Daftar Diag Dan Tindakan

FORMULIR RENCANA PASIEN PULANG
Penyakit : Anak Ruang : INA DRG

No RM : Kelas :
Nama : Tgl Masuk :
Jenis Kelamin : Tgl Keluar :
Tanggal Lahir : Cara Pulang : Sehat / Meninggal / Dirujuk / P. paksa
Dx Utama :
Dx Sekunder :
Operasi :
Tind. Penunjang :
No. Diagnosis ICD X No Prosedur ICD IXCM

1 Thypoid Abdominal A01.0 1 Microscopic examination of blood 90.59
2 Diare Dan Gastroenteritis Yang Diduga Berasal Dari/colitis A09 2 Examination physical 89.7
3 TBC PARU A15 3 Injection or infusion of electrolyts 99.18
4 Kp (tuberkulosis Sistem Napas Ytt, Konfirmasi Tidak Di A16.9 4 Injection of antibiotic 99.21
5 PERTUSIS A37 5 Oxygen terapy 93.96
6 Typhus, Fever (demam Typhus) A75.9 6 Consultation specified type 89.08
7 Demam berdarah dengue (DHF) A91 7 USG Abdomen 88.76
8 VARICELLA B01 8 X ray of bronchus, heart, lung, trachea 87.49
9 MORBILI B05 9 Scan Thorax 87.41
10 PAROTITIS B26 10 Other diagnostic ultasound multiple sites 88.79
11 CANDIDIASIS B37 11 Consultation on a single organ sistem 89.06
12 Moniliasis(candidiasis, Unspecified) B37.9 12 Transfusion of packed cells 99.04
13 Hemofilia/defisiensi Faktor Viii Herediter D66 13 Transfusion of thrombocytes 99.05
14 EPILEPSI G40 14 Injection anti invective 99.22
15 CONJUNCTIVITIS H10 15 Biopsi nasopharinx 29.12
16 Serumen impak H61.2 16 EKG 89.15
17 LIMFADENITIS AKUT, KRONIK NON SPESISFIK I88 17
18 Lymphadenitis, Unspecified I88.9 18
19 Rhinopharyngitis/rhinitis Alergika/common Cold/rhinitis Ac J00 19
20 Pharyngitis J02 20
21 Acute pharyngitis due to other specified organisms J02.8
22 Pharyngitis Acute, Unspecified J02.9
23 TONSILITIS ACUTE J03
24 Tonsillitis,(acute)(follicular)(gangrenous),unspecified J03.9
25 Tonsilo Pharingitis J06.8
26 Ispa J06.9
27 BRONCHO PNEMONI J18
28 Bronchiolitis(acute)(infective)(sub Acute) J21.9
29 Rhinitis Allergica, Unspecified J30.4
30 RHINITIS KRONIC J31
31 Rhinitis J31.0
32 Bronkitis, tidak dirinci sebagai akut atau kronis J40
33 BRONKITIS, EMFISEMA DAN PENYAKIT PARU OBS J41
34 ASMA BRONCHIALE J45
35 Asma / Asthma, Unspecified J45.9
36 Stomatitis (denture) (ulcerative) K12.1
37 Gastritis K29.7
38 Dispepsia K30
39 HERNIA INGUINALIS K40
40 GASTROENTERITIS DAN COLITIS NON INFEKSI K52
41 Obstipasi K59.0
42 HEPATITIS K73
43 ABSES L02
44 Furuncle/carbuncle L02.9
45 PYODERMIA L08
46 Dermatitis Kontak/alergi, Unspecified Cause L23.9
47 Dermatitis L30.9
48 URTICARIA L50
49 Miliaria, unspecified L74.3
50 NEFROTIK SYNDROMA N04
51 Isk/ Urinary Tract Infection, Site Not Specified N39.0
52 Phymosis.paraphymosis Dan Prepisisum Berlebihan N47
53 ICTERUS NEONATORUM P59
54 Epistaxis R04.0
55 Cegukan/cough R05
56 ABDOMINAL PAIN R10
57 Vomiting R11
58 Febris/hiperpirexia R50
59 Kejang Demam R50.0
60 Febris/fever, Unspecified R50.9
61 ANOREXIA R63
62 Test Mantoux/abnormal Reaction To Tuberculin Test R76.1
63 CONTUSIO MUSCULORUM T14
64 ALERGI REACTION T78
Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :
Perawat :
Catatan : Apabila ada diagnosis dan prosedur selain yang ada di atas, agar ditambahkan
Sub bid Rekam Medis

Penyakit : Anak Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :
DIAG ICD IX TIND

No. Diagnosis ICD X No Prosedur
U S K CM O P
1 Acute pharyngitis J02.8 1 Ambil darah 38.21
2 ALL (Acute lymfoblastik leukemia) C91.0 2 Circumsisi female 71.4
3 Circumsisi male 64
3 Ascites R18 4 Consultation on a single organ sistem 89.06
4 ASD (atrial septal defect) Q21.1 5 Consultation specified type 89.08
5 ASMA BRONCHIALE J45 6 CT Scan kepala 87.03
6 Bronchiolitis(acute)(infective)(sub Acute) J21.9 7 EKG 89.15
7 BRONCHO PNEMONI J18 8 Examination physical 89.7
8 CONJUNCTIVITIS H10 9 Exchange Transfusion 99.01
10 Herniotomy 53.00
9 Dehidrasi E86 11 Injection of antibiotic 99.21
10 Demam berdarah dengue (DHF) A91 12 Injection of steroid NEC 03.92
11 Diare Dan Gastroenteritis A09 13 Injection or infusion of electrolyts 99.18
12 Diare kronik K52.9 14 Injection terapeutic agent NEC 99.2
13 DIFTERI LARING A36.2 15 Intubation nasogastric (decompression) 96.07
14 DIFTERI NASAL A36.8 16 Intubation nasogastric (feeding) 96.6
15 DIFTERI NASO PHARING A36.1 17 Laboratory physical, general 89.7
16 DIFTERI TONSIL / FARING A36.0 18 Microscopic examination of blood 90.59
19 Nebulizer 93.94
17 Dispepsia K30 20 Other diagnostic USG multiple sites 88.79
18 EPILEPSI G40 21 Oxygen terapy 93.96
22 Pasang Infus 99.18
19 Gizi kurang E44.1 23 Rehabilitation programs 93.89
24 Suctioning 31.44
20 Glumerulo nefritis akut N00 25 Transfusion of antihemophilic factor 99.06
21 Hemofilia/defisiensi Faktor Viii Herediter D66 26 Transfusion of plasma 99.07
22 HEPATITIS K73 27 Transfusion of PRC (packed red cells) 99.04
23 Hepatitis akut K72.0 28 Transfusion of thrombocytes 99.05
24 HIV, AIDS B24 29 Transfusion of whole blood (NOS) 99.03
25 Isk/ Urinary Tract Infection N39.0 30 USG Abdomen 88.76
26 Kejang Demam R50.0 31 X ray of bronchus, heart, lung, trachea 87.49
27 Kwashiorchor E40 32 X ray of Thorax 87.41
28 LIMFADENITIS AKUT, KRONIK NON S I88 33
29 LIMFADENITIS TB A18.2
30 Marasmic E41
31 Marasmic kwashiorchor E42
32 Meningitis Bakterial G00.9
33 Meningitis TB A17.0+601*
34 Meningitis Virus A87.9
35 Meningoensefalitis G04.2
36 Moniliasis(candidiasis, Unspecified) B37.9
37 MORBILI B05
38 NEFROTIK SYNDROMA N04
39 Obesitas E66.9
40 Obstipasi K59.0
41 PAROTITIS B26
42 Parotitis/mump B26.9
43 PDA (patent ductus arteriosus) Q25.0
44 PERTUSIS A37
45 Pharyngitis J02
46 Pharyngitis Acute, Unspecified J02.9
47 Phymosis and paraphymosis N47
48 Pleura efusi J90
49 RHEUMATIC FEVER I00
50 Rheumatic Heart Disease I09
51 Rhinitis Allergica, Unspecified J30.4
52 Rhinopharyngitis/rhinitis Alergika/common J00
53 SLE (Systems Lupus Erythema) M32.9
55 TBC PARU A15
56 Test Mantoux/abnormal Reaction To Tuberc R76.1
57 TETANUS A35
58 Tetralogi of fallot Q21.3
60 Tonsillitis,(acute)(follicular)(gangrenous),u J03.9
62 Typhus, Fever (demam Typhus) A75.9
63 VARICELLA B01
64 VSD (ventricle septal defect) Q21.0
Perawat :
ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

TIND = O : Tindakan Operasi, P : Tindakan Penunjang
Sub bid Rekam Medis (15 Oktober 2008)

Penyakit : Neonatus Ruang : INA DRG :

No RM : Kelas :
Nama : Tgl Masuk :
BB LAHIR :
DIAG ICD IX TIND
No. Diagnosis ICD X No Prosedur O P
U S K CM
1 Acidosis metabolic P74.0 1 Consultation on a single organ sistem 89.06
2 Acidosis respiratoric E87.2 2 Consultation specified type 89.08
3 Anemia of diabetic mother P70.0 3 CT Scan kepala 87.03
4 Anemia of prematurity P61.2 4 EKG 89.15
5 Apneic spell P28.2 5 Examination physical 89.7
6 Apneu of prematurity P28.4 6 Exchange Transfusion 99.01
7 Asfiksia berat P21.0 7 Injection of antibiotic 99.21
8 Asfiksia sedang P21.1 8 Injection of steroid NEC 03.92
9 Aspiration pneumonia P24.3 9 Injection or infusion of electrolyts 99.18
10 atelectasis P28.0 10 Injection terapeutic agent NEC 99.2
11 Aterm Z38.0 11 Intubation nasogastric (decompression) 96.07
12 BBLR : weight low(1000gr-2499gr) P07.1 12 Intubation nasogastric (feeding) 96.6
13 BBLR :Extremely (999gr or less) P07.0 13 Laboratory physical, general 89.7
14 BMK (other heavy for gestational age) P08.1 14 Microscopic examination of blood 90.59
15 Bronchopneumonia J18.0 15 Nebulizer 93.94
16 convulsi R56.8 16 Other diagnostic USG multiple sites 88.79
17 Dehidrasi E86 17 Oxygen terapy 93.96
Diare Dan Gastroenteritis A09 Perawatan tali pusat 79.9
18 Edema cerebri G93.6 18 Photo terapy of newborn 99.83
19 Exceptionally large baby (>4500gr) P08.0 19 Rehabilitation programs 93.89
20 Gemelli Z38.3 20 RJP 99.60
21 hemorhagic disease of the newborn P53 21 Transfusion of antihemophilic factor 99.06
22 Hypocalamia P71.0 22 Transfusion of plasma 99.07
23 Hypoglycemia P70.4 23 Transfusion of PRC (packed red cells) 99.04
24 Hypokalemia E87.6 24 Transfusion of thrombocytes 99.05
25 Hyponatremia E87.1 25 Transfusion of whole blood (NOS) 99.03
26 Icern icterus P57.9 26 USG Abdomen 88.76
27 Icterus ABO in compa P59.2 27 X ray of bronchus, heart, lung, trachea 87.49
28 Icterus GGPD P22.0 28 X ray of thorax 87.41
29 Icterus Neo hepato cell damage P59.2
30 Icterus Neo sebab lain P59.8
31 Icterus neonatorum P59.8
32 Icterus rhesus P55.0
33 KMK (small for gestational age) P05.1
34 Meconeas aspiration syndrome P24.0
35 meningitis bact G00.9
36 Neonatus post term P08.2
37 Neonatus preterm P07.3
38 pneumothorax P25.1
39 Polycithemia P61.1
40 Respiratory faillure P28.5
41 Sclerema neonatus P83.0
42 Sepsis P36
43 Tindik telinga Z41.3
44 Transiet Tachipnoe of the newborn P22.1
45
46
47
Perawat :

Penyakit : DALAM Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :
DIAG (ü) TIND

ICD IX (ü)
CM
U S K O P
1 Abses hati amuba A06.4 1 Bone marrow aspiration (for biopsy) 41.31
2 Acquired coagulation factor deficiency D68.4 2 Bone marrow aspiration stem cell 99.79
3 Acute lymphoblastic leukaemia C91.0 3 Consultation on a single organ sistem 89.06
4 Amubiasis, YTT A06.9 4 Consultation single organ system 89.06
5 ANEMIA D64 5 Consultation specified type 89.08
6 ANEMIA DEFISIENSI ZAT BESI D50 6 CT Scan abdomen 88.01
7 CELLULITIS A48 7 CT Scan kepala 87.03
8 Chikungunya virus disease A92.0 8 EKG 89.15
Cml,(chronic Myeloid Leukaemia) C92.1 Endoscopic retrograde cholangio pancreatograph

9 9 51.10
10 Cystic fibrosis, unspecified E84.9 10 Endoscopic sclerotherapy 42.33
11 Demam berdarah dengue (DHF) A91 11 Endoscopy bledder 57.32
12 Demam dengue (dengue klasik) A90 12 Endoscopy colon 45.23
13 Demam paratifoid, YTT A01.4 13 Endoscopy ileum 45.13
14 DEMAM TYPHUS A75 14 Examination physical 89.7
15 Diabetes Melitus E14 15 General physical examination 89.7
16 DIABETES MELITUS YDT LAINNYA E13 16 Hemodialysis 39.95
Diabetes mellitus dependen insulin tanpa
17 E10.9 17 Injection of antibiotic 99.21
komplikas
Diabetes mellitus non-dependen insulin
18 dengan komp
E11.8 18 Injection of insulin 99.17
Diabetes mellitus non-dependen insulin
19 tanpa kompl
E11.9 19 Injection of steroid NEC 03.92
Diabetes mellitus YTT dengan komplikasi
20 E14.6 20 Injection or infusion of electrolyts 99.18
lainnya
Diare Dan Gastroenteritis Yang Diduga
21 A09 21 Injection terapeutic agent NEC 99.2
Berasal Dari/colitis
Diffuse non-Hodgkin's lymphoma,
22 unspecified
C83.9 22 Intubation nasogastric (decompression) 96.07
23 Disentri amuba akut A06.0 23 Intubation nasogastric (feeding) 96.6
DM dependen insulin dng komplikasi
24 E10.5 24 Kemoterapi 99.25
pembuluh darah
25 Dm Insulin Dependen Type 1 E10 25 Laboratory physical, general 89.7
26 DM MALNUTRISI RILATED E12 26 Microscopic examination of blood 90.59
27 Dm Non Insulin Dependen Type 2 E11 27 Other diagnostic USG multiple sites 88.79
DM non-dependen insulin dng komplikasi
E11.5 Other injection of theraupetic substance into liver 50.94
28 pembuluh darah 28
DM YTT dng komplikasi pembuluh darah
29 perifer (gang
E14.5 29 Oxygen terapy 93.96
30 Enteritis due to Yersinia enterocolitica A04.6 30 Rehabilitation programs 93.89
31 Erysipeloid, unspecified A26.9 31 Transfusion of antihemophilic factor 99.06
32 GONORRHOE A54 32 Transfusion of plasma 99.07
33 Hemofilia/defisiensi Faktor Viii Herediter D66 33 Transfusion of PRC (packed red cells) 99.04
34 HEPATITIS A AKUT B15 34 Transfusion of thrombocytes 99.05
35 Hepatitis A without hepatic coma B15.9 35 Transfusion of whole blood (NOS) 99.03
36 HEPATITIS B AKUT B16 36 USG Abdomen 88.76
37 Hepatitis B kronis tanpa delta-agent B18.1 37 X ray of bronchus, heart, lung, trachea 87.49
38 Hepatitis C akut B17.1 38 X ray of Thorax 87.41
39 Hepatitis C kronis B18.2 39
40 Hepatitis virus kronis YTT B18.9 40
41 HEPATITIS VIRUS YANG TIDAK SPESIFIK B19

42 HERPES ZOSTER B02
43 HIPERPARATIROID E21
44 HIV (HUMAN IMUNO DEFISIENSI VIRUS) B20
45 Hyperchylomicronaemia E78.3
46 Hyperkalaemia E87.5
47 Hyperlipidaemia, unspecified E78.5
48 HYPERLIPIDEMIA E78
49 Hypertyroid/thyrotoxicosis, Unspecified E05.9
Hyperuricaemia without signs of
50 inflammatory arthr E79.0
51 Hyperuricemia E79
52 Hypercholesterolaemia E78.0
53 Hypoglycaemia, unspecified E16.2
54 Idiopathic thrombocytopenic purpura D69.3
55 Kolitis amuba non-disentri A06.2
56 Leukaemia, unspecified C95.9
57 LIMFOMA HODGKIN C81
58 LIMFOMA NON HODGKIN C82
59 Lipid storage disorder, unspecified E75.6
60 Malaria YTT B54
61 MORBILI B05
62 OBISYTY E66
OTHER BACTERIAL INTESTINAL
63 INFECTION A04
64 SEPSIS/SHOCK SEPTIC A41
65 Thrombocytopenia, unspecified D69.6
66 Thyroiditis, unspecified E06.9
67 TIPOID ABDOMINAL A01
68 VARICELLA B01
69 Viral infection, unspecified B34.9
70 sirosis hepatis K74.6
71 Hematomeses K92.0
72 Melena K92.1
73 Dyspepsi K30
74 Gastritis errosis K29.1
75 Ulkus peptikum K27
Perawat :

Catatan : Beri tanda (ü) pada kolom DIAG dan TIND

Apabila ada diagnosis dan prosedur selain yang ada di atas, agar ditambahkan
Sub bid Rekam Medis (25 nop 2008)

Penyakit : BEDAH SYARAF Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :
DIAG (ü) ICD IX TIND (ü)

CM
U S K O P
1 ABSES L02 1 Consultation on a single organ sistem 89.06
2 ATEROMA D23 2 Consultation single organ system 89.06
3 Brain, supratentorial D33.0 3 Consultation specified type 89.08
4 Brain, supratentorial D43.0 4 CT Scan kepala 87.03
5 Cephalgia/sakit Kepala R51 5 EKG 89.15
6 Cob/cedera Kepala Berat S09.7 6 Eksternal drainage liquor c.s 01.02
7 COMOTIO CEREBRI S06 7 Examination physical 89.7
8 Cor/cedera Kepala Ringan S09.9 8 General physical examination 89.7
9 Counselling, unspecified Z71.9 9 Injection nerve (cranial, perioheral) 04.80
10 Craniosynostosis Q75.0 10 Injection of antibiotic 99.21
11 Cva Bleeding (intracerebral Haemorhage) I61 11 Injection or infusion of electrolyts 99.18
12 Cva Infark (infarc Cerebri) I63 12 Injection terapeutic agent NEC 99.2
Discitis, unspecified M46.4 Intubation nasogastric (decompression) 96.07

13 13
14 Edema Cerebra G93.6 14 Intubation nasogastric (feeding) 96.6
Encephalitis, myelitis and encephalomyelitis,
15 unspecified G04.9 15 Kranioplasty 02.0
16 Encephalocele of other sites Q01.8 16 Laboratory physical, general 89.7
17 Encephalocele, unspecified Q01.9 17 Laminektomi (HNP) 80.51
Hipertensi esensial (primer) I10

18 18 Laminektomi (HNP) dengan instrumentasi 81.0
19 HNP M51 19 Microscopic examination of blood 90.59
20 HYDROCEPHALUS Q03 20 Other diagnostic USG multiple sites 88.79
21 Hyperaesthesia R20.3 21 Oxygen terapy 93.96
22 Low back pain M54.5 22 Transfusion of plasma 99.07
23 MENIGOKEL,ENSEFALOKEL Q01 23 Transfusion of PRC (packed red cells) 99.04
24 Meningitis, unspecified G03.9 24 Transfusion of thrombocytes 99.05
25 MIALGIA M79 25 Transfusion of whole blood (NOS) 99.03
26 Oa / Ostreo Arthritis (oa) M19 26 Trepanasi 01.24
27 PAROTITIS B26 27 Trepanasi tumor 01.5
28 Patellar tendinitis M76.5 28 USG Abdomen 88.76
29 Penyakit infeksi lainnya dan YTT B99 29 VP shunt 02.34
30 Sequelae of open wound of head T90.1 30 X ray of bronchus, heart, lung, trachea 87.49
31 Sequelae of superficial injury of head T90.0 31 X ray of Thorax 87.41
32 Sequelae of unspecified injury of head T90.9 32
33 Spondylolisthesis M43.1 33
34 SPONDYLOSIS/ARTHROSIS M47 34
35 SUPERFICIAL INJURY OF HEAD S00 35
36 Syncope Dan Kolaps (pingsan) R55
37 Tetraplegia, unspecified G82.5
38 TRAUMATIC CYST/BAHER CHIST M71
39 Traumatic subarachnoid haemorrhage S06.6
40 Vertigo R42
41
42
43
44
45
Perawat :



ü
Penyakit : BEDAH UMUM Ruang : INA DRG:
No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 ABSES L02 1 Amputasi below/above knee 84.10
2 APENDISITIS AKUT K35 2 Anoplasti sederhana 49.79
3 Appendisitis Chronic K36 3 Anterior reseksi 48.63
4 ATEROMA D23 4 Appendiktomi 47
5 Basedow Disease E05.0 5 Biopsi 86.11
6 Benjolan payudara YTT N63 6 Cimino shunt 39.29
7 CA.KOLON C18 7 Circumsisi 64.0
8 CA.MAMMA C50 8 Consultation on a single organ sistem 89.06
9 Ca/neoplasma Ganas Rektum C20 9 Consultation single organ system 89.06
10 Clavus (mata Ikan)/callus L84 10 Consultation specified type 89.08
Combustio Gr I-ii 12 % (burns Involving
11 T31.1 11 CT Scan kepala 87.03
10-19% Of Body Surface)
12 CONTUSIO MUSCULORUM T14 12 Drainase abses 86.22
DM dependen insulin dng komplikasi
13 E10.5 13 EKG 89.15
pembuluh darah
DM non-dependen insulin dng komplikasi
14 E11.5 14 Eksisi fibroadenoma mamma 85.21
pembuluh daRAH
15 EDEMA R60 15 Eksisi fibroadenoma mamma bilateral 85.36
16 Excoriasi Kaki S90 16 Eksisi luas/wide eksisi tumor 86.4
17 EXCORIASI TANGAN S60 17 Eksisi mamma abberans 85.24
18 Fam/fibroadenosis Of Breast N60.2 18 Eksplorasi duktus 51.41
Fibroblastic disorder, unspecified M72.9

19 19 Eksplorasi korpus alineum untuk pemeriksaan 88.90
Fibrosclerosis of breast N60.3

20 20 Eksplorasi korpus alineum untuk tindakan 86.05
21 FISTULA ANI K60 21 Eksterpasi/eksisi tumor jinak 86
22 Fistula Perianal K60.3 22 Examination physical 89.7
23 FISTULA UMBILICO URINARY Q64 23 Excision of urethral septum 58.0
24 Furuncle/carbuncle L02.9 24 Fistulektomi 48.73
25 Ganglion M67.4 25 General physical examination 89.7
26 Gangren, YTT R02 26 Hemodialysis 39.95
Granulation/ Other Disorders Following
27 H95.1 27 Hemoroidektomi 49.46
Mastoidectomy
28 Granuloma L92.9 28 Hernikolektomi 45.7
29 Hemangioma D18.0 29 Herniotomi + pasang mesh 53.5
Hematoma(traumatic)(skin Surface
30 T14.0 30 Herniotomi bilateral / duplek 53.10
Intact)/insect Bite
31 HEMOROID I84 31 Herniotomi NEC 53.9
32 HERNIA INGUINALIS K40 32 Herniotomi unilateral 53.00
33 HERNIA INGUINALIS MEDIALIS K45 33 Incisi
34 HERNIA LAINNYA K46 34 Injection of antibiotic 99.21
Injection of infusion of cancer chemotherapeutic
HERNIA UMBILIKALIS K42 99.25
35 35 substance
36 Hipertensi esensial (primer) I10 36 Injection or infusion of electrolyts 99.18
37 Hydrocele, unspecified N43.3 37 Injection terapeutic agent NEC 99.2
Ingrowing nail L60.0

38 38 Intubation nasogastric (decompression) 96.07
39 KELOID L91 39 Intubation nasogastric (feeding) 96.6
40 Lymphadenitis, Unspecified I88.9 40 IOID (Fraktur mandibula) 76.76
LIMFADENITIS AKUT, KRONIK NON
41 SPESISFIK I88 41 IOID+Suspensi maksila 76.74
42 LIPOMA D17 42 Kholedokoyeyunostomi 51.32
43 LYMPODENOPATHY R59 43 Kholesistektomi 51.2
44 MAMA ABERANT Q83 44 Kolostomi 46.03
45 Mastalgia N64.4 45 Laboratory physical, general 89.7
46 Mastitis/gangguan Radang Payudara N61 46 Laparatomi eksplorasi 54.11
47 MASTODYNIA N64 47 Laparoskopi 54.21
48 Neoplasma jinak payudara D24 48 Mastektomi radikal modifikasi 85.43
49 Nevus/melanocytic Naevi, Unspecified D22.9 49 Mastektomi simpel + toilet aksila 85.43
Open wound of other parts of foot S91.3

50 50 Mastektomi simpel + toilet aksila + skin graft 86.69
Open Wound Of Toe(s) With Damage To
51 S91.2 51 Microscopic examination of blood 90.59
Nail/avulsi Nail
52 Other specified sites D36.7 52 Miles 48.5
53 PAPILOMA D41 53 Other diagnostic USG multiple sites 88.79
54 PERITONITIS K65 54 Oxygen terapy 93.96
55 Soft tissue disorder, unspecified M79.9 55 Parotidektomi superfisial 26.31
56 STRUMA NODOSA E04 56 Parotidektomi total 26.32
Struma Nodosa /nontoxic Goitre,
57 E04.9 57 Pemasangan thoraks drain 34.04
Unspecified
58 TUMOR JINAK JARINGAN LUNAK D21 58 Rehabilitation programs 93.89
Ulkus / Chronic Ulcer Of Skin, Not
59 L98.4 59 Reposisi nasal 21.71
Elsewhere Classified
Ulkus anggauta gerak bawah, tanpa kode
60 L97 60 Reseksi dan anastomose usus 45
lain
Varises / Varicose Veins Of Lower
61 I83.9 61 Rozer plasty 86.23
Extremities Without Ulcer
VULNUS APERTUM DAERAH KEPALA DAN
62 S01 62 Splenektomi 41.5
MUKA
63 VULNUS APERTUM JARI TANGAN S61 63 suspensi maksila 76.74
64 VULNUS APERTUM PEDIS S91 64 Tiroidektomi subtotal 06.2
65 PAI K37 65 Tiroidektomi total 06.4
66 Tumor Paratotitis D11.0 66 Trakeostomi 31.1
67 Basalioma D33.0 67 Transfusion of plasma 99.07
68 Squamons cell ca Q51.8 68 Transfusion of PRC (packed red cells) 99.04
69 69 Transfusion of thrombocytes 99.05
70 70 Transfusion of whole blood (NOS) 99.03
71 71 Tur Prostat 60.29
72 72 Tutup kolostomi 46.52
73 73 USG Abdomen 88.76
74 74 X ray of bronchus, heart, lung, trachea 87.49
75 75 X ray of Thorax 87.41
Excisional debridement of wound,infection,or
86.22
76 burn
RAWAT LUKA 96.59
angkat jahitan di perut 97.83
HECTING 86.59
ANGKAT JAHITAN 97.89
Perawat :


Sub bid Rekam Medis (25 Nop 2008)

Penyakit : THT Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 Abscess of external ear H60.0 1 Axcision of lesion of tonsil and adenoid 28.92
2 Abscess Parapharingeal J39.1 2 Biopsi Telinga 18.12
3 Abscess Peritonsiler J36 3 Biopsi Tumor Hidung 21.22
4 Abscess Retro Pharingeal J30.0 4 Biopsi Tumor Nasopharing 29.12
Acute pharyngitis due to other specified
5 organisms J02.8 5 Calanoplsty 18.6
6 Bronkitis. tidak dirinci sebagai akut atau kronis J40 6 Cauterisasi 18.29
7 Cegukan/cough R05 7 Consultation on a single organ sistem 89.06
8 Chronic Otitis Media Beningn Type H66.9 8 Consultation spesified type 89.08
Chronic pharyngitis J31.2 Diagnostic ultrasound of head and neck 88.71

9 9
10 Conductive hearing loss. bilateral H90.0 10 Examination of physical 89.7
Conductive hearing loss. unspecified H90.2

11 11 Fungsional Endoscopy Sinus Surgero(FSS) 22.19
Corpus Alenium Orbit / Retained (old) Foreign
12 Body Following Penetrating H05.5 12 Glosstectomy 25.3
13 CORPUS ALIENUM HIDUNG T17 13 Incisi abses 18.09
Corpus/benda Asing (corpus Alienum) Pada
14 Telinga T16 14 Incisi Alis Peritonsil 54.19
Corpus/benda Asing Masuk Ke Dalam Atau
15 Melalui Mata Atau W44 15 Injection of antibiotic 99.21
16 DEAFNES H91 16 Injection or infusion of electrolyts 99.18
17 Disorders Of External Ear In Diseases Classified H62 17 Injection terapeutic agent NEC 99.2
Epistaxis R04.0 Intubation nasogastric (decompression) 96.07

18 18
19 Eusta Chian blockage H68.1 19 Intubation nasogastric (feeding) 96.6
20 Mastoidectomy H95.1 20 Irigasi Cerumen 96.52
21 Hearing loss. unspecified H91.9 21 Microscopic examination of blood 90.59
22 Herpes Zoster Oticus B02.* H94.0 22 oxygen terapy 93.96
Ispa J06.9 20.42

23 23 Radical Mastodectomy/ Tympanomastodectomy
24 KONDUKSI/SNHL H90 24 Rekontruksi Of Nasal 21.83
25 LARINGITIS ACUT J04 25 Reposisi Of Nasal 22.71
26 LARINGITIS KRONIC J37 26 Rhinoplasty 21.87
27 LIPOMA D17 27 Rhinoscopy 21.21
28 Lymphadenitis. Unspecified I88.9 28 Septo Rhinoplasty 21.84
29 Mastoiditis H70 29 Simple Mastoidectomy 20.41
30 Otalgia H92.0 30 Sinusectomy. not otherwise specified 22.6
31 Otalgia And Effusion Of Ear H92 31 Submucous resection of nasal septum 21.5
32 Otitic barotrauma T70.0 32 Tonsilectomy with adenoidectomy 28.3
33 OTITIS EXTERNA H60 33 Tonsilectomy without adenoidectomy 28.2
34 Otitis externa. unspecified H60.9 34 Tranfusion of packed cells 99.04
35 Otitis Interna H83.0 35 Tranfusion of trombocytes 99.05
36 Otitis Media Acute Alergic H65.1 36 Tympanomastoidectomy 20.42
37 OTITIS MEDIA AKUTA H66 37 Tympanoplasty 19.4
OTITIS MEDIA KRONIK H65

38 38 Uvula Palatoplasty PharingoPlasty(UPP) 27.69
39 Otitis Media. Allergic H65.9 39 Xray of bronchus.heart.lung.trachea 87.49
40 Pain in throat R07.0 40 Rhinotomi laterslis 21.1
41 PAROTITIS B26 41 caldwell luc (cwl) 22.39
Pharyngitis J02
42 42 Open reduction reposisi motela frakture
43 Pharyngitis Acute. Unspecified J02.9 43 Bronchoscopy 33.23
44 POLIPNASI J33 44 esophaguscopy 42.23
45 Positional Vertigo R42 Toilet telinga 96.52
46 Rhinitis J31.0
47 Rhinitis Allergica. Unspecified J30.4
48 RHINITIS KRONIC J31
49 RHINITIS VASOMOTOR J30
Rhinopharyngitis/rhinitis Alergika/common
50 J00
Cold/rhinitis Acute
51 Senile nuclear cataract H25.1
52 SEPTUM DEVIASI J34
53 Serumen impak H61.2
54 Sinus. fistula and cyst of branchial cleft Q18.0
55 SINUSITIS MAXILARIS J32
56 Sinusitis. Unspecified J32.9
68 STRUMA NODOSA E04
69 Sudden Hearing Loss H91,9
70 Tinnitus H93.1
71 Tonsil. unspecified C09.9
73 TONSILITIS KRONIC J35
Tonsillitis.(acute)(follicular)
74 (gangrenous).unspecified J03.9
76 Fraktur nasal S02.2
77 Angiofibroma juvenile D10.6
78 Tumor nasopharings C11.9
79 Tumor Cauetas nasi (Tumor sinonasal) C31.9
80 Fraktur Maxilla S02.4
81 Tumor tonsil C09.9
Tumor lidah C02.9
82
Tumor larynx C32.9

83
84 Trauma Larynx
85 Corpus aleum bronchus T17.5
86 Corpus aleum esophagus T18.1

Perawat :
ket: DIAG = U : UTAMA. S : SEKUNDER. K : KOMPLIKASI

TIND = O : Tindakan Operasi. P : Tindakan Penunjang

Apabila ada diagnosis dan prosedur selain yang ada di atas. agar ditambahkan

Penyakit : ORTHOPEDI Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :
DIAG (ü) ICD IX

No. Diagnosis ICD X No Prosedur TIND (ü)
CM
U S K O P
1 Arthritis. unspecified M13.9 1 ABP 78.5
2 ATEROMA D23 2 Aff plate screw atau aff wire 78.60
3 Dislocation of ankle joint S93.0 3 AMP 78.5
4 DISLOKASI S33 4 Amputasi distal metakarpal 84.3
5 EDEMA R60 5 Artrodesis sendi besar 81.20
6 FR. CLAVICULA S42 6 Artroskopi 80.20
7 FR. OF FOOT.EXCEPT ANKLE S92 7 Blood tranfusion thrombocytes 99.05
8 FR.CERVIKAL S12 8 Blood transfusion plasma 99.07
9 FR.COSTAE S23 9 Bone graft tibia and fibula 78.07
10 FR.CRURIS S82 10 Consultation single organ system 89.06
11 FR.FEMUR S72 11 Consultation spesified type 89.08
12 FR.NASAL S02 12 Debridemen 79.6
13 FR.PERGELANGAN DAN TANGAN S62 13 Dekompresi selubung tendon dan sinovia 82.1
14 FR.V.LUMBAL S32 14 Eksisi ganglion 82.1

15 Fracture of calcaneus S92.0 15 Injection Antibiotic 99.21
16 Fracture Of Elbow S52.0 16 Injection of infusion of electrolytes 99.18
Injection of theraupeutic substance into
17 Fracture of fibula alone S82.4 17
temporamandibular joint
76.96
18 Fracture of first metacarpal bone S62.2 18 Intubation nasogastric (decompression) 96.07

19 Fracture of foot. unspecified S92.9 19 Intubation nasogastric (feeding) 96.6
20 Fracture of lower end of humerus S42.4 20 Kelainan kongenital / CTEV (koreksi) 83.84
21 Fracture of lower end of radius S52.5 21 Kelainan tangan bawaan (rekonstruksi) 82.8
22 Fracture of lower end of tibia S82.3 22 Microscopic Examination of Blood 90.59

23 Fracture of metatarsal bone S92.3 23 Rekonstruksi sendi / ARTROPLASTI 81.96
24 Fracture of other metacarpal bone S62.3 24 Reposisi fraktur tertutup/dislokasi 79
25 Fracture of other toe S92.5 25 Tendontransfer 83.75
26 Fracture of patella S82.0 26 Tendoplasty 83.88
27 Fracture of shaft of tibia S82.2 27 Orif (pasang plate screw) 79.3
28 Fractures of other parts of lower leg S82.8 28 pasang gips 93.44
29 Fraktur anggauta gerak atas. level YTT. terbuka T10.1 29
30 Fraktur anggauta gerak atas. level YTT. tertutup T10.0 30

Fraktur anggauta gerak bawah. level YTT.
31 T12.1 31
terbuka
Fraktur anggauta gerak bawah. level YTT.
32 T12.0 32
tertutup
33 FRAKTUR MELIPUTI DAERAH BADAN MULTIPEL T02 33
34 Fraktur tulang belakang. level YTT. terbuka T08.1
35 Fraktur tulang belakang. level YTT. tertutup T08.0

36 Ganglion M67.4
37 GOUT ARTRITIS M10
38 Low back pain M54.5
39 MALUNION FRAKTUR M84
40 Oa / Ostreo Arthritis (oa) M19
41 Open wound of finger(s) with damage to nail S61.1
42 Open wound of other parts of foot S91.3
43 OSTEOMIELITIS M86
44 OSTEOPOROSIS M81
45 RUPTURE I71
46 Soft tissue disorder. unspecified M79.9
47 Sprain and strain of ankle S93.4
48 TBC TULANG DAN SENDI A18.0
Traumatic amputation of one foot and other leg
49 T05.4
[an
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
Perawat :


Sub bid Rekam Medis (25 Nop 2008)

Penyakit : MATA Ruang :

INA DRG:
No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
Acute and unspecified inflammation of lacrimal
H04.3 Blepharorrhaphy canthorrhaphy tarsorrhaphy 08.52
1 passages 1
Acute atopic conjunctivitis H10.1 Canthotomy enlargement of palpebral fissure 08.51

2 2
3 Acute inflammation of orbit H05.0 3 Dacryocystorhinostomy [DCR] 09.81
4 Adherent leukoma H17.0 4 diagnostic aspiration of vitreous 14.11
Discission of secondary membrane (after
After-cataract
5 H26.4 5 cataract) 13.64
6 Amblyopia Ex Anopsia H53.0 6 excision of chalazion 08.21
7 Anisometropia and aniseikonia H52.3 7 Excision of other minor lesion of eyelid 08.22
8 Aphakia H27.0 8 Excision of prolapsed iris 12.13
Astigmatism H52.2
9 9 Excision of pterygium with corneal graft 11.32
excision of secondary mambrane (after cataract)
Blepharochalasis H02.3
10 10 capsulectomy 13.65
Extracapsular extraction of lens by linear
Blepharoconjunctivitis H10.5
11 11 extraction technique 13.2
Extracapsular extraction of lens by simple

12 Bullous keratopathy H18.1 12 aspiration (and irrigation) technique 13.3
Incision of cornea incision of cornea for removal
Central retinal artery occlusion
13 H34.1 13 of foreign body 11.1
14 Chalazion H00.1 14 Incision of lacrimal sac 09.53
15 changes in corneal membranes H18.3 15 Injection into anterior chamber 12.92
Chorioretinal scars H31.0 Insertion of intraocular lens prosthesis at time of

16 16 cataract extraction,one-stage 13.71
17 Choroidal detachment H31.8 17 Iridotomy and simple iridectomy 12.1
choroidal haemorrhage and rupture Linear repair of laceration of eyelid or eyebrow 08.81
18 H31.3 18
Chronic conjunctivitis H10.4 Magnetic removal of embedded foreign body

19 19 from cornea that with incision (11.1) 11.0
20 chronic iridocyclitis H20.1 20 Ophthalmoscopy 16.21
21 Colour vision deficiencies H53.5 21 Other diagnostic procedures on orbit and eyeball 16.29
22 Complicated cataract H26.2 22 Other epilation of eyelid 08.93
Congenital Glaucoma Q15.0 Other excision of pterygium excision or

23 23 destruction of tissue or other lesion of cornea 11.39
Other incision, of eyelid diagnostic procedures on
Conjunctival haemorrhage H11.3 08.09
24 24 eyelid
25 Conjunctival scars H11.2 25 Other intracapsular extraction of lens 13.19
Conjunctivitis in infectious and parasitic diseases
26 classified elsewhere
H13.1* 26 Other repair of cornea 11.59
Other repair of laceration of eyelid,full- thickness 08.85

27 Convergent concomitant strabismus H50.0 27
Other repair of laceration of eyelid,partial-
Corneal degeneration 08.83
28 H18.4 28 thickness
29 Corneal neovascularization H16.4 29 Phacoemulsification and aspiration of cataract 13.41

Postoperative revision of scleral fistulization
Corneal ulcer H16.0 procedure revision of filtering bleb repair of
30 30 fistula (12.82) 12.66
31 CORPUS ALIENUM MATA T15 31 Probing of lacrimal canaliculi 09.42
Corrosion of unspecified degree of head and
32 neck T20.4 32 Probing of lacrimal punctum 09.41
33 Crystalline deposits in vitraous body H43.2 33 Probing of nasolacrimal duct 09.43
Removal of embedded foreign body from
Dacryoadenitis H04.0
34 34 conjunctiva by incision 10.0
Degenerated conditions of globe (absolute Removal of implanted lens removal of
H44.5
35 glaucoma) 35 pseudophakos 13.8
Degeneration of macula and posterior pole H35.3 Removal of intraocular foreign body from
36 36 anterior segment of eye without use of magnet 12.02
Repair of blepharoptosis by frontalis muscle
Degenerative myopia 08.32
37 H44.2 37 technique with fascial sling
Repair of blepharoptosis by frontalis muscle
08.31
38 Diplopia H53.2 38 technique with suture
Repair of blepharoptosis by other levator muscle
Dislocation of lens 08.34
39 H27.1 39 techniques
Disorders of optic nerve, not elsewhere repair of blepharoptosis by resection or

08.33
classified advancement of levator muscle or apneurosis
40 H47.0 40
Divergent concomitant strabismus Repair of blepharoptosis by tarsal techniques 08.35

41 H50.1 41
Repair of canaliculus fistulization of lacrimal
Drug-induced cataract 09.73
42 H26.3 42 tract to nasal cavity
Repair of corneal laceration or wound with
Dysthyroid exophthalmos (E05.-+) H06.2*
43 43 conjunctival flap 11.53
repair of entropion or ectropion by suture
Ectropion of eyelid H02.1 08.42
44 44 technique
repair of entropion or ectropion with lid
Enophthalmic conditions H05.2 08.44
45 45 reconstruction
repair of entropion or ectropion with wedge
Enophthalmos H05.4 08.43
46 46 resection
Entropion/trichiasis(entropion And Trichiasis Of Repair of laceration involving lid margin,full-
H02.0 08.84
47 Eyelid) 47 thickness
Repair of laceration involving lid margin,partial-
Epiphora H04.2 08.82
48 48 thickness
Repair of laceration of conjunctiva that with
49 Episcleritis H15.1 49 repair of sclera(12.82) 10.6
Repair of postoperative wound dehiscence of
Exophthalmic conditions H05.2
50 50 cornea 11.52
51 Floater/other Vitreous Opacities H43.3 51 Repair of rupture of eyeball 16.82
Focal chrorioretinal inflammation

52 H30.0 52 Revision of enucleation socket with graft 16.63
Fourth [trochlear] nerve palsy Revision of operative wound of anterior

53 H49.1 53 segment,not elsewhere classified 12.83
Secondary insertion of intraocular lens prosthesis
Glaucoma secondary to drugs
54 H40.6 54 removal of implanted lens 13.72
55 Glaucoma secondary to eye inflammation H40.4 55 Subconjunctival injection 10.91
56 Glaucoma secondary to eye trauma H40.3 56 Suture of corneal laceration 11.51
Glaucoma secondary to other eye disorders Suture of laceration of sclera suture of sclera with
57 H40.5 57 synchronous repair of conjunctiva 12.81
Therapeutic evacuation of anterior chamber
Glaucoma suspect paracentesis of anterior chamber diagnostic
58 H40.0 58 aspiration (12.21) 12.91
59 Granuloma L92.9 59 Trabeculectomy ab externo 12.64
60 Hereditary retinal dystrophy H35.5 60 Transposition of pterygium 11.31
61 Herpesviral keratitis and keratoconjunctivitis H19.1

62 Heterophoria H50.5
Hordeolum and other deep inflammation of
63 H00.0
eyelid
64 Hypermetropia H52.0
65 Hypertension Ocular,glaucoma Suspect H40.0
66 Hyphaema H21.0
67 Hypopion(acute And Subacute Iridocyclitis) H20.0
68 Hypotony of eye H44.4
69 Infantile, juvenile and presenile cataract H26.0
70 Intermittent heterotropia H50.3
iridocyclitis in infectious and parasitic diseases
71 classified elsewhere H22.0*
72 KATARAC H26
KERATITIS DAN GANGGUAN LAIN SKLERA DAN
73 H19
KORNEA
74 Keratitis, unspecified H16.9
75 KERATO CONJUNCTIVITIS/KERATITIS H16
76 Keratoconjunctivitis H16.2
77 Keratoconus H18.6
78 Lagophthalmos H02.2
lens-induced iridocyclitis
79 H20.2
80 Mechanical strabismus H50.6

81 Mucopurulent conjungtivitis H10.0
82 Myopia H52.1
83 Neuritis optikus H46
84 Nystagmus and other irregular eye movements H55
85 Optic atrophy H47.2
86 Other acute conjunctivitis H10.3
Other adhesions and disruptions of iris and
87 cillary body H21.5
88 Other conjunctivitis H10.8
89 Other corneal defarmities H18.7
90 Other corneal oedema H18.2
91 Other Corneal oedema H18.2
92 Other corneal scars and opacities H17.8
93 Other disorders of lacrimal gland H04.1
94 Other disorders of vitreous body H43.8
95 Other disorders of vitreous body H43.8
96 Other keratitis H16.8
97 Other proliferative retinopathy H35.2
98 Other retinal vascular occlusions H34.8
100 Other senile cataract H25.8
101 Other specified disorders of conjunctiva H11.8
102 Other specified disorders of eyelid H02.8
103 Other superficial keratitis without conjunctivitis H16.1

104 Papilloedema,unspecified H47.1
105 Peripheral retinal degeneration H35.4
106 Presbyopia H52.4
107 Primary angle-closure glaucoma H40.2
108 Primary open-angle glaucoma H40.1
109 Pseudofaki Z96.1
110 Pterygium H11.0
111 Ptosis of eyelid H02.4
112 pupillary membranes H21.4
Retained (old) foreign body following
113 penetrating wound of orbit H05.5
114 Retained (old) intraocular foreign body,magnetic H44.6

Retained (old) intraocular foreign
115 body,nonmagnetic H44.7
116 Retinal haemorrhage H35.6
117 Retinopathy And Retinal Vascular Change H35.0
118 Retinopathy of prematurity H35.1
119 SCLERITIS H15.0
120 Senile cataract, morgagnian type H25.2
121 Senile incipient cataract H25.0
122 Senile nuclear cataract H25.1
123 Separation of retinal layers H35.7
124 Serous retinal detachment H33.2
125 Sixth [abducent] nerver palsy H49.2
126 Subjective visual disturbances H53.1
127 Third [oculomotor] nerve palsy H49.0
128 Total (external) ophthalmoplegia H49.3
129 Tracoma A71
130 Traction detachment of retina H33.4
131 Traumatic cataract H26.1
132 Vertical strabismus H50.2
133 Visual field defects H53.4
134 Vitreous haemorrhage H43.1
135 Xanthelasma of eyelid H02.6
136

Perawat :



Penyakit : PARU Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 TBC PARU A15 1 Consultation on a single organ sistem 89.06
2 Asma / Asthma. Unspecified J45.9 2 Consultation specified type 89.08
3 ASMA BRONCHIALE J45 3 Culture darah khusus paru 90.4
Bronchiolitis(acute)(infective)(sub Acute) J21.9

4 4 Drainage by thorax 34.04
5 BRONCHITIS AKUT J20 5 Endoscopy bronchus 33.23
6 BRONCHO PNEMONI J18 6 Endoscopy Thorax 34.21
7 Bronchopneumonia. unspecified J18.0 7 Examination Physical 89.7
8 Bronkitis kronis YTT J42 8 FNAB 33.26
BRONKITIS. EMFISEMA DAN PENYAKIT PARU
J41
9 OBSTRUKTIFKRONIK LAINNYA 9 Injection of antibiotic 99.21
Bronkitis. tidak dirinci sebagai akut atau kronis J40

10 10 Injection or infusion of electrolyts 99.18
11 CA.PARU C34 11 Intubation nasogastric (decompression) 96.07
12 Cegukan/cough R05 12 Intubation nasogastric (feeding) 96.6
13 Chest pain. unspecified R07.4 13 Kemoterapi 99.25
14 Dispepsia K30 14 Microscopic examination of blood 90.59
Dyspnoea R06.0 Microscopic examination of specimen from 90.42

trachea. bronchus. pleaura. lung. and other
15 15 thoracic specimen. and of sputum culture
Efusi pleura (pleural effusion). tanpa kode lain J90

16 16 Nebulizer 93.94
17 Epistaxis R04.0 17 Oxigen Terapy 93.96
18 Haemoptysis R04.2 18 Pleurodesis 34.6
INFEKSI SALURAN NAPAS BAGIAN ATAS
AKUT LAINNYA
J05
19 19 Scan Thorax 87.41
20 Ispa J06.9 20 Tranfusion of thrombocytes 99.05
21 Kp (tuberkulosis Sistem Napas Ytt A16.9 21 Transfusion of packed cells 99.04
22 LARINGITIS ACUT J04 22 Xray of bronchus.heart.lung.trachea 87.49
23 Lobar pneumonia. unspecified J18.1 23 Cairan Pleura / Acutest 90.4
24 Oedema pulmonar J81 24 Spirometri 89.37
25 Pharyngitis J02 25
Pneumonia Infeksi J16

26 26 Pemeriksaan Sputum, cairan, sikatan, aspirasi 90.4
27 Pneumonia. unspecified J18.9 27 Thora coscopy 34.21
28 PPOM J44 28 Miles 48.5
29 Respiratory failure. unspecified J96.9 29
30 Rhinitis J31.0 30
31 Rhinitis Allergica. Unspecified J30.4 31
32 RHINITIS KRONIC J31 32
Rhinopharyngitis/rhinitis Alergika/common
J00
33 Cold/rhinitis Acute 33
B90.9.
SINDROM OBSTRUKSI PASCA TB
34 2
35 SINUSITIS MAXILARIS J32
36 Sinusitis. Unspecified J32.9
37 Status Asthmaticus J46
38 TBC ORGAN LAIN A18.8
Test Mantoux/abnormal Reaction To Tuberculin Test R76.1

39
Tuberculosis complicating pregnancy. childbirth an O98.0

41
Tuberkulosis kelenjar getah bening intratoraks A15.4
42
Tuberkulosis paru. bakteriologi dan histologi A16.0

43
Tuberkulosis paru. mikroskopis sputum positif A15.0

44
Tuberkulosis sistem napas lainnya. konfirmasi tida A16.8

45
46 Upper Respiratory Infection J98.8
47 Recurrent Haemoptoe R04.2
48 Haemothorax J94.2
49 Pneumothorax J93
50 Pneumonia Sepsis A41.9
51 Oedema Paru Non Cardiogenic J81
52 Massive Pleural Effusion J90
53 Massive Haemoptisis R04.2
54 Injury Paru T17.8
55 Emboli Paru I26.0
56 Aspirasi Pneumonia J69.0
57 Asma Bronchitis Moderat Severe J45.9
58
59
60
61
62
63
64
65
66
67
Perawat :



Penyakit : KULIT Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 ABSES L02 1 Aplikasi TCA 86.3
2 Acne Vulgaris/pustular L70.0 2 Candilectomy 77.8
3 ALERGI REACTION T78 3 Consultation on a single organ sistem 89.06
4 Candiloma A63.0 4 Consultation specified type 89.08
5 Clavus (mata Ikan)/callus L84 5 Examination physical 89.7
Combustio Gr I-ii 12 % (burns Involving 10-
6 T31.1 6 Injection of antibiotic 99.21
19% Of Body Surface)
Creeping Eruption / Hookworm Disease,
7 B76.9 7 Injection of infusion of electrolytes 99.18
Unspecified
8 Dermatitis L30.9 8 Injeksi keloid / triamicinolon 99.23
9 Dermatitis Atopic, Unspecified L20.9 9 Intubation nasogastric (decompression) 96.07
10 Dermatitis Contact, Unspecified Cause L25.9 10 Intubation nasogastric (feeding) 96.6
11 DERMATITIS KONTAK L23 11 Microscopic examination of blood 90.59
12 Dermatitis Kontak/alergi, Unspecified Cause L23.9 12 Oxygen terapy 93.96
13 Dermatitis Numular L30.0 13 Cautherisasi 86.3
14 DERMATITIS SEBORHOEIC L21 14 Chemopeel skin 86,243
Drug Eruption/generalized Skin Eruption Due To
15 Drug And Medicam L27.0 15 Excisi / extraksi skin 86.3
16 EFLUVIUM L65 16
17 Fluor,(vaginalis) N89.9 17
18 FOLICULITIS L73 18
19 Freckles L81.2 19
20 Furuncle/carbuncle L02.9 20
21 GONORRHOE A54 21
22 Granuloma L92.9 22
23 Hemangioma D18.0 23
Hematoma(traumatic)(skin Surface
24 Intact)/insect Bite T14.0 24
25 HERPES SIMPLEX A60 25
26 HERPES ZOSTER B02 26
27 Hyperkeratosis L85.9 27
28 Hyperpigmentation L81.0 28
29 ICHTYIOSIS Q80 29
30 IMPETIGO L01 30
31 KELOID L91 31
32 Keratosis seboroik L82 32
33 Komedo L70 33
34 MELASMA L81
35 MH [LEPROSY] A30
36 Miliaria, unspecified L74.3
37 MILIUM L72
38 Molluscum contagiosum B08.1
39 NEORO DERMATITIS/PRORIGO L28
40 Neurodermatitis L28.0
41 Nevus/melanocytic Naevi, Unspecified D22.9
42 PAPILOMA D41
43 Pemphigus foliaceus L10.2
44 Pit Alba L30.5
45 Pitiriasis rosea L42
46 Pityriasis versicolor B36.0
47 Prurigo L28.2
48 PRURITUS L29
49 Psoriasis vulgaris L40.0
50 Psoriasis, unspecified L40.9
51 Pyoderma L08.0
52 PYODERMIA L08
53 Scabies B86
54 Seborrhea,seborheic R23.8
55 Syringomyelia and syringobulbia G95.0
56 Tinea corporis B35.4
57 Tinea cruris B35.6
58 Tinea pedis B35.3
59 Tinea(intersecta) B35.9
60 Tinea, Capitis B35.0
61 URTICARIA L50
62 VAGINITIS N76
63 VARICELLA B01
64 VERUCA B83
65 Vitiligo L80
66 XANTHELASMA H02
67
68
69
70
71
72
73
Perawat :

ü
Penyakit : JIWA Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 Demensia YTT F03 1
2 Anxiety disorder, unspecified F41.9 2
3 Anxious [avoidant] personality disorder F60.6 3
4 DELIRIUM F05 4
5 DEMENSIA FO3 5
6 DEPRESI F32 6
7 Depresi / Severe Depressive Episode With Psych F32.3 7
8 DEPRESI BERULANG F33 8
9 Depressive episode, unspecified F32.9 9
10 Emotionally unstable personality disorder F60.3 10
11 EPILEPSI G40 11
12 GANGGUAN AFEKTIF BIPOLAR F31 12
13 Gangguan jiwa organik dan simptomatik YTT F09 13
14 Gangguan jiwa YTT F99 14
15 Gangguan kepribadian campuran dan lainnya F61 15
16 Gangguan kepribadian dan perilaku dewasa YTT F69 16
GANGGUAN KEPRIBADIAN,GANGGUAN
KEBIASAAN DAN IMPULSGANGGUAN F66
17 IDENTITAS,GANGGUAN PREVENSI SEKSUAL 17
GANGGUAN KEPRIBADIAN,GANGGUAN
KEBIASAAN DAN IMPULSGANGGUAN F68
18 IDENTITAS,GANGGUAN PREVENSI SEKSUAL 18
19 GANGGUAN PERKEMBANGAN PSIKOLOGIS F84 19
20 GANGGUAN SKIZOAFEKTIF F25 20
21 Gangguan suasana perasaan (mood/ afektif) YTT F39 21
22 Generalized anxiety disorder F41.1 22
23 GMP AKIBAT PENGGUNAAN ZAT MULTIPLE F19 23
24 Hyperkinetic disorder, unspecified F90.9 24
25 Insomnia f51.0 25
26 PARANOID PERSONALITY F60 27
27 PSIKOSA F23 28
28 Psikosis non-organik YTT F29 29
29 PSIKOSOMATIS F45 30
30 REAKSI KONVERSI, HISTERIA F44 31
31 Schizoaffective disorder, unspecified F25.9 32
32 Schizophrenia, unspecified F20.9 33
33 SEXUAL DYSFUNCTION F52
34 SIZOFREN F20
36
37
38
39
40
41
42
43
Perawat :



Penyakit : JANTUNG Ruang :

INA DRG:
No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 Rheumatic fever without mention of heart involvement I00

2. Acute rheumatic pericarditis I 01.0
Acute rheumatic endocarditis I01.1
Other acute rheumatic heart disease I01.8
Rheumatic Chorea I02
Mitral stenosis I05.0
Rheumatic mitral insuffciency I05.1
Mitral stenosis with insufficiency I05.2
Rheumatic aortic stenosis I06.0
Rheumatic aortic insufficiency I06.1
Rheumatic aortic stenosis with insufficiency I06.2
Perawat :



Penyakit : SYARAF Ruang :

INA DRG:
No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
Diabetic polyneuropathy (E10-E14+ with
1 G63.2 1 Consultation on a single organ sistem 89.06
common fo
2 Arteritis. unspecified I77.6 2 Consultation specified type 89.08
3 Arthralgia. Psychogenic F45.4 3 CT Scan kepala 87.03
4 Arthralgia.(allergic) M25.5 4 Electro Encephalo Grafi 89.14
5 Bell's palsy G51.0 5 Electrocardiogram 89.52
6 Bppv / Benign Paroxysmal Potitonal Vertigo H81.1 6 Examination physical 89.7
7 Calcaneal spur M77.3 7 Injection nerve ( crania. peripheral ) 4.8
8 Cephalgia/sakit Kepala R51 8 Injection of antibiotic 99.21
9 Cervicalgia M54.2 9 Injection of infusion of electrolytes 99.18
CRS ( CERVIKAL ROOT SYNDROM ) M53 Intubation nasogastric (decompression) 96.07

10 10
11 Cva Bleeding (intracerebral Haemorhage) I61 11 Intubation nasogastric (feeding) 96.6
12 CVA BLEEDING LAIN I62 12 Lumbal Punksi 92.03
13 Cva Infark (infarc Cerebri) I63 13 Microscopic examination of blood 90.59
14 DEMENTIA F00 14 MRI 88.97
15 DISKINETIA G80.3 15 Other diagnostic USG multiple sites 88.79
Encephalitis. myelitis and encephalomyelitis.
16 unsp G04.9 16 Oxygen terapy 93.96
17 EPILEPSI G40 17 Polysomnogram 89.17
18 FROZEN SHOULDER M75 18 Rehabilitation programs 93.89
19 HEMIPARESIS.HEMIPLEGIA G81 19 Tranfusion of thrombocytes 99.05
20 HNP M51 20 Transfusion of antihemophilic factor 99.06
21 Hyperlipidaemia. unspecified E78.5 21 Transfusion of plasma 99.07
22 HYPERLIPIDEMIA E78 22 Transfusion of PRC (packed red cells) 99.04
23 INSOMNIA G47 23 Transfusion of whole blood (NOS) 99.03
24 Ischialgia/ Sciatica M54.3 24 USG Abdomen 88.76
25 Kejang Demam R50.0 25 X Ray Elbow 88.22
26 Low back pain M54.5 26 X ray of bronchus. heart. lung. trachea 87.49
27 MIGRAIN G43 27 X Ray shoulder 88.21
28 MUSCLE SPASM M62 28 X Ray Thorax 87.41
29 MUSCLE STRAIN M62.6 29 X Ray skull 87.02
30 Myalgia M79.1 30 X Lumbo sacral 87.24
31 Myasthenia gravis G70.0 31 X Ray cervical 87.22
32 Neuralgic amyotrophy G54.5 32 X Ray calcaneus / foot 88.27
33 NEUROPATY G58 33 X Ray genu 88.27
34 Oa / Ostreo Arthritis (oa) M19 34 X Ray pelvic 88.26
35 OSTEOPOROSIS M81 35 Inj joint (therapeutic agent) 81.92
36 Paraesthesia R20 36 Inj joint temporomandibular 76.96
37 Paraplegia. unspecified G82.2
38 PARESE G83
39 Parkinson G20
40 POLINEUROPATI G62
41 Rhematoid(neuralgia And Neuritis. Unspecified M79.2

42 Scoliosis. unspecified M41.9
43 Spondylolisthesis M43.1
44 Spondylolysis M43.0
45 Spondylosis. unspecified M47.9
46 SPONDYLOSIS/ARTHROSIS M47
47 Syncope Dan Kolaps (pingsan) R55
48 Tendinitis M77
49 Tetraplegia. unspecified G82.5
50 THA G44
51 TIA G45
Tic Facialis / Disorder Of Facial Nerve.
52 Unspecified G51.9
53 Tn/trigeminal Neuralgia G50.0
54 Torticollis M43.6
55 Trigger finger M65.3
56 Vertigo R42
57 Vertigo of central origin H81.4
58 Tumor otak P33.0
59 Meningitis A87
60
61
62
63
64
65
66
67
68
69
70
71
72
Perawat :



Penyakit : GIGI Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 Abrasion of teeth K03.1 1 Bedah dan combinasi alat orto 24.8
2 Abscess of salivary gland K11.3 2 Preparasi 86.71
3 Acute apical periodontitis of pulpal origin K04.4 3 extractie 23.09
4 Acute periodontitis K05.2 4 Operasi gigi 24.99
5 Anomalies of dental arch relationship K07.2 5 Pulpectomi / pulpotomi 23.70
6 Anomalies of jaw-cranial base relationship K07.1 6 Gingivoplasty 24.2
7 Anomalies of tooth position K07.3 7 Alveoplasty 24.5
8 Caries limited to enamel K02.0 8 Exposure of tooth 24.6
9 Caries of cementum K02.2 9 Scaling / polishing 96.54
10 Caries of dentine K02.1 10 Replacement of dental packing 97.22
11 Chronic apical periodontitis K04.5 11 Implantation of tooth 23.5
12 Chronic atrophic gastritis K29.4 12 Retoration of tooth by filling 23.2
13 Counselling, unspecified Z71.9 13 Restoration of tooth by inlay 23.3
14 Cyst of oral region, unspecified K09.9 14 Removal of impacted tooth 23.19
15 Dental caries, unspecified K02.9 15
16 Dental examination Z01.2 16
17 Disease of hard tissues of teeth, unspecified K03.9 17
Disorder of teeth and supporting structures,
18 K08.9 18
unspecified
19 Disorder of tooth development, unspecified K00.9 19
20 Disturbances in tooth eruption K00.6 20
Drug Eruption/generalized Skin Eruption Due To
21 Drugs And Medicam
L27.0 21
22 Ed /erosion Of Dental K03.2 22
23 Embedded teeth K01.0 23
24 Fracture of tooth S02.5 24
Gingival and edentulous alveolar ridge lesions
25 K06.2 25
ass
26 Gingival recession K06.0 26
27 Gingivitis K05.1 27
28 Gingivitis,acute K05.0 28
29 GP (GANGRENA PULPAE) K04 29
30 GR K08 30
Granuloma and granuloma-like lesions of oral
31 mucos K13.4 31
Hereditary disturbances in tooth structure, not
32 el K00.5 32
33 HP/CARIES K02 33
34 Impacted teeth K01.1
35 INPAKSI K01
36 KG/ABRASI K03
37 Loss of teeth due to accident, extraction or local K08.1

38 MUCOCELE K82
39 Mucocele of salivary gland K11.6
40 Necrosis of pulp K04.1
Non Vital Tooth/other And Unspecified Diseases
41 Of Pulp And Periapi K04.9
42 Odontalgia K08.8
43 Odontodysplasia,regional K00.4
44 Other superficial keratitis without conjunctivitis H16.1

45 Pemeriksaan medis umum Z00.0
46 Periapical abscess with sinus K04.6
47 Periapical abscess without sinus K04.7
48 PERIODONTITIS K05
49 Periodontosis K05.4
50 PERITONITIS K65
51 PERSISTENSI K00
52 Pulp degeneration K04.2
53 Pulpitis K04.0
54 Radicular cyst K04.8
55 Retained dental root K08.3
56 RETRAKSI K06
58 Supernumerary teeth K00.1
59 Tonsil, unspecified C09.9
60 Unsocialized conduct disorder F91.1
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
Perawat :



Penyakit : BEDAH PLASTIK Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 ABSES L02 1 Augmentasi mamma 85.5
2 ATEROMA D23 2 Blepharoplasty 08.3
3 CHEILO SCHIZIS Q36 3 Cheek dimple 27.5
4 Cleft lip, unilateral Q36.9 4 Cheek reduction 27.5
Combustio Gr I-ii 12 % (burns Involving 10-
5 T31.1 5 Consultation on a single organ sistem 89.06
19% Of Body Surface)
6 CONTUSIO MUSCULORUM T14 6 Consultation single organ system 89.06
7 H95.1 7 Consultation specified type 89.08
Mastoidectomy
8 Granuloma L92.9 8 Cuci luka combustio 86.22
9 Hemangioma D18.0 9 Dermabrasi 86.25
10 KELOID L91 10 Eksisi intra keloidal 86.2
11 LIPOMA D17 11 Eksisi kista atheroma 86.2
12 Lipomatosis, not elsewhere classified E88.2 12 Eksisi nevus 86.2
13 MELASMA L81 13 Face lift 86.82
14 Nevus/melanocytic Naevi, Unspecified D22.9 14 General phisycal examination 89.7
15 Other specified sites D36.7 15 Genioplasty 76.68
16 PAPILOMA D41 16 Injection of antibiotic 99.21
17 Pit Alba L30.5 17 Injection of infusion of electrolytes 99.18
Skin of other and unspecified parts of face D04.3 Intubation nasogastric (decompression) 96.07
18 18
19 Skin, unspecified D23.9 19 Intubation nasogastric (feeding) 96.6
20 STRUMA NODOSA E04 20 Labioplasty 27.54
21 Surgical procedure, unspecified Y83.9 21 Liposuction 86.83
22 Tindik telinga Z41.3 22 Microscopic examination of blood 90.59
23 VULNUS APERTUM JARI TANGAN S61 23 Orif hand 81.7
24 24 Orif maksilofasial 76.7
25 25 Palatoplasty 27.62
26 26 Polydactily 86.85
27 27 Reduksi mamma 85.3
28 28 Rekonstruksi soft tissue 86.89
29 29 Release kontraktur 86.84
30 30 Repair cleft facial 76.4
31 31 repair scar 86.84
32 32 Repair vulnus besar 86.22
33 33 Skin graft luas 88.60
34 34 Skin graft sedang 88.60
35 35 Syndactily 86.85
36 Temporoplasty (brow lift) 76.5
37 Transfusion of packed cells 99.04
38 Transfusion of thrombocytes 99.05
39 Cheiloplasty 27.59
40 Cheilorhapy 27.51
41
42
43
44
45
Perawat :



Penyakit : HAMIL Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 Amenorrhoe primer N91.0 1 Breech Extraction 72.52
Amenorrhoe sekunder N91.1

2 2 Cesarean section of other specified type 74.4
3 Amenorrhoe YTT N91.2 3 Closed biopsy of uterus 68.16
4 Care and examination immediately after delivery Z39.0 4 Consultation on a single organ sistem 89.06
5 Contraceptive management, unspecified Z30.9 5 Consultation specified type 89.08
Dilation and curatage following delivery of
Delivery by caesarean section, unspecified O82.9
6 6 abortion 69.02
7 Delivery by emergency caesarean section O82.1 7 Episiotomy 73.6
8 Diabetes mellitus in pregnancy, unspecified O24.9 8 Examination Physical 89.7
Diseases of the respiratory system complicating Excision or other destruction of bartholin gland
O99.5
9 pregnancy 9 cyst 71.24
10 Gynaecological examination (general)(routine) Z01.4 10 Hysterectomy total 68.9
11 Haemorrhage in early pregnancy, unspecified O20.9 11 hysterectomy vagina 68.5

12 HEMOROID I84 12 Injection of antibiotic 99.21
Injection or infusion of cancer chemotherapeutic
HYPEREMESIS (GRAVIDARUM) O21
13 13 substance 99.25
Hyperemesis gravidarum with metabolic
14 disturbance O21.1 14 Injection or infusion of electrolyts 99.18
15 Kehamilan berkepanjangan (postterm) O48 15 Intubation nasogastric (decompression) 96.07
16 KEHAMILAN KEMBAR O30 16 Intubation nasogastric (feeding) 96.6
17 KEHAMILAN NORMAL Z34 17 Microscopic examination of blood 90.59
Microscopic examination of specimen from

KEHAMILAN PADA DIABETES MELITUS O24 bladder, urethra, prostat seminal vesicle,
perivesical tiisue, and of urine and semen other
18 18 microscopicexamination 91.39
KEHAMILAN RESIKO TINGGI Z35 Microscopic examination of spesimen from other

19 19 site cell block and pap-smear 91.86
20 KET O00 20 Other apendictomy 47.09
21 LEOKORE N89 21 Other laparotomy 54.19
22 LETAK SUNGSANG O32 22 Other partial salpingectomy 66.69
Maternal care due to uterine scar from previous
O34.2
23 su 23 Other unilateral salpingo-oophorectomy 65.49
24 Maternal care for breech presentation O32.1 24 Other vaginal hysterectomy 68.59
Maternal care for congenital malformation of
25 uteru O34.0 25 Oxigen Terapy 93.96
Maternal care for malpresentation of fetus,
O32.9
26 unspec 26 Repair of other current obstetric laceratio 75.69
27 Mild hyperemesis gravidarum O21.0 27 Repair of vagina, vulva, perinum 75.69
28 MYOMA UTERI D25 28 Scan Thorax 87.41
29 Other haemorrhage in early pregnancy O20.8 29 Tranfusion of thrombocytes 99.05
30 Other vomiting complicating pregnancy O21.8 30 Transfusion of packed cells 99.04
31 Pemeriksaan medis umum Z00.0 31 Xray of bronchus,heart,lung,trachea 87.49
PENYULIT KEHAMILAN DAN PERSALINAN
32 LAINNYA O82 32
PERAWATAN IBU YANG BERKAITAN DENGAN
JANIN DANKETUBAN DAN MASALAH O39
33 PERSALINAN 33
34 Placenta praevia with haemorrhage O44.1
35 PLASENTA PREVIA O44
36 Polihidramnios O40
37 POST PARTUM Z39
38 PRE-ECLAMPSIA O14
39 Pre-eclampsia, unspecified O14.9
40 Supervision of elderly primigravida Z35.5
41 Supervision of normal first pregnancy Z34.0
42 Supervision of normal pregnancy, unspecified Z34.9
43 Supervision of pregnancy with grand multiparity Z35.4
44 Supervision of pregnancy with history of infertili Z35.0

Supervision of pregnancy with other poor
45 reproduct Z35.2
46 Threatened abortion O20.0
Varises / Varicose Veins Of Lower Extremities
47 Without Ulcer I83.9
48 Vomiting of pregnancy, unspecified O21.9
50 BEKAS SC O34.2
51
52
53
54
55
56
57
58
59
60
Perawat :

Penyakit : UROLOGI Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :
DIAG (ü) TIND

ICD IX (ü)
CM
U S K O P
1 Balanoposthitis N48.1 1 Aff DJ Stent 97.62
2 Batu Buli Buli / Calculus In Bladder N21.0 2 Aff DJ Stent local anastesi 97.62
Batu Empedu / Calculus Of Gallbladder Without
Cholecystitis
K80.2
3 3 Biopsi testis 62.12
4 Batu Ginjal / Calculus Of Kidney N20.0 4 Bivalve Nefrolitotomi 55.01
5 BATU URETER N20 5 BNI (Bladder neck incisisi) 60.29
6 Bph / Hiperplasia Prostat N40 6 Cirkumsisi 64.0
7 Btl BTL 7 Consultation on a single organ sistem 89.06
8 CIRCUMCISION Z41 8 Consultation single organ system 89.06
9 Colic Abd/pain, Unspecified R52.9 9 Consultation specified type 89.08
10 Cystitis N30 10 CT Scan kepala 87.03
11 Cystitis, unspecified N30.9 11 Examination physical 89.7
12 Dysuria R30.0 12 Hidrokelektomi 61.2
13 Epididymis C63.0 13 Injection of antibiotic 99.21
14 GAGAL GINJAL KRONIK [CRF] N18 14 Injection or infusion of electrolyts 99.18
15 HEMATURIA K31 15 Injection terapeutic agent NEC 99.2
Hematuria R31
16 16 Intubation nasogastric (decompression) 96.07
17 HERNIA INGUINALIS MEDIALIS K45 17 Intubation nasogastric (feeding) 96.6
18 Hydrocele, unspecified N43.3 18 Laboratory physical, general 89.7
Inkontinensia urinasi (buang air kecil) YTT R32

19 19 Meatotomi 58.0
Isk/ Urinary Tract Infection, Site Not Specified N39.0

20 20 Microscopic examination of blood 90.59
21 Kolik Ureter/kolikginjal Ytt N23 21 Nefrektomi 55.52
22 Low back pain M54.5 22 Nefrolitotomi 55.01
Neoplasm,abdomen In Situ Of Other Specified Sites D09.7

23 23 Nefrostomi 55.02
24 Neoplasma ganas prostat C61 24 Orkidektomi 62.3
25 NEOPLASMA GANAS TESTIS C62 25 Orkidopeksi 62.5
Orchitis, epididymitis and epididymo-orchitis with N45.0

26 26 Other diagnostic USG multiple sites 88.79
Orchitis, epididymitis and epididymo-orchitis with N45.9

27 27 Oxygen terapy 93.96
Other female urinary-genital tract fistulae N82.1

28 28 Pielotitomi 55.11
Phymosis.paraphymosis Dan Prepisisum Berlebihan N47

29 29 PNL 55.03
30 Poliuri R35 30 Prostatektomi terbuka 60.3
31 RETENSIO URINE K33 31 RPG 87.74
32 Retensio urine R33 32 Sistoskopi 57.32
33 STRIKTUR URETRA N35 33 Sistostomi terbuka 57.18
34 Undescended testicle, unspecified Q53.9 34 Torsio testis (eksplorasi/repair) 62.5
35 Urethritis N34.2 35 Trokar sistostomi 57.17
36 Urinary catheterization Y84.6 36 Tur buli 57.49
Urolithiasis/urinary Calculus, Unspecified N20.9 Tur Prostat 60.29

37 37
38 Varicocele (scrotal Varices) I86.1 38 Ureterolitotomi 56.2
39 39 Uretroskopi 56.31
40 40 Uretrotomi interna (sachse) 58.5
41 41 Vasektomi 63.73
42 42 vasoligasi tinggi varikokel 63.1
43 43 vesikolitotomi 57.19
44
45
46
47
48
49
50
Perawat :



Penyakit : KANDUNGAN INA DRG:

Ruang :
No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
1 ABORTUS IMINENT O20 1 Breech Extraction 72.52
Ab Incomplet N96 Cesarean section of other specified type 74.4

2 2
3 ABORTUS SPONTAN / completus O03 3 Closed biopsy of uterus 68.16
4 Acute vaginitis N76.0 4 Consultation on a single organ sistem 89.06
5 ADNEXITIS N70 5 Consultation specified type 89.08
Dilation and curatage following delivery of
ADNEXITIS SINESTRA N73 69.02
6 6 abortion
7 Amenorrhoe primer N91.0 7 Episiotomy 73.6
8 Amenorrhoe sekunder N91.1 8 Examination Physical 89.7
Excision or other destruction of bartholin gland
BARTHOLINITIS A44 71.24
9 9 cyst
10 CA.CERVIX C53 10 Hysterectomy total 68.9
11 Complete uterovaginal prolapse Grad N81.3 11 hysterectomy vagina 68.5
12 CYSTOMA OVARIUM N83 12 Injection of antibiotic 99.21
Injection or infusion of cancer chemotherapeutic
Delivery by caesarean hysterectomy O82.2 substance
99.25
13 13
14 Delivery by caesarean section, unspecified O82.9 14 Injection or infusion of electrolyts 99.18
Delivery by elective caesarean section O82.0 Intubation nasogastric (decompression) 96.07

15 15
16 DUB N93 16 Intubation nasogastric (feeding) 96.6
17 DYS MENORRHE/PREMENSTRUAL SYNDROM N94 17 Microscopic examination of blood 90.59
Microscopic examination of specimen from

bladder, urethra, prostat seminal vesicle,
18 Dysmenorrhoea, unspecified N94.6 18
perivesical tiisue, and of urine and semen other
91.39
microscopicexamination
Microscopic examination of spesimen from other

ENDOMETRIOSIS N80 site cell block and pap-smear
91.86
19 19
20 Endometrial glandular hyperplasia N85.0 20 Other apendictomy 47.09
21 Endometriosis, unspecified N80.9 21 Other laparotomy 54.19
22 Endometrium C54.1 22 Other partial salpingectomy 66.69
Erosi dan ektropion serviks uteri N86 Other unilateral salpingo-oophorectomy 65.49
23 23
24 Female infertility, unspecified N97.9 24 Other vaginal hysterectomy 68.59
25 General counselling and advice on contraception Z30.0 25 Oxigen Terapy 93.96
26 Gynaecological examination (general)(routine) Z01.4 26 Partus spontan 73.59
Haemorrhage in early pregnancy, unspecified O20.9 Repair of other current obstetric laceratio 75.69
27 27
28 HYPEREMESIS (GRAVIDARUM) O21 28 Repair of vagina, vulva, perinum 75.69
29 Hypertrophy of uterus N85.2 29 Tranfusion of thrombocytes 99.05
30 Incomplete uterovaginal prolapse N81.2 30 Transfusion of packed cells 99.04
31 INFERTILITY PRIMER N97 31 X Ray Thorax 87.41
32 KB Z30.9 32 Xray of bronchus,heart,lung,trachea 87.49
33 KET O00 33 Cesarean section 74.99
34 LEOKORE N89 34 Removal IUD 97.71
Menometrorrhagia/menstruasi Berlebihan &
35 N92.1 35 Partus spontan 73.59
Sering Siklus Tak Teratur
36 Menopausal and female climacteric states N95.1
Menopausal and perimenopausal disorder,
37 N95.9
unspecifie
38 Menorrhagia/polymenorrhea N92.0
39 Menstrual extraction Z30.3
40 Menstruasi berlebihan pada pubertas (DUB) N92.2
41 Menstruasi ireguler YTT N92.6
42 MOLA HYDATIDOSA O01
43 MYOMA UTERI D26.9
44 Neoplasma jinak ovarium D27
45 Oligohydramnios O41.0
46 Oligomenorrhoe YTT N91.5
Other specified abnormal uterine and vaginal
47 bleed N93.8
Other specified noninflammatory disorders of
48 vagin N89.8
Perdarahan ovulasi (perdarahan intermenstruasi
49 reg N92.3
50 POST PARTUM Z39
51 PROLAPS UTERUS N81.2
Radiological examination, not elsewhere
52 classified
Z01.6
53 Rectocele N81.6
54 Special examination, unspecified Z01.9
55 Supervision of normal first pregnancy Z34.0
56 Trichomoniasis, unspecified A59.9
57 VAGINITIS N76
58 Vomiting of pregnancy, unspecified O21.9
59 Cystoval N81.1
60 Bligted ovum O.02.0
61 KPD O42.9
62 Ca Corpus C54.1
63 Cystocele O34.8
64 Rectocele N81.6
65 Hyperplasia uterus N85.1
66 Hypertropi uterus N85.2
67 IUD Z30.5
68 Polyp Cervik uteri N84.1
69
70
71
72
73
74
75
Perawat :


ü
Penyakit : REHAB MEDIS Ruang : INA DRG:

No RM : Kelas :
Nama : Tgl Masuk :

CM
U S K O P
Psychotherapy, not elsewhere classified Z50.4 TENS(trancutanious electrical nerve stimulasi) 93.39
1 1
2 Low back pain M54.5 2
3 Oa / Ostreo Arthritis (oa) M19 3
4 FROSEN SHOULDER M75 4
5 CRS ( CERVIKAL SYNDROM ) M53 5
6 Bell's palsy G51.0 6
7 SINUSITIS MAXILARIS J32 7
8 Tennis Elbow/lateral Epicondylitis M77.1 8
9 HNP M51 9
10 Trigger finger M65.3 10
11 Calcaneal spur M77.3 11
12 ARTRALGIA/LITHAGIN OVINE M25 12
13 Sinusitis, Unspecified J32.9 13
14 THA G44 14
15 Senile nuclear cataract H25.1 15
16 Hypermetropia H52.0 16
17 Psoriasis, unspecified L40.9 17
18 * Arthritis in other viral diseases M01.5 18
19 Spondylosis M47 19
20 Dm Non Insulin Dependen Type 2 E11 20
21 PRURITUS L29 21
22 Dermatitis L30.9 22
23 Hipertensi esensial (primer) I10 23
24 Cva Infark (infarc Cerebri) I63 24
25 BRONCHO PNEMONI J18 25
26 HP/CARIES K02 26
27 GP (GANGRENA PULPAE) K04 27
28 Pulpitis K04.0 28
29 Dispepsia K30 29
30 Pseudofaki Z96.1 30
31 PROLAPS UTERUS N81 31
32 Colic Abd/pain, Unspecified R52.9 32
33 Aff Plate Or Pin Orthopedic Z47.0 33
34 Orthopaedic follow-up care, unspecified Z47.9 34
35 Osseous and subluxation stenosis of intervertebral M99.6 35
36 Sirosis hati lainnya dan YTT K74.6
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Perawat :



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FORMULIR RENCANA PASIEN PULANG

Penyakit : Anak Ruang : INA DRG

No. Diagnosis ICD X No Prosedur ICD IXCM

Nama Tanda Tangan Tgl/jam

Sub bid Rekam Medis

Penyakit : Anak Ruang : INA DRG:

DIAG ICD IX TIND

Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :

ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

Sub bid Rekam Medis (15 Oktober 2008)

Penyakit : Neonatus Ruang : INA DRG :

ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

Penyakit : DALAM Ruang : INA DRG:

DIAG (ü) TIND

Cml,(chronic Myeloid Leukaemia) C92.1 Endoscopic retrograde cholangio pancreatograph

41 HEPATITIS VIRUS YANG TIDAK SPESIFIK B19

Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :

ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

Catatan : Beri tanda (ü) pada kolom DIAG dan TIND

Sub bid Rekam Medis (25 nop 2008)

Penyakit : BEDAH SYARAF Ruang : INA DRG:

DIAG (ü) ICD IX TIND (ü)

Discitis, unspecified M46.4 Intubation nasogastric (decompression) 96.07

Hipertensi esensial (primer) I10

Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :

ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

Catatan : Beri tanda (ü) pada kolom DIAG dan TIND

Sub bid Rekam Medis (20 Oktober 2008)

DIAG (ü) ICD IX TIND (ü)

Fibroblastic disorder, unspecified M72.9

Fibrosclerosis of breast N60.3

Ingrowing nail L60.0

Open wound of other parts of foot S91.3

Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :

ket: DIAG = U : UTAMA, S : SEKUNDER, K : KOMPLIKASI

Catatan : Beri tanda (ü) pada kolom DIAG dan TIND

Sub bid Rekam Medis (25 Nop 2008)

Penyakit : THT Ruang : INA DRG:

DIAG (ü) ICD IX TIND (ü)

Chronic pharyngitis J31.2 Diagnostic ultrasound of head and neck 88.71

Conductive hearing loss. unspecified H90.2

Epistaxis R04.0 Intubation nasogastric (decompression) 96.07

Ispa J06.9 20.42

OTITIS MEDIA KRONIK H65

Tumor larynx C32.9

Nama Tanda Tangan Tgl/jam

ket: DIAG = U : UTAMA. S : SEKUNDER. K : KOMPLIKASI

Catatan : Beri tanda (ü) pada kolom DIAG dan TIND

Sub bid Rekam Medis (25 nop 2008)

Penyakit : ORTHOPEDI Ruang : INA DRG:

DIAG (ü) ICD IX

14 FR.V.LUMBAL S32 14 Eksisi ganglion 82.1

18 Fracture of first metacarpal bone S62.2 18 Intubation nasogastric (decompression) 96.07

22 Fracture of lower end of tibia S82.3 22 Microscopic Examination of Blood 90.59

30 Fraktur anggauta gerak atas. level YTT. tertutup T10.0 30

34 Fraktur tulang belakang. level YTT. terbuka T08.1

35 Fraktur tulang belakang. level YTT. tertutup T08.0

Nama Tanda Tangan Tgl/jam

Dokter Yang Merawat :