Tata Cara Pengisian ICD

1. ICD ditulis dengan huruf cetak setelah tindakan/ resume pasien keluar dari VK dan IGD
2. Lembar rangkuman pulang wajib diisi lengkap H-1 pasien pulang.
3. Dokter Penanggung Jawab Pelayanan wajib menandatangani di lembar rangkuman, tindakan dan laporan
tindakan saat H-1.
4. Untuk kasus campuran (mixed case). kode ICD dapat ditanyakan /dilaporkan langsung ke dokter residen stase
medrek atau konsulen penanggung jawab Medical Record.
5. Urutan pengisian ICD:
a. Maternal condition
b. Methods of delivery
c. Outcome

2
Partus Spontan (LOS 1 hari)

Diagnosa Utama : O80.0 Spontaneous vertex delivery

Diagnosa Sekunder : Z37.0 Single live birth

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 73.6 Episiotomy

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring

INA-CBG : O-6-13-I PERSALINAN VAGINAL (RINGAN)

LOS = Length of Stay (Lama hari rawat)

3
 Augmentasi drip (LOS 1 hari)

Diagnosa Utama : O62.1 Secondary uterine inertia

Diagnosa Sekunder : Z37.0 Single live birth
O80.0 Spontaneous vertex delivery

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
75.34 Other fetal monitoring
73.6 Episiotomy
73.01 Induction of labor by artificial rupture of
membranes

INA-CBG : O-6-12-I PERSALINAN VAGINAL DENGAN

PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET (RINGAN)

LOS = Length of Stay (Lama hari rawat)

4
Misoprostol (LOS 1 hari)

Diagnosa Utama : O62.2 Other uterine inertia

Diagnosa Sekunder : O80.0 Spontaneous vertex delivery
Z37.0 Single live birth

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 73.4 Medical induction of labor

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.6 Episiotomy
73.01 Induction of labor by artificial rupture of
membranes

INA-CBG : O-6-12-I PERSALINAN VAGINAL DENGAN

PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET (RINGAN)

LOS = Length of Stay (Lama hari rawat)

5
Spontan Bracht (LOS 1 hari)

Diagnosa Utama : O62.2 Other uterine inertia

Diagnosa Sekunder : O80.1 Spontaneous breech delivery
Z37.0 Single live birth

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
75.34 Other fetal monitoring
73.4 Medical induction of labor
73.01 Induction of labor by artificial rupture of
membranes

INA-CBG : O-6-12-I PERSALINAN VAGINAL DENGAN

PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET (RINGAN)

LOS = Length of Stay (Lama hari rawat)

6
Spontan Gemeli (LOS 1 hari)

Diagnosa Utama : O84.0 Multiple delivery, all spontaneous

Diagnosa Sekunder : Z37.2 Twins, both liveborn
O30.0 Twin pregnancy

Tindakan utama : 73.59 Manually Assisted delivery

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.01 Induction of labor by artificial rupture of
membranes
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-13-II PERSALINAN VAGINAL (SEDANG)

LOS = Length of Stay (Lama hari rawat)

7
Spontan Preterm (LOS 1 hari)

Diagnosa Utama : O60.1 Preterm labour with preterm delivery

Diagnosa Sekunder : O80.0 Spontaneous vertex delivery
Z37.0 Single live birth

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.01 Induction of labor by artificial rupture of
membranes
73.6 Episiotomy
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-12-I PERSALINAN VAGINAL DENGAN

PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET (RINGAN)

8
Spontan KPD (LOS 1 hari)

Diagnosa Utama : Z37.0 Single live birth

Diagnosa Sekunder : O80.0 Spontaneous vertex delivery
O42.9 Premature rupture of membranes,
unspecified

Tindakan utama : 73.59 Manually assisted delivery

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.01 Induction of labor by artificial rupture of
membranes
99.29 Injection or infusion of other therapeutic
or prophylactic substance
99.21 Injection of antibiotic
73.6 Episiotomy

INA-CBG : Z-4-12-II FAKTOR-FAKTOR YANG

MEMPENGARUHI STATUS KESEHATAN
LAIN-LAIN (SEDANG)

9
Sungsang Manual aid (LOS 1 hari)

Diagnosa Utama : O83.1 Other assisted breech delivery

Diagnosa Sekunder : Z37.0 Single live birth
O32.1 Maternal care for breech presentation
O62.2 Other uterine inertia

Tindakan utama : 72.52 Other partial breech extraction

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.01 Induction of labor by artificial rupture of
membranes
73.6 Episiotomy

INA-CBG : O-6-13-I PERSALINAN VAGINAL (RINGAN)

LOS = Length of Stay (Lama hari rawat)

10
Forceps kala II Lama Gawat janin (LOS 1 hari)

Diagnosa Utama : O63.1 Prolonged second stage of labour

Diagnosa Sekunder : P03.2 Fetus and newborn affected by forceps
delivery
Z37.0 Single live birth
O68.9 Labour and delivery complicated by fetal
stress, unspecified

Tindakan utama : 72.1 Low forceps operation with episiotomy

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
73.01 Induction of labor by artificial rupture of
membranes
73.6 Episiotomy

INA-CBG : O-6-13-I PERSALINAN VAGINAL (RINGAN)

11
Shoulder dystocia (LOS 1 hari)

Diagnosa Utama : O66.0 Prolonged second stage of labour

Diagnosa Sekunder : Z37.0 Single live birth

Tindakan utama : 73.59 Other manually assisted delivery

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring

INA-CBG : O-6-13-I PERSALINAN VAGINAL (RINGAN)

LOS = Length of Stay (Lama hari rawat)

12
Vakum Kala II Lama Gawat Janin (LOS 1 hari)

Diagnosa Utama : O63.1 Prolonged second stage of labour

Diagnosa Sekunder : Z37.0 Single live birth
O68.9 Labour and delivery complicated by fetal
stress, unspecified
O81.4 Vacuum extractor delivery

Tindakan utama : 72.71 Vacuum extraction with episiotomy

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring

INA-CBG : O-6-12-I PERSALINAN VAGINAL DENGAN

PROSEDUR SELAIN STERILISASI &/
DILATASI &KURET (RINGAN)

LOS = Length of Stay (Lama hari rawat)

13
Forceps PEB (LOS 1 hari)

Diagnosa Utama : O14.1 Severe pre-eclampsia

Diagnosa Sekunder : P03.2 Fetus and newborn affected by forceps
delivery
Z37.0 Single live birth
O81.4 Vacuum extractor delivery

Tindakan utama : 72.1 Low forceps operation with episiotomy

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring
73.6 Episiotomy
72.71 Vacuum extraction with episiotomy
57.94 Insertion of indwelling urinary catheter
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-13-II PERSALINAN VAGINAL (SEDANG)

LOS = Length of Stay (Lama hari rawat)

Forceps Superimposed PEB (LOS 2 hari)

14
 Diagnosa Utama : O10.0 Pre-existing essential hypertension
complicating pregnancy, childbirth and
the puerperium
Diagnosa Sekunder : O14.1 Severe pre-eclampsia
Z37.0 Single live birth

Tindakan utama : 72.1 Low forceps operation with

episiotomy
Tindakan tambahan : 99.18 Injection or infusion of
electrolytes
75.34 Other fetal monitoring
73.6 Episiotomy
57.94 Insertion of indwelling urinary
catheter
99.29 Injection or infusion of other
therapeutic or prophylactic
substance

INA-CBG : O-6-13-II PERSALINAN VAGINAL

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

Forceps PEB Edema Paru (LOS 2 hari)

15
 Diagnosa Utama : O99.5 Diseases of the respiratory system
complicating pregnancy, childbirth and
the puerperium
Diagnosa Sekunder : J81 Pulmonary oedema
O14.1 Severe pre-eclampsia
P03.2 Fetus and newborn affected by forceps
delivery
Z37.0 Single live birth

Tindakan utama : 72.1 Low forceps operation with episiotomy

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring
73.6 Episiotomy
57.94 Insertion of indwelling urinary catheter
99.29 Injection or infusion of other therapeutic
or prophylactic substance
89.68 Monitoring of cardiac output by other
technique

INA-CBG : O-6-13-II PERSALINAN VAGINAL (SEDANG)

LOS = Length of Stay (Lama hari rawat)

Forceps PEB Cardiomiopati (LOS 2 hari)

16
 Diagnosa Utama : O99.4 Diseases of the circulatory system
complicating pregnancy, childbirth and the
puerperium
Diagnosa Sekunder : I42.0 Dilated cardiomyopathy
O14.1 Severe pre-eclampsia
Z37.0 Single live birth
O81.0 Low forceps delivery

Tindakan utama : 72.1 Low forceps operation with episiotomy

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
99.29 Injection or infusion of other therapeutic
or prophylactic substance
89.68 Monitoring of cardiac output by other
technique

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

SC Sungsang Cord Prolaps (LOS 3 hari)

17
 Diagnosa Utama : O82.1 Delivery by emergency caesarean section
Diagnosa Sekunder : O69.0 Labour and delivery complicated by
prolapse of cord
O32.1 Maternal care for breech presentation
Z37.0 Single live birth

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
75.34 Other fetal monitoring
99.21 Injection of antibiotic

INA-CBG : O-6-10-I OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

18
SC KPD Gawat Janin (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean section

Diagnosa Sekunder : Z37.0 Single live birth
O42.0 Premature rupture of membranes, onset
of labour within 24 hours
P01.1 Fetus and newborn affected by premature
rupture of membranes
P20.1 Intrauterine hypoxia first noted during
labour and delivery

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

SC Gemeli (LOS 3 hari)

19
 Diagnosa Utama : O82.1 Delivery by emergency caesarean section
Diagnosa Sekunder : O30.0 Twin pregnancy
O42.0 Premature rupture of membranes, onset
of labour within 24 hours
P01.1 Fetus and newborn affected by premature
rupture of membranes
P20.1 Intrauterine hypoxia first noted during
labour and delivery

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic or
prophylactic substance

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

SC PEB (LOS 3 hari)

20
 Diagnosa Utama : O15.0 Eclampsia in pregnancy
Diagnosa Sekunder : O14.1 Severe pre-eclampsia
Z37.0 Single live birth

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary
catheter
90.59 Microscopic examination of blood,
Other microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other
therapeutic or prophylactic
substance

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

21
SC PEB Gawat Janin (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean section

Diagnosa Sekunder : Z37.0 Single live birth
O42.0 Premature rupture of membranes, onset
of labour within 24 hours
P01.1 Fetus and newborn affected by premature
rupture of membranes
P20.1 Intrauterine hypoxia first noted during
labour and delivery

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

22
SC PEB Gawat Janin (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean section

Diagnosa Sekunder : Z37.0 Single live birth
O42.0 Premature rupture of membranes, onset
of labour within 24 hours
P01.1 Fetus and newborn affected by premature
rupture of membranes
P20.1 Intrauterine hypoxia first noted during
labour and delivery

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

23
SC PEB Solutio Placenta (LOS 3 hari)

Diagnosa Utama : O45.0 Premature separation of placenta with

coagulation defect
Diagnosa Sekunder : O14.1 Severe pre-eclampsia
O82.0 Delivery by elective caesarean section
Z37.0 Single live birth

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance
88.79 Other diagnostic ultrasound

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

24
SC PEB Edema Paru (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean section

Diagnosa Sekunder : O99.5 Diseases of the respiratory system
complicating pregnancy, childbirth and the
puerperium
J81 Pulmonary oedema
O14.1 Severe pre-eclampsia
O68.8 Labour and delivery complicated by other
evidence of fetal stress
Z37.0 Single live birth

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
75.34 Other fetal monitoring
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance
88.68 Monitoring of cardiac output by other
technique

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

SC PEB Cardiomiopati (LOS 3 hari)

25
 Diagnosa Utama : O82.1 Delivery by emergency caesarean section
Diagnosa Sekunder : O99.4 Diseases of the circulatory system
complicating pregnancy, childbirth and the
puerperium
I42.0 Dilated cardiomyopathy
O14.1 Severe pre-eclampsia
Z37.0 Single live birth

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
99.21 Injection of antibiotic
99.29 Injection or infusion of other therapeutic
or prophylactic substance
88.68 Monitoring of cardiac output by other
technique

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

SC Bekas SC Inersia uteri (LOS 3 hari)

26
 Diagnosa Utama : O82.1 Delivery by emergency caesarean section
Diagnosa Sekunder : Z37.0 Single live birth
O34.2 Maternal care due to uterine scar from
previous surgery
O62.1 Secondary uterine inertia

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
75.34 Other fetal monitoring
99.21 Injection of antibiotic

INA-CBG : O-6-10-I OPERASI PEMBEDAHAN CAESAR

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

27
SC Placenta Previa Totalis (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean section

Diagnosa Sekunder : Z37.0 Single live birth
O46.9 Antepartum haemorrhage, unspecified
O44.0 Placenta praevia specified as without
haemorrhage

Tindakan utama : 74.1 Low cervical cesarean section

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
75.34 Other fetal monitoring
99.21 Injection of antibiotic

INA-CBG : O-6-10-II OPERASI PEMBEDAHAN CAESAR

(SEDANG)

LOS = Length of Stay (Lama hari rawat)

28
SC Atonia Histerektomi (LOS 3 hari)

Diagnosa Utama : O82.2 Delivery by caesarean hysterectomy

Diagnosa Sekunder : O62.1 Secondary uterine inertia
Z37.0 Single live birth

Tindakan utama : 68.39 Other and unspecified subtotal abdominal

hysterectomy
Tindakan tambahan : 99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
74.1 Low cervical cesarean section
99.21 Injection of antibiotic
75.34 Other fetal monitoring

INA-CBG : W-1-20-II PROSEDUR PADA RAHIM &

ADNEKSA (SEDANG)

LOS = Length of Stay (Lama hari rawat)

29
SC Atonia B-Lynch Suture (LOS 3 hari)

Diagnosa Utama : O82.1 Delivery by emergency caesarean

section
Diagnosa Sekunder : O62.1 Secondary uterine inertia
Z37.0 Single live birth

Tindakan utama : 75.52 Repair of current obstetric laceration of

corpus uteri
Tindakan tambahan : 74.1 Low cervical cesarean section
99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
75.34 Other fetal monitoring

INA-CBG : W-1-20-II PROSEDUR PADA RAHIM &

ADNEKSA (SEDANG)

30
SC Placenta Akreta Histerektomi (LOS 3 hari)

Diagnosa Utama : O82.2 Delivery by caesarean hysterectomy

Diagnosa Sekunder : O43.2 Morbidly adherent placenta
Z37.0 Single live birth

Tindakan utama : 68.9 Other and unspecified hysterectomy

Tindakan tambahan : 74.1 Low cervical cesarean section

99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
75.34 Other fetal monitoring

INA-CBG : W-1-20-II PROSEDUR PADA RAHIM &

ADNEKSA (SEDANG)

31
SC Placenta Akreta Histerektomi (LOS 3 hari)

Diagnosa Utama : O82.2 Delivery by caesarean hysterectomy

Diagnosa Sekunder : O43.2 Morbidly adherent placenta
Z37.0 Single live birth

Tindakan utama : 68.9 Other and unspecified hysterectomy

Tindakan tambahan : 74.1 Low cervical cesarean section

99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
75.34 Other fetal monitoring

INA-CBG : W-1-20-II PROSEDUR PADA RAHIM &

ADNEKSA (SEDANG)

LOS = Length of Stay (Lama hari rawat)

32
Kuretase Sisa Placenta (LOS 1 hari)

Diagnosa Utama : O72.2 Delayed and secondary postpartum

haemorrhage
Diagnosa Sekunder : O73.0 Retained placenta without haemorrhage

Tindakan utama : 69.02 Dilation and curettage following delivery

or abortion
Tindakan tambahan : 99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
99.08 Transfusion of blood expander

INA-CBG : W-1-10-II PROSEDUR ABORSI (SEDANG)

LOS = Length of Stay (Lama hari rawat)

33
Abortus Incomplete (LOS 1 hari)

Diagnosa Utama : O03.4 Spontaneous abortion, incomplete, without

complication
Diagnosa Sekunder :

Tindakan utama : 69.02 Dilation and curettage following

delivery or abortion
Tindakan tambahan : 99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood,
Other microscopic examination
88.79 Other diagnostic ultrasound

INA-CBG : W-1-10-II PROSEDUR ABORSI (SEDANG)

LOS = Length of Stay (Lama hari rawat)

34
Kuretase Mola hidatidosa (LOS 1 hari)

Diagnosa Utama : O01.9 Hydatidiform mole, unspecified

Diagnosa Sekunder :

Tindakan utama : 69.09 Other dilation and curettage of uterus

Tindakan tambahan : 99.21 Injection of antibiotic

99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary
catheter
90.59 Microscopic examination of blood,
Other microscopic examination
88.79 Other diagnostic ultrasound
99.08 Transfusion of blood expander

INA-CBG : W-1a-11-II PROSEDUR DILATASI, KURET,

INTRAUTERIN & SERVIK
(SEDANG)

35
Kuretase PA (DUB) (LOS 1 hari)

Diagnosa Utama : N93.8 Other specified abnormal uterine and

vaginal bleeding
Diagnosa Sekunder :

Tindakan utama : 69.09 Other dilation and curettage of uterus

Tindakan tambahan : 99.21 Injection of antibiotic

99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary
catheter
90.59 Microscopic examination of blood,
Other microscopic examination
88.79 Other diagnostic ultrasound

INA-CBG : W-1-11-I PROSEDUR DILATASI, KURET,

INTRAUTERIN & SERVIK
(RINGAN)

36
Kuretase PA (Mioma) (LOS 1 hari)

Diagnosa Utama : D25.9 Leiomyoma of uterus, unspecified

Diagnosa Sekunder :

Tindakan utama : 69.09 Other dilation and curettage of

uterus
Tindakan tambahan : 99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary
catheter
90.59 Microscopic examination of blood,
Other microscopic examination
88.79 Other diagnostic ultrasound

INA-CBG : W-1-11-I PROSEDUR DILATASI, KURET,

INTRAUTERIN & SERVIK
(RINGAN)

LOS = Length of Stay (Lama hari rawat)

37
Konservatif Abortus Eminen (LOS 2 hari)

Diagnosa Utama : O20.0 Threatened abortion

Diagnosa Sekunder :

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic
substance
Tindakan tambahan : 99.18 Injection or infusion of electrolytes
88.78 Diagnostic ultrasound of gravid
uterus

INA-CBG : W-4-14-I ABORTUS MENGANCAM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

38
Konservatif Hyperemesis Gravidarum (LOS 2 hari)

Diagnosa Utama : O21.1 Hyperemesis gravidarum with

metabolic disturbance
Diagnosa Sekunder :

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic
substance
Tindakan tambahan : 99.18 Injection or infusion of electrolytes
88.78 Diagnostic ultrasound of gravid
uterus

INA-CBG : W-4-16-I GANGGUAN ANTEPARTUM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

39
Konservatif PEB (LOS 2 hari)

Diagnosa Utama : O14.1 Severe pre-eclampsia

Diagnosa Sekunder :

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic substance
Tindakan tambahan : 75.34 Other fetal monitoring
88.78 Diagnostic ultrasound of gravid uterus
99.18 Injection or infusion of electrolytes

INA-CBG : W-4-16-I GANGGUAN ANTEPARTUM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

40
Konservatif Superimposed PEB (LOS 2 hari)

Diagnosa Utama : O10.0 Pre-existing essential hypertension

complicating pregnancy, childbirth
and the puerperium
Diagnosa Sekunder : O14.1 Severe pre-eclampsia

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic substance
Tindakan tambahan : 75.34 Other fetal monitoring
88.78 Diagnostic ultrasound of gravid uterus
99.18 Injection or infusion of electrolytes

INA-CBG : W-4-16-I GANGGUAN ANTEPARTUM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

41
Konservatif Placenta Previa (LOS 2 hari)

Diagnosa Utama : O46.9 Antepartum haemorrhage, unspecified

Diagnosa Sekunder : O44.0 Placenta praevia specified as without
haemorrhage

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic substance
Tindakan tambahan : 75.34 Other fetal monitoring
88.78 Diagnostic ultrasound of gravid uterus
99.18 Injection or infusion of electrolytes

INA-CBG : W-4-16-I GANGGUAN ANTEPARTUM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

42
Konservatif Ketuban Pecah Dini (LOS 2 hari)

Diagnosa Utama : O42.9 Premature rupture of membranes,

unspecified
Diagnosa Sekunder :

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic
substance
Tindakan tambahan : 99.21 Injection of antibiotic
88.78 Diagnostic ultrasound of gravid
uterus
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring

INA-CBG : W-4-16-I GANGGUAN ANTEPARTUM

(RINGAN)

LOS = Length of Stay (Lama hari rawat)

43
Konservatif Prematur Kontraksi (LOS 2 hari)

Diagnosa Utama : O60.0 Preterm labour without delivery

Diagnosa Sekunder :

Tindakan utama : 99.29 Injection or infusion of other

therapeutic or prophylactic
substance
Tindakan tambahan : 88.78 Diagnostic ultrasound of gravid
uterus
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring

INA-CBG : W-4-15-I PERSALINAN PALSU (RINGAN)

LOS = Length of Stay (Lama hari rawat)

44
UROGINEKOLOGI

45
Abses Bartholin Rawat Jalan

Diagnosa Utama : N75.1 Abscess of Bartholin's gland

Diagnosa Sekunder :

Tindakan utama : 71.23 Marsupialization of Bartholin's gland

(cyst)
Tindakan tambahan : 99.18 Injection or infusion of electrolytes
99.21 Injection of antibiotic

INA-CBG : W-2-33-0 PROSEDUR KECIL VULVOVAGINAL

46
Adhesi Labia

Diagnosa Utama : Q52.5 Fusion of labia

Diagnosa Sekunder : R33 Retention of urine
N99.2 Postoperative adhesions of vagina

Tindakan utama : 71.01 Lysis of vulvar adhesions

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

99.21 Injection of antibiotic

INA-CBG : W-1-30-II PROSEDUR PADA VAGINA, SERVIK

& VULVA (SEDANG)

47
MRKH

Diagnosa Utama : Q51.0 Agenesis and aplasia of uterus

Diagnosa Sekunder :

Tindakan utama : 70.62 Vaginal reconstruction

Tindakan tambahan : 99.21 Injection of antibiotic

99.18 Injection or infusion of electrolytes

INA-CBG : W-1-30-I PROSEDUR PADA VAGINA, SERVIK

& VULVA (RINGAN)

48
Prolaps Uteri Rectokel Sistokel

Diagnosa Utama : N81.2 Incomplete uterovaginal prolapse

Diagnosa Sekunder : N81.6 Rectocele
N81.1 Cystocele

Tindakan utama : 68.59 Other and unspecified vaginal hysterectomy

Tindakan tambahan : 70.54 Repair of cystocele with graft or prosthesis

99.18 Injection or infusion of electrolytes
99.21 Injection of antibiotic

INA-CBG : W-1-30-I PROSEDUR PADA VAGINA, SERVIK &

VULVA (RINGAN)

49
Rektovaginal Fistule

Diagnosa Utama : N82.4 Other female intestinal-genital tract

fistulae
Diagnosa Sekunder :

Tindakan utama : 99.21 Injection of antibiotic

Tindakan tambahan : 99.18 Injection or infusion of electrolytes

70.73 Repair of rectovaginal fistula

INA-CBG : K-1-50-I PROSEDUR ANAL (RINGAN)

50
Inkontinensia Alvi

Diagnosa Utama : R15 Faecal incontinence

Diagnosa Sekunder :

Prosedur : 49.79 Other repair of anal sphincter

71.79 Other repair of vulva and perineum
99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes

INA-CBG : W-1-30-I PROSEDUR PADA VAGINA, SERVIK

& VULVA (RINGAN)

51
Ruptur perineum gr 4

Diagnosa Utama : O70.3 Fourth degree perineal laceration during

delivery
Diagnosa Sekunder :

Tindakan utama : 75.62 Repair of current obstetric laceration of

rectum and sphincter ani
Tindakan tambahan : 99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes

INA-CBG : W-4-17-I GANGGUAN POSTPARTUM

(RINGAN)

52
Vesicovaginal Fistula

Diagnosa Utama : N82.0 Vesicovaginal fistula

Diagnosa Sekunder :

Tindakan utama : 57.84 Repair of other fistula of bladder

Tindakan tambahan : 99.21 Injection of antibiotic

99.18 Injection or infusion of electrolytes

INA-CBG : N-1-11-I PROSEDUR KANDUNG KEMIH

KOMPLEK (RINGAN)

53
GINEKOLOGI

54
Endometriosis dengan salpingoovarektomi
Diagnosa Utama : N80.1 Endometriosis of ovary
Diagnosa Sekunder :

Tindakan utama : 65.61 Other removal of both ovaries and tubes

at same operative episode
Tindakan tambahan : 90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter

INA-CBG : W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA

(RINGAN)

55
Kista ovarium dengan salpingoovarektomi
Diagnosa Utama : N80.1 Endometriosis of ovary
Diagnosa Sekunder :

Tindakan utama : 90.59 Microscopic examination of blood, Other

microscopic examination
Tindakan tambahan : 99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
88.79 Other diagnostic ultrasound
65.61 Other removal of both ovaries and tubes
at same operative episode

INA-CBG : W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA

(RINGAN)

56
Mioma dengan histerektomi totalis salpingoovarektomi bilateral
Diagnosa Utama : D25.1 Intramural leiomyoma of uterus
Diagnosa Sekunder : N80.1 Endometriosis of ovary

Tindakan utama : 68.49 Other and unspecified total abdominal

hysterectomy
Tindakan tambahan : 65.61 Other removal of both ovaries and tubes
at same operative episode
90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
99.21 Injection of antibiotic

INA-CBG : W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA

(RINGAN)

57
Rupture perineum grade III

Diagnosa Utama : O70.2 Third degree perineal laceration during

delivery
Diagnosa Sekunder : O80.0 Spontaneous vertex delivery
Z37.0 Single live birth

Tindakan utama : 73.59 Other manually assisted delivery

Tindakan tambahan : 73.4 Medical induction of labor

90.59 Microscopic examination of blood, Other
microscopic examination
99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
75.34 Other fetal monitoring
71.79 Other repair of vulva and perineum

INA-CBG : W-1-30-I PROSEDUR PADA VAGINA, SERVIK &

VULVA (RINGAN)

58
Total vagina histerektomi
Diagnosa Utama : N81.3 Complete uterovaginal prolapse
Diagnosa Sekunder :

Tindakan utama : 68.59 Other and unspecified vaginal

hysterectomy
Tindakan tambahan : 70.50 Repair of cystocele and rectocele
99.21 Injection of antibiotic
99.18 Injection or infusion of electrolytes
57.94 Insertion of indwelling urinary catheter
90.59 Microscopic examination of blood, Other
microscopic examination

INA-CBG : W-1-30-I PROSEDUR PADA VAGINA, SERVIK &

VULVA (RINGAN)

59
Karsinoma servik dengan kemoterapi;haemodialisis
Diagnosa Utama : Z51.1 Chemotherapy session for neoplasm
Malignant neoplasm, cervix uteri,
Diagnosa Sekunder : C53.9
unspecified
D63.0 Anaemia in neoplastic disease
N18.3 Chronic kidney disease, stage 3

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 99.21 Injection of antibiotic
90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes
39.95 Hemodialysis

INA-CBG : C-4-13-II KEMOTERAPI (SEDANG)

60
Servik dengan kemoterapi; anemia

Diagnosa Utama : Z51.1 Chemotherapy session for neoplasm

Malignant neoplasm, cervix uteri,
Diagnosa Sekunder : C53.9
unspecified
D63.0 Anaemia in neoplastic disease

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 99.21 Injection of antibiotic
90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes

INA-CBG : C-4-13-II KEMOTERAPI (SEDANG)

61
Servik dengan histerektomi; radikal

Diagnosa Utama : C53.9 Malignant neoplasm, cervix uteri,

unspecified
Diagnosa Sekunder :

Tindakan utama : 57.94 Insertion of indwelling urinary catheter

Tindakan tambahan : 99.21 Injection of antibiotic

90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes
68.69 Other and unspecified radical abdominal
hysterectomy

INA-CBG : W-1-20-I PROSEDUR PADA RAHIM & ADNEKSA

(RINGAN)

62
Kemoterapi revisi
Diagnosa Utama : Z51.1 Chemotherapy session for neoplasm
Diagnosa Sekunder : C56 Malignant neoplasm of ovary

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 99.21 Injection of antibiotic
90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes

INA-CBG : C-4-13-I KEMOTERAPI (RINGAN)

63
Karsinoma ovarium dengan kemoterapi
Diagnosa Utama :
C56 Malignant neoplasm of ovary
Diagnosa Sekunder : Z51.1 Chemotherapy session for neoplasm

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 99.21 Injection of antibiotic
90.59 Microscopic examination of blood, Other
microscopic examination
99.18 Injection or infusion of electrolytes

INA-CBG : W-4-10-II TUMOR SISTEM REPRODUKSI WANITA

(SEDANG)

64
Karsinoma ovarium dengan HTSOB
Diagnosa Utama :
C56 Malignant neoplasm of ovary
Diagnosa Sekunder :

Tindakan utama : 99.21 Injection of antibiotic

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
99.18 Injection or infusion of electrolytes
68.49 Other and unspecified total abdominal
hysterectomy
65.61 Other removal of both ovaries and tubes
at same operative episode

INA-CBG : W-1-20-I PROSEDUR PADA RAHIM &

ADNEKSA (RINGAN)

65
Tumor trophoblastic gestasional dengan kemoterapi
Diagnosa Utama : Z51.1 Chemotherapy session for neoplasm
Diagnosa Sekunder : C58 Malignant neoplasm of placenta

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 90.59 Microscopic examination of blood, Other
microscopic examination
57.94 Insertion of indwelling urinary catheter
99.18 Injection or infusion of electrolytes

INA-CBG : C-4-13-I KEMOTERAPI (RINGAN)

66
Tumor trophoblastic gestasional anemia
Diagnosa Utama : Z51.1 Chemotherapy session for neoplasm
Diagnosa Sekunder : C58 Malignant neoplasm of placenta
O99.0 Anaemia complicating pregnancy,
childbirth and the puerperium

Tindakan utama : 99.25 Injection or infusion of cancer

chemotherapeutic substance
Tindakan tambahan : 99.21 Injection of antibiotic
90.59 Microscopic examination of blood, Other
microscopic examination
57.94 Insertion of indwelling urinary catheter
99.18 Injection or infusion of electrolytes
99.08 Transfusion of blood expander

INA-CBG : C-4-13-II KEMOTERAPI (SEDANG)

67
Molahidatidosa
Diagnosa Utama : O01.9 Hydatidiform mole, unspecified
Diagnosa Sekunder :

Tindakan utama : 99.21 Injection of antibiotic

Tindakan tambahan : 57.94 Insertion of indwelling urinary catheter

99.18 Injection or infusion of electrolytes
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
69.01 Dilation and curettage for termination of
pregnancy

INA-CBG : W-1-10-I PROSEDUR ABORSI (RINGAN)

68
Molahidatidosa dengan kelainan tiroid
Diagnosa Utama : O01.9 Hydatidiform mole, unspecified
Diagnosa Sekunder : O99.2 Endocrine, nutritional metabolic diseases
complicating pregnancy, childbirth and
the puerperium

Tindakan utama : 99.21 Injection of antibiotic

Tindakan tambahan : 57.94 Insertion of indwelling urinary catheter

99.18 Injection or infusion of electrolytes
90.59 Microscopic examination of blood, Other
microscopic examination
88.79 Other diagnostic ultrasound
69.01 Dilation and curettage for termination of
pregnancy

INA-CBG : W-1-10-II PROSEDUR ABORSI (SEDANG)

69
POLIKLINIK

70
Pemeriksaan Antenatal
Diagnosa Utama : Z36.9 Antenatal screening, unspecified
Diagnosa Sekunder :

Tindakan utama : 88.78 Diagnostic ultrasound of gravid uterus

Tindakan tambahan : 75.34 Other fetal monitoring

INA-CBG : Z-3-25-0 PROSEDUR ULTRASOUND

GINEKOLOGIK

71
Pemeriksaan Antenatal dengan Komplikasi
Diagnosa Utama : Z36.9 Antenatal screening, unspecified
Diagnosa Sekunder : Z 35.9 Supervision of high-risk pregnancy,
unspecified

Tindakan utama : 88.78 Diagnostic ultrasound of gravid uterus

Tindakan tambahan : 90.59 Microscopic examination of blood

75.34 Other fetal monitoring

INA-CBG : Z-3-25-0 PROSEDUR ULTRASOUND

GINEKOLOGIK

72
Wound care Pasca Seksio Sesarea

Diagnosa Utama : O90.0 Disruption of caesarean section wound

Diagnosa Sekunder : N80.1 -

Tindakan utama : 91.79 Microscopic examination of specimen

from operative wound
Tindakan tambahan : 93.57 Application of other wound dressing

INA-CBG : Z-3-27-0 PERAWATAN LUKA

73
Amniocentesis
Diagnosa Utama : Z36.0 Antenatal screening for chromosomal
abnormalities
Diagnosa Sekunder : -

Tindakan utama : 75.1 Diagnostic amniocentesis

Tindakan tambahan : 88.78 Diagnostic ultrasound of gravid uterus

INA-CBG : W-2-34-0 PROSEDUR GINEKOLOGI LAIN-

LAIN

74
Amnioinfusion
Diagnosa Utama : O41.8 Other specified disorders of amniotic
fluid and membranes
Diagnosa Sekunder :

Tindakan utama : 75.37 Amnioinfusion

Tindakan tambahan : 75.34 Other fetal monitoring

88.78 Diagnostic ultrasound of gravid uterus

INA-CBG : Z-3-25-0 PROSEDUR ULTRASOUND

GINEKOLOGIK

75
Karsinoma servik
Diagnosa Utama : C53.9 Malignant neoplasm, cervix uteri,
unspecified
Diagnosa Sekunder :

Tindakan utama : 67.11 Endocervical biopsy

Tindakan tambahan : 89.26 Gynecological examination

INA-CBG : W-2-34-0 PROSEDUR GINEKOLOGI LAIN-

LAIN

76
Karsinoma ovarium
Diagnosa Utama : C56 Malignant neoplasm of ovary
Diagnosa Sekunder :

Tindakan utama : 89.26 Gynecological examination

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
88.79 Other diagnostic ultrasound

INA-CBG : Z-3-23-0 PROSEDUR ULTRASOUND LAIN-LAIN

77
Kista ovarium
Diagnosa Utama : D27 Benign neoplasm of ovary
Diagnosa Sekunder :

Tindakan utama : 89.26 Gynecological examination

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
88.79 Other diagnostic ultrasound

INA-CBG : Z-3-23-0 PROSEDUR ULTRASOUND LAIN-LAIN

78
Injeksi Tapros
Diagnosa Utama : N80.1 Endometriosis of ovary
Diagnosa Sekunder :

Tindakan utama : 99.25 Injection or infusion of other theurapeutic

or prophylactic substance
Tindakan tambahan :

INA-CBG : Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN

79
Pemeriksaan Duh Tubuh

Diagnosa Utama :
N76.2 Acute vulvitis
Vulvovaginal ulceration and
Diagnosa Sekunder :
N77.8 inflammation in other disease classified
elsewhere

Tindakan utama : 91.49 Microscopic examination of specimen

from genital tract
Tindakan tambahan : 89.26 Gynecological examination

INA-CBG : Q-5-42-0 PENYAKIT AKUT KECIL LAIN-LAIN

80
Prolaps Uteri; Cystocele; Rectocele

Diagnosa Utama :
N81.2 Incomplete uterovaginal prolapse
Diagnosa Sekunder : N81.1 Cystocele
N 81.6 Recocele

Tindakan utama : 89.26 Gynecological examination

Tindakan tambahan : 90.59 Microscopic examination of blood, Other

microscopic examination
91.46 Microscopic examination of specimen
from female genital tract, cell block and
papanicolaou smear

INA-CBG : Q-5-44-0 PENYAKIT KRONIS KECIL LAIN-LAIN

81