KODING INA CBG'S RITL PURI BUNDA

(haram hukumnya memasukkan kode Z di RITL)  jd klo ada indikasi SC krn HSVB, BOH, primitua sekunder, usia>35th (ya udiin, g usah d masukin)
NO DIAGNOSA (dx) ICD 10 TINDAKAN ICD 9 Keterangan
KASUS OBSTETRIC /KASUS HAMIL-MELAHIRKAN
1. Lahir normal : NP (normal O80.8 Other single SptB/partus fisiologis 73.59 Other manually assisted delivery kaidah koding permenkes :
partus)/partus fisiologis/ spontaneous delivery Normal partus selalu jadi dx sekunder, jika
SptB (spontan brach) ada penyulit lain. KECUALI penyulitnya
adalah ketuban pecah dini/PROM ( ),
maka dx O80.8 jd dx sekunder
2. SC (sectio caesarian) O82.9 Delivery by caesarean 74.1 Low cervical cesarean section SC juga selalu jd dx sekunder jika ada
section, unspecified SCTP penyulit lainnya. Namun jika penyulit/dx
lainya menjadikan grouper lain/aneh
(bukan caesar/gangguan
antepartum/tindakan rahim/adneksa),
maka pindah saja jd dx primer
3. floating head/kepala bayi O32.4 maternal care for high
masih tinggi /U head at term
4. Bekas SC O34.2 Maternal care due to
uterine scar from
previous surgery
CPD O33.8 Maternal care for
disproportion of other
origin
5. pecah ketuban O42.0 Premature rupture of klo prom kc inget permenkes :PROM gak boleh jd dx
(KPD:ketuban pecah membranes, onset of prophylaxis ya.. PRIMER, krn emang nilainya jd tinggi
dini/PROM:premature labour within 24 hours
rupture of membrane)
(liat dr status
UGD/kaber), klo rx px
pecah ketuban sampai
melahirkan krg dari 24
jam pake kode 
6. PROM/pecah ketuban O42.1 Premature rupture of
sampai melahirkan >24 membranes, onset of
jam pake kode ini (lbh labour after 24 hours
tinggi dptnya yg ini
heheee )
 PROM yang dirawat O42.2 Premature rupture of
konservatif, krn masih membranes, labour
belum waktunya delayed by therapy
melahirkan
7. lilitan tali pusat (LLTP) O69.1 Labour and delivery
complicated by cord
around neck, with
compression
8. postdate/post term O48 prolonged pregnancy menaikkan nilai, klo lahirannya normal..klo
(hamil lewat waktu), jika SC g ngaruh..hehe
usia kehamilan ≥41-42
minggu
9. preterm/premature, jika O60.1 preterm with preterm
usia kehamilan labour (jd lahir
<37minggu premature)
10. IUFD (intrauterine fetal O36.4 Maternal care for
death)/ janin meninggal intrauterine death
dlm kandungan
11. IUGR (intrauterine O36.5 Maternal care for poor
growth retardation) fetal growth
12. fetal distress O68.9 Labour and delivery NST patologis 75.34 other fetal monitoring
complicated by fetal
stress, unspecified
13. makrosomia (unusually O33.5 Maternal care for
large baby) : bai besar disproportion due to
>3500g unusually large fetus
15. prolonged kala 1 fs O63.0 prolonged first stage
laten/aktif (kala 1 (of labour)
memanjang)
16. prolonged kala 2 (kala 2 O63.1 prolonged second harus ada bukti partograf!!!
lama/partus kasep) stage (of labour)
17. PER (pre eclampsia O14.9 pre eclampsia, prophylaxis
ringan) unspecified
18. PES (pre eclampsia O14.0 moderate pre prophylaxis (Inj SM
sedang) eclampsia boka-boki)
19. PEB (pre eclampsia berat) O14.1 severe pre eclampsia prophylaxis (inj.SM
boka boki)
Eklampsia (kejang saat O15.0 Eclampsia
 hamil)
SIPE (impending
eclampsia)
20. HT gestasional (tensi O13 Gestational prophylaxis
tinggi saat hamil tnp [pregnancy-induced]
adanya proteinuri +) hypertension without
significant proteinuria
21. HT primer + hamil O10.0 Pre-existing essential
hypertension
complicating
pregnancy, childbirth
and the puerperium
22. high myopi (minus tinggi) H44.2 degenerative myopia
23. gagal OD (gagal induksi O61.0 Failed medical
oxitocyn drip) induction of labour
24. letsu/letak sungsang O32.1 Maternal care for
breech presentation
25. letlin/letak lintang O32.2 Maternal care for
transverse and oblique
lie
26. letak oblique O32.2 Maternal care for
transverse and oblique
lie
Presentasi puncak, muka, O32.3 Maternal care for face,
dahi brow and chin
presentation
Arrest of dilation 1. O64.8 (krn Obstructed labour due
ec......(partus macet/ndak malpresen to other malposition
turun karena.....) tasi) and malpresentation
2. O64.4 Obstructed labour due
(distosia to shoulder
bahu/pres presentation
entasi
bahu)
3. O64.3 Obstructed labour due
(presentas to brow presentation
i puncak)
4. O64.1 Obstructed labour due
 (letsu) to breech presentation
5. O64.2 Obstructed labour due
(presentas to face presentation
i muka)
6. O64.0 Obstructed labour due
(kepala to incomplete rotation
tdk paksi of fetal head
sempurna/
tdk
memutar
sempurna)
Arrest of dilation O62.0 Primary inadequate
contractions
27. oligohidramnion (cairan O41.0 Oligohydramnions
ketuban sedikit)
28. IUD insitu (IUD nya masih O26.3 Retained intrauterine
didalam rahim, saat contraceptive device in
hamil) pregnancy
HPP (hemorage post O72.1 Other immediate
partum)/perdarahan postpartum
habis melahirkan haemorrhage
Late HPP O72.2 Delayed and secondary
postpartum
haemorrhage
PPI usia kehamilan <37 O47.0 False labour before 37
minggu completed weeks of
gestation
PPI usia kehamilan >37 O47.1 False labour at, after
minggu 37 completed weeks of
gestation
Kenceng2 aja O47.2 False labour,
unspecified
Solutio placenta O45.9 Premature separation
of placenta,
unspecified
KASUS GYNECOLOGI / KASUS PENYAKIT KANDUNGAN YANG SERING
28. Cysta N83.2 Other and unspecified cystectomi 65.93 Manual rupture of ovarian cyst
ovarian cysts
 marsupilasi 65.21 Marsupialization of ovarian cyst
Laparascopic 65.23 Laparoscopic marsupialization of
marsupilasi ovarian cyst
31. myoma uteri D25.9 Leiomyoma of uterus, myomectomi 68.29 Other excision or destruction of lesion
unspecified of uterus
SVH (supravaginal 68.49 Other and unspecified total abdominal
hysterectomy) yang hysterectomy
dibedah lewat insisi
abdomen (perut) /
TAH (total abdomen
hysterectomy)
BSO (bilateral 65.61 Other removal of both ovaries and
salpingo- tubes at same operative episode
oophorectomy)

Unilateral SO 65.49
(kanan/Dextra) atau
(kiri/Sinistra)
Bilateral 65.61
salpingectomy
Adheolisis (ovarian 65.89
dan tubal adhesi)
Oopherectomy 65.39
unilateral (satu sisi aja)
Oopherectomy 65.52
bilateral (dua-duanya)
Ovarian biopsi 65.12
Ovarian drilling 65.99
Salpingectomy / 66.4
tubektomi total
Salpingektomi partial 66.69
Tuboplasty / 66.79
Fimbrioplasty
Reseksi wedges of 65.22
ovary (Wedge
resection of ovary)
32. KET (kehamilan ektopik O00.9 Ectopic pregnancy, Salpingectomi With 66.62
terganggu) unspecified remove of tubal
 pregnancy
33. gravida mola / mola O01.9 Hydatidiform mole, Suction / aspirasi 69.59 Other aspiration curettage of uterus
hidatidos unspecified
34. endometriosis N80.0 Curret Kuret 69.09 Other dilation and curettage
35. abortus imminens O20.0 threatened abortion bedrest/konservatif 99.29 Injection or infusion of other
therapeutic or prophylactic substance
36. abortus inkomplit O06.4 incomplete abortion Kuret abortus 69.02 Dilation and curettage following
delivery or abortion
37. BO (blighted ovum) O02.0 Blighted ovum and Kuret 69.09 Other dilation and curettage
nonhydatidiform mole
38. death conceptus O02.1 Missed abortion Kuret 69.02 Dilation and curettage following
delivery or abortion
39. bartholinitis N75.9 Disease of Bartholin's Insisi bartholin 71.22 Incision of Bartholin's gland (cyst)
gland, unspecified
abses bartholin N75.1 Abscess of Bartholin's
gland
Cysta bartholin N75.0 Cyst of Bartholin's
gland
MOW Z30.2 sterilization MOW 66.31 Other bilateral ligation and crushing of
fallopian tubes
LAB
leukositosis pre op/sblm D72.8 Other specified injection antibiotic 99.21 Injection of antibiotic
tindakan disorders of white
blood cells
anaemia (klo Hb <9) D64.9 anaemia, unspecified transfusi PRC 99.04 transfusion packed cell
anaemia (klo Hb >9) O99.0 anaemia in pregnancy

KASUS KONSERVATIF klo ibu yg dirawat karena penyakit infeksi apapun dan dalam keadaan hamil , jangan lupa tambahin kode dx O98.8 Other maternal infectious and parasitic
(ANAK/IBU) diseases complicating pregnancy
40. DHF (dengue A91 Dengue haemorrhagic cairan infus 99.18 Injection or infusion of electrolyt liat labnya : leukosit turun, trombosit
haemorragic fever)/ DBD fever turun, Hb naik, HCT/PCV ngikutin Hb. Atau
(demam berdarah IgM/IgG dengue +
dengue)
41. DD (demam dengue) A90 Dengue fever [classical prophylactic 99.29 Injection or infusion of other
 dengue] therapeutic or prophylactic substance
42. Typhoid fever A01.0 Typhoid fever + Antibiotic 99.21 Injection of antibiotic liat widal, klo + 1/160 bs dimasukin, klo
masih 1/80 g usah…atau IgM/IgG
salmonella +
43. BP (bronchopneumoni) : J18.0 Bronchopneumonia, + Nebul 93.94 Respiratory medication administered by klo bisa ada expertise (hasil bacaan) foto
batuk, sesak, panas pada unspecified nebulizer thorax AP
anak
44. Bronkiolitis J21.9 Acute bronchiolitis,
unspecified
45. OF (observasi febris) / R50.9 fever, unspecified
hyperpirexia
Diare A09 Diarrhoea and
(GEA/Gastroenteritis gastroenteritis of
akut) presumed infectious
origin
46. Muntah2 R11 Nausea & vomiting
Dehidrasi E86 Volume depletion
Intake sulit R63.8 Other symptoms and
signs concerning food
and fluid intake
Kejang demam R56 Febrile convulsions
47. ILO (infeksi luka operasi) O86.0 Infection of obstetric Rawat luka 93.57 Wound dressing
surgical wound
Hiperemesis gravidarum O21.0 Mild hyperemesis
gravidarum
Hiperemesis gravidarum O21.1 Hyperemesis
dg gangguan metabolik gravidarum with
(yg hasil UL nya keton metabolic disturbance
positif)
KASUS BAYI BARU LAHIR
bayi lahir krn SC P03.4 Fetus and newborn general exam 89.7 General physical examination
affected by caesarean
delivery
Inj. Hep B + Vit K 99.55 Prophylactic administration of vaccine
against other diseases
bayi asfiksia ringan (7-10) P21.9 Birth asphyxia,
unspecified
 Asfiksia sedang (4-6) P21.1 Mild and moderate oxygen enrichment 93.96 Other oxygen enrichment
asphyxia
Asfiksia berat (0-3) P21.0 Severe birth asphyxia resusitasi 93.93 Nonmechanical methods of
resuscitation
bayi P59.9 Neonatal jaundice, fototerapi 99.83 Other phototherapy
kuning/jaundice/ikterik unspecified
neonaturum
Bayi berat lahir rendah P07.1 Other low birth weight
(BBLR)

KASUS BEDAH
48. appendisitis akut K35.9 Acute appendicitis, appendektomi 47.09 Other appendectomy
unspecified
49. sirkumsisi / khitan 64.0 Circumcision
50 Abses mammae O91.1 Abscess of breast Insisi abses mammae 85.21 Local excision of lesion of breast
associated with
childbirth
FAM (fibroadenoma N60.2 Fibroadenosis of breast Lokal excisi FAM 85.21 Local excision of lesion of breast
mammae)