prop Impacted cerumen H.61.2

83 Skabies Scabies B.86

84 Skistosomiasis Skistosomiasis unspecified B.65.9

85 Strongiloidiasis Strongyloidiasis B.78.9

86 Taeniasis Taeniasis B.68.9

87 Tension Headache Tension–type headache G.44.2

88 Tonsilitis Acute tonsillitis J.03

Respiratory tuberkulosis, bacteriologically


89 Tuberkulosis paru tanpa komplikasi A.15
and histologically confirmed

90 Urtikaria ( akut & kronis ) Urticaria L.50

91 Vaginitis Acute Vaginitis N.76.0

Varicella without complication (Varicella


92 Varisela tanpa komplikasi NOS) B.01.9

93 Vertigo (benign paroxymal positional vertigo) Dizziness and giddiness R.42

94 Veruka vulgaris Viral warts B.07

95 Vulvitis Acute Vaginitis N.76.0

Somatoform disorders
96 Gangguan somatoform F.45

97 Episkleritis Episcleritis H.15.1


No. Nama Diagnosa Nama ICD X Kode ICD X

98 Mabuk Perjalanan *tidak ditemukan Panduan Klinis di KMK

99 Ulkus mulut (aptosa, herpes) Stomatitis and related lesions K.12

Acute tubulo-interstitial nephritis


100 Pielonefritis tanpa komplikasi N.10
(applicable to: acute pyelonephritis)

101 Sindrom duh (discharge) genital (gonore dan Complication associated with artificial N.98.9
non gonore) fertilization, unspecified

Urinary tract infection, site not specified


102 Infeksi saluran kemih bagian bawah N.39.0

103 Vaginosis bakterialis Acute Vaginitis N.76.0

104 Salpingitis *tidak ditemukan Panduan Klinis di KMK

105 Abses Folikel rambut atau kelenjar sebasea *tidak ditemukan Panduan Klinis di KMK
Cracked nipple associated with the
puerperium; Cracked nipple associated with O.92.13
106 cracked nipple lactation
Retracted nipple associated with the
puerperium; Retracted nipple associated
107 Inverted nipple O.92.02
with
lactation
108 Defisiensi Vitamin *tidak ditemukan Panduan Klinis di KMK

Iron Deficiency Anemias


109 Anemia defisiensi besi

Varicose veins of lower extremities with


110 Ulkus pada tungkai ulcer; Ulcer of lower limb, notelsewhere L.97
classified

111 Sifilis stadium 1 dan 2 *tidak ditemukan Panduan Klinis di KMK

112 Impetigo Impetigo L.01

113 Impetigo ulseratif (ektima) Impetigo L.02

114 Folikulitis superfisialis Pioderma L.08.0

115 Furunkel, karbunkel Cutaneous abscess, furuncle and carbuncle L.02

116 Eritrasma Erythrasmay L.08.1

117 Eriseplas Erysipelas A.46


No. Nama Diagnosa Nama ICD X Kode ICD X

Tuberculosis of skin and subcutaneous


118 Skrofuloderma A.18.4
tissue

119 Kandidiosis mukokutan ringan Candidiasis unspecified B.37.9

Pthiriasis
120 Pedikulosis pubis B.85.3

121 Akne vulgaris ringan Acne vulgaris L.70.0

122 Hidradenitis supuratif Hidradenitis suppurativa L.73.2

123 Dermatitis perioral Perioral dermatitis L.71.0

124 Vulnus laseratum, punctum Open wound of unspecified body region T.14.1

125 Kekerasan tumpul *tidak ditemukan Panduan Klinis di KMK

126 kekerasan tajam *tidak ditemukan Panduan Klinis di KMK


TAS DI PUSKESMAS

Keterangan

penanganan awal

tergantung letak benda asing dan pasien


kooperatif

tergantung letak benda asing dan pasien


kooperatif

Kendala lab widal harus di FKRTL


Keterangan

puskesmas klinik IMS, tapi pemeriksaan


Lab tdk masuk ke dalam kapitasi
Keterangan

2 minggu tidak ada perubahan rujuk

Kejang Demam Sederhana

berdasarkan lokasi dan ukuran


Keterangan

2 minggu tidak ada perubahan rujuk

penanganan awal
Keterangan

pada pasien yang kooperatif

2 minggu tidak ada perubahan rujuk

obat tersedia, tapi utk Cek dahak BTA dan


foto thoraks (tdk masuk dalam kapitasi)

jumlah maksimal 2
Keterangan

puskesmas klinik IMS, tapi pemeriksaan


Lab tdk masuk ke dalam kapitasi

Hanya vit B1, C, Bcomplex, Vit A


Keterangan

lokasi dan komplikasi

kedalaman sd jaringan subkutan, luas,


dan lokasi
LAMPIRAN KESEPAKATAN

DAFTAR NAMA DIAGNOSA PENYAKIT YANG DAPAT TUNTAS DI FKTP SWASTA

No. Nama Diagnosa Nama ICD X Kode ICD X

1 Alergi makanan Dermatitis due to ingested food L27.2

2 Anemia defisiensi besi pada kehamilan Iron deficiency anaemia D50

3 Askariasis Ascariaris unspecified B77.9

4 Asma Bronkial Asthma J45

5 Benda asing di hidung Foreign body in nostril T17.1

6 Blefaritis Blepharitis H01.0

7 Bronkitis akut Acute bronchitis, unspecified J20.9

8 Cutaneus larva migran Hookworm disease, unspecified B76.9

Typhoid fever
9 Demam tifoid A01.0

10 Dermatitis atopik (kecuali recalcitrant) Atopic dermatitis L20

11 Dermatitis kontak iritan Irritant contact dermatitis L24

Other atopic dermatitis


12 Dermatitis numularis L20.8

Seborrhoeic dermatitis
13 Dermatitis seboroik L21

Tinea barbae and tinea capitis


14 Tinea kapitis B35.0

15 Tinea barbae Tinea barbae and tinea capitis B35.0

16 Tinea Imbricate Tinea Imbricate B35.5

Tinea corporis
17 Tinea korporis B35.4

18 Tinea manum Tinea manuum B35.2


No. Nama Diagnosa Nama ICD X Kode ICD X

19 Tinea unguium Tinea unguium B35.1

Tinea cruris
20 Tinea kruris B35.6

Tinea pedis
21 Tinea pedis B35.3

22 Diabetes melitus tipe 1 Diabetes insulin dependent T89

Non-insulin-dependent diabetes mellitus


23 Diabetes melitus tipe 2 E11

24 Disentri basiler dan amuba Acute amoebic dysentery A06.0

25 Epistaksis Epistaxis R04.0

Acute pharyngitis, unspecified


26 Faringitis J02.9

27 Furunkel pada hidung Abscess, furuncle and carbuncle of nose J34.0

Gastritis, unspecified
28 Gastritis K29.7

Diarrhoea and gastroenteritis of presumed A09


29 Gastroenteritis (termasuk kolera, giardiasis) infection origin

30 Gonore Gonococcal infection, unspecified A54.9

31 Hemoroid grade 1-2 Haemorrhoids I84

32 Herpes simpleks tanpa komplikasi Herpesviral infection, unspecified B009

33 Herpes zoster tanpa komplikasi Zoster without complication B02.9

Essential (primary) hypertension


34 Hipertensi esensial I10

35 Hiperuricemia (Gout) Gout M10

hypoglycaemia unspecified
36 Hipoglikemia ringan E16.2

Hordeolum and other deep inflammation of H00.0


37 Hordeolum eyelid

Omphalitis of newborn with or without


38 Infeksi pada umbilikus P38
mild haemorrhage
No. Nama Diagnosa Nama ICD X Kode ICD X

39 Infeksi saluran kemih Urinary tract infection, site not specified N39.0

40 Influenza Influenza, virus not identified J11

41 Insomnia Insomnia non organik pada psikiatri F51

42 Intoleransi makanan Malabsorption due to intolerance K90.4

43 Kandidiasis mulut Candidiasis unspecified B37.9

44 Kehamilan normal Single spontaneous delivery, unspecified O80.9

45 Konjungtivitis Conjunctivitis, unspecified H10.9

46 Laringitis Acute laryngitis J04.0

47 Limfadenitis Lymphadenitis Acute B70

burn and corrosion, body region


48 Luka bakar derajat 1 dan 2 T30
unspecified

49 Mastitis Inflammatory disorders of breast N61

50 Mata kering Otherdisorders of lacrimal gland H04.1

Migraine, unspecified
51 Migren G43.9

52 Miliaria Miliaria, unspecified L74.3

Measles without complication (Measles


53 Morbili tanpa komplikasi B05.9
NOS).

Diaper (napkin) dermatitis


54 Napkin eczema L22

Otitis externa, unspecified


55 Otitis eksterna H60.9

56 Otitis media akut Acute serous otitis media H65.0

57 Parotitis Mumps B26

Pediculosis due to Pediculus humanus


58 Pedikulosis kapitis capitis B85.0
No. Nama Diagnosa Nama ICD X Kode ICD X

59 Penyakit cacing tambang Ankylostomiasis B76.0

60 Pertusis *tidak ditemukan Panduan Klinis di KMK

61 Pitiriasis rosea L42

62 Pitiriasis versikolor Pityriasis versicolor B36.0

63 Pneumonia, bronkopneumonia Bronchopneumonia, unspecified J18.0

64 Reaksi gigitan serangga Venom of other arthropods T63.4

Gastro-oesophageal reflux disease without K21.9


65 Refluks gastroesofageal oesophagitis

66 Rhinitis akut Acute nasopharyngitis (common cold) J00

67 Rhinitis alergika Allergic rhinitis, unspecified J30.4

68 Rhinitis vasomotor Vasomotor rhinitis J30.0

First degree perineal laceration during


69 Ruptur perineum tingkat 1-2 O70.0
delivery

70 Serumen prop Impacted cerumen H61.2

71 Skabies Scabies B86

72 Skistosomiasis Skistosomiasis unspecified B65.9

73 Strongiloidiasis Strongyloidiasis B78.9

74 Taeniasis Taeniasis B68.9

75 Tension headache Tension–type headache G44.2

76 Tonsilitis Acute tonsillitis J03

77 Urtikaria (akut & kronis) Urticaria L50

78 Vaginitis Acute Vaginitis N76.0


No. Nama Diagnosa Nama ICD X Kode ICD X

Varicella without complication (Varicella


79 Varisela tanpa komplikasi NOS) B01.9

80 Vertigo (Benign paroxysmal positional vertigo) Dizziness and giddiness R42

81 Vulvitis Acute Vaginitis N76.0

Somatoform disorders
82 Gangguan somatoform F45

83 Mabuk perjalanan *tidak ditemukan Panduan Klinis di KMK

84 Ulkus mulut (aptosa, herpes) Stomatitis and related lesions K12

Urinary tract infection, site not specified


85 Infeksi saluran kemih bagian bawah N39.0

86 Vaginosis bakterialis Acute Vaginitis N76.0

87 Abses folikel rambut atau kelenjar sebasea *tidak ditemukan Panduan Klinis di KMK

Cracked nipple associated with the


puerperium; Cracked nipple associated with O9212;
88 Cracked nipple lactation O9213
Retracted nipple associated with the
puerperium; Retracted nipple associated O92.02;
89 Inverted nipple with O92.03
lactation

90 Defisiensi vitamin *tidak ditemukan Panduan Klinis di KMK

Iron Deficiency Anemias


91 Anemia defisiensi besi 280

Varicose veins of lower extremities with


92 Ulkus pada tungkai ulcer; Ulcer of lower limb, notelsewhere I83.0; L97
classified

93 Impetigo Impetigo L01

94 Impetigo ulseratif (ektima) Impetigo L02

95 Folikulitis superfisialis Pioderma L08.0

96 Furunkel, karbunkel Cutaneous abscess, furuncle and carbuncle L02

97 Eritrasma Erythrasmay L08.1


No. Nama Diagnosa Nama ICD X Kode ICD X

98 Erisipelas Erysipelas A46

99 Kandidosis mukokutan ringan Candidiasis unspecified B37.9

Pthiriasis
100 Pedikulosis pubis B85.3

101 Akne vulgaris ringan Acne vulgaris L70.0

102 Hidradenitis supuratif Hidradenitis suppurativa L73.2

103 Dermatitis perioral Perioral dermatitis L71.0

104 Vulnus laseratum, punctum Open wound of unspecified body region T14.1

105 Kekerasan tumpul *tidak ditemukan Panduan Klinis di KMK

106 Kekerasan tajam *tidak ditemukan Panduan Klinis di KMK

107 Bell's Palsy Bells’ palsy G51.0

108 Lipoma Benign lipomatous neoplasm D17.9

Other specified disorders of eye and adnexa H57.8


109 Perdarahan subkonjungtiva

110 Veruka vulgaris Viral warts B07

111 Defisiensi mineral *tidak ditemukan Panduan Klinis di KMK


TAS DI FKTP SWASTA

Keterangan

Tergantung Letak Benda asing dan Pasien


Kooperatif

Kendala Lab Widal harus di FKRTL


Keterangan
Keterangan

2 Minggu Tidak Ada Perubahan Rujuk

Tergantung Luas

2 Minggu Tidak Ada Perubahan Rujuk


Keterangan

Pada Pasien yang Kooperatif

2 Minggu Tidak Ada Perubahan Rujuk


Keterangan
Keterangan

Harus Ada Permintaan Visum dari


Kepolisian

Harus Ada Permintaan Visum dari


Kepolisian

Ringan, Lokasi selain Danger Area &


Ukuran Maks 5 CM

Jumlah Maksimal Satu, Lokasi Non Danger


Area