PPK Gigi - KEWENANGAN KLINIK (ICD) PABMI

Kewenangan Tindakan Medik
Dokter Gigi
Spesialis Bedah Mulut dan Maksilofasial
Indonesia
KEWENANGAN TINDAKAN MEDIK
DOKTER GIGI
SPESIALIS BEDAH MULUT DAN MAKSILOFASIAL
INDONESIA
EDISI PERTAMA
PENGURUS PUSAT
PERSATUAN AHLI BEDAH MULUT
DAN MAKSILOFASIAL INDONESIA
(PP PABMI)
2017
2
TIM EDITOR DAN KONTRIBUTOR
Tim Editor Coen Pramono D. (Ketua)

Ni Putu Mira Sumarta (Sekretaris)
Iwan Tofani
Benny Latif
Harmas Yasid Yusuf
SetyoHarnowo
Peter Agus
Kontributor
1. Ketua PP PABMI : Safrudin Haq

2. Ketua Kolegium : Coen Pramono D.
3. Ketua Program Studi BBM FKG UNPAD: Endang Sjamsudin
4. Ketua Program Studi BBM FKG UNAIR : A. Harijadi Oesodo
5. Ketua Program Studi BBM FKG UI:Lilies Dwi Suryani
6. Ketua Program Studi BBM FKG UGM: Rahardjo
Saran, keluhan dan laporan kelalaian tindak medik dapat ditujukan kepada
Pengurus Pusat PABMI
3
Kata Pengantar
Tim Editor Buku Kewenangan Tindak Medik (KTM) Edisi Pertama
Keberadaan dan partisipasi PABMI sebagai bagian dari organisasi profesi kedokteran
gigi dalam mendukung program-program pelayanan kesehatan menuju visi Indonesia
Sehat yang di dasari atas jiwa melayani demi kemanusiaan dan sesuai dengan Sumpah
Hipocrates (460 SM) yang dalam hal ini dikerjakan demi menjaga KEHORMATAN dan
MARTABAT profesi Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial Indonesia.
Buku KTM diterbitkan dengan tujuan menjaga Kehormatan dan Martabat profesi
Bedah Mulut dan Maksilofasial dengan mengedepankan saling menghormati dan
menghargai keberadaan seluruh profesi di bidang bedah, termasuk saling, menolong dan
mengisi kekurangan masing-masing. Untuk memenuhi pelayanan kasus bedah mulut dan
maksilofasial di Indonesia yang mencakup daerah dengan geografis yang sangat luas dan
banyak daerah terpencil serta banyaknya pulau-pulau terluar disertai banyaknya faktor
penghambat sehingga, seperti enggannya Dokter Gigi Spesialis Bedah Mulut dan
Maksilofasial untuk bekerja mengabdi ke daerah terpencil karena lebih memilih bekerja di
kota-kota besar, khususnya di Pulau Jawa. Oleh karena itu PP PABMI sangat mendukung
pernyataan Menteri Kesehatan Republik Indonesia Dr. Nasfiah Mboi, Sp.A(K) bahwa
dalam upaya untuk mengisi kekurangan dan untuk menjangkau pelayanan di daerah TTPK
(Tertinggal, Terpencil, Perbatasan dan Kepulauan terluar) yang memungkinkan bagi para
spesialis bedah mulut dan maksilofasial untuk dapat mengabdi memberikan pelayanannya.
Melalui penerbitan buku ini setiap anggota profesi akan tunduk pada peraturan
Organisai Profesi PABMI karena Kewenangan Klinis mutlak menjadi kewenangan dan
tanggung jawab perhimpunan terkait beserta Kolegiumnya untuk membuat aturan yang
baku sebagai dasar acuan. Melalui penerbitan buku ini, diharapkan dapat dipakai oleh
Direktur Rumah Sakit/ RSGM dalam menerbitkan Surat Penugasan Klinik (SPK) dengan
rincian Kewenangan Klinik (RKK) bagi staf Bedah Mulut dan Maksilofasial yang berada
di Rumah Sakit atau RSGM.
PP PABMI sangat menghargai serta apresiasi setinggi-tingginya pada anggota-
anggota yang rela berkorban mengabdi dengan tulus ke daerah-daerah TTKP. PP PABMI
berharap para Direktur Rumah Sakit dan RSGM se-Indonesia dapat memberikan perlakuan
adil dan proporsional serta bijaksana dalam menyelesaikan kasus-kasus tumpang tindih
diantara bidang bedah lainnya melalui pemberian penerbitan Surat Tugas Kewenangan
Klinis (Clinical Appointment). Semoga keberadaan buku ini dapat dipergunakan oleh
Direktur Rumah Sakit/RSGM dalam memberikan Kewenangan Klinis (Clinical
Appointment) tanpa mengesampingkan keberadaan profesi di bidang bedah yang lain.
Surabaya, 16 Januari 2017

Tim Editor
4
Kata Pengantar Ketua Kolegium PABMI
Dengan semangat pengabdian dan rasa kepemilikan serta tanggung jawab pada
profesi bedah, akhirnya Buku Kewenangan Tindakan Medik Dokter Gigi Spesialis Bedah
Mulut dan Maksilofasial 2017 dapat diterbitkan oleh PP PABMI. Penulisan buku ini dibuat
atas dasar:
1. Undang-Undang Dasar Republik Indonesia 1945 Pasal 28 H Ayat 1, Pasal 34 Ayat 3,
mengenai upaya mensejahterakan rakyat.
2. Undang-Undang Nomor 29 Tahun 2004, Tentang Praktik Kedokteran Pasal 4 Ayat 1,
Pasal 44 Ayat 1mengenai Upaya Penjagaan Mutu Pelayanan Kedokteran.
3. Standar Akreditasi Rumah Sakit versi 2012, mengenai Penerbitan Surat Penugasan
Klinis.
Buku ini disusun dengan mengacu pada Clinical Classification of Disease 9th
Revision Clinical Modification (ICD-9-CM, 1992), sedangkan untuk diagnosa penyakit
berdasarkan pada International Statistical Classification of Disease and Related Health
Problems (ICD-10 tahun 1992 dan 1994)yang tidak tercantum dalam buku ini tetapi
mengikuti pada setiap tindakan medik.
Terbitnya buku ini telah memperoleh dukungan dari Ketua PB PDGI, Ketua
ARSGMPI dan Ketua MKKGI dan kepada Tim Editor disampaikan terima kasih.
Selamat bekerja dan mengabdi.
Surabaya, 16 Januari 2017
Coen Pramono D.
(Ketua)
5
Sambutan Ketua PP PABMI
Sambutan Ketua Umum PDGI
Sambutan Ketua Konsil Kedokteran Gigi Indonesia
6
Daftar Isi
Tim Edit Editor dan Kontributor
Kata Pengantar Tim Editor Buku KTM
Kata Pengantar Ketua Kolegium PABMI
Sambutan Ketua PP PABMI
Sambutan Ketua Umum Persatuan Dokter Gigi Indonesia
Sambutan Ketua Konsil Kedokteran Gigi Indonesia
Tata Cara Pembuatan Surat Penugasan Klinik dan White Paper Berdasar Rincian
Clinical Previllage danClinical Appointment Dokter Gigi Spesialis Bedah Mulut
dan Maksilofasial Indonesia
Penyangkalan atau Discalaimer
Daftar Kompetensi dan Kewenangan Klinis Dokter Gigi Spesialis Bedah Mulut
dan Maksilofasial
LAMPIRAN
Lampiran 1. Profil PP PABMI Visi, Misi, Nilai, Azas dan Tujuan PABMI
Lampiran 2. Contoh Surat Penugasan Klinis (SPK)/ Clinical Appointment untuk

Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial
Lampiran 3. Contoh Modifikasi Rincian Kewenangan Klinis (RKK)
Lampiran 4. Contoh Formulir Saran, Keluhan dan Laporan Pengaduan Kelalaian

Tindak Medik
7
Tata Cara Pembuatan Surat Penugasan Klinik dan White paper
Berdasar Rincian Clinical Previllage dan Clinical Appointment
Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial Indonesia
1.Kerangka dasar pembuatan Surat Penugasan Klinis

1.1. Kewenangan tindak medik dalam pelayanan kesehatan yang tertera di dalam
Undang Undang Nomor 29 tahun 2004 tentang Praktek Kedokteran berdasarkan
amanat UUD 1945 pasal 28 H ayat 1 dan pasal 34 ayat 3 tentang upaya
mensejahterakan masyarakat Indonesia.
1.2. Profesi yang mengacu pada standar pendidikan dan modul pembelajaran yang
diterbitkan oleh Kolegium Spesialis di bidang Kedokteran Gigi (OPSKG) yang
telah disahkan oleh KKI.
1.3. Standar Kompetensi dan Standar Pelayanan yang disusun oleh Organisasi Profesi
Kedokteran Gigi (OPSKG).
1.4. Standar Etik atau Kode Etik dikeluarkan oleh Majelis Kehormatan dan Etika
Kedokteran Gigi (MKEKG).
1.5. Standar Akreditasi Rumah Sakit Versi 2012.
1.6. Visi, Misi, Asas Tujuan Penyelenggaraan RS / RSGM.
2. Kewenangan Tindak Medik Dokter Gigi Spesialis Kedokteran Gigi

diberikan kepada dokter gigi masing-masing staf medis di RSGM terkait
dengan rincian kewenangan klinik meliputi:
2.1. Penegakkan diagnosis penyakit di bidang kedokteran gigi sesuai klasifikasi ICD-
10 (anamnesis dan pemeriksaan klinis yang terarah, dilengkapi dengan
pemeriksaan penunjang laboratorium, pencitraan USG, ekokardiografi, ECG,
biopsi / FNAB, dll).
2.2. Memberikan terapi dalam bentuk tindakan bedah atau non-bedah (kasus bedah
tanpa operasi seperti: perawatan infeksi dengan trismus, perawatan emergensi
dental, termasuk melakukan terapi penunjang: memberikan terapi antibiotika
rasional, analgesik, nutrisi, cairan elektrolit, dll.
2.3. Melakukan perawatan kasus bedah di bidang kedokteran gigi akut maupun elektif.
2.4. Melakukan perawatan kasus di bidang kedokteran gigi akut maupun elektif.
2.5. Mendeteksi dan menangani komplikasi durante dan pasca operasi di bidang
kedokteran gigi.
2.6. Memberikan rehabilitasi kasus bedah mulut dan maksilofasial dan follow up-nya.
2.7. Memberikan rehabilitasi kasus di bidang kedokteran gigi dan follow up-nya.
2.8. Memberikan konsultasi, informasi, edukasi (KIE) pada pasien maupun
keluarganya.
2.9. Mencatat semua proses asuhan medis pada semua kasus perawatan di Rumah
Sakit dalam dokumen rekam medik.
2.10.Sebelum melakukan semua tindakan invasif maupun non-invasif harus membuat
informed consent yang ditandatangani bersama dokter dan penderita serta
keluarganya.
8
2.11.Dalam melaksanakan tindakan bedah dan tindakan kedokteran gigi harus
mengikuti standar patient safety, misal : melakukan time out sebelum melakukan
tindakan medis.
3. Bagan alur pengajuan pembuatan Surat Penugasan Klinik (White Paper)

3.1. Dokter yang telah bekerja di suatu rumah sakit
Dokter Gigi Spesialis, Staf Medis  Membuat rincian kewenangan tindakan
yang berangkutan medis sesuai dengan acuan Organisasi
Profesi Kedokteran Gigi dan Kolegium
terkait
 Rincian tertulis tersebut diajukan kepada
Ketua Departemen terkait.
Ketua Departemen/ SMF Bedah  Melakukan penelitian kebenaran

Mulut dan Maksilofasial dokumen yang berisi kompetensi dokter
gigi spesialis Bedah Mulut dan
Maksilofasial.
Komite Medis RS/RSGM  Melakukan verifikasi dan validasi serta

Sub Komite Kredensial evaluasi akhir semua dokumen dokter
gigi Spesialis Bedah Muliut dan
Maksilofasial yang bersangkutan.
 Memberi rekomendasi kepada Direktur
Rumah Sakit/ RSGM.
Direktur Rumah Sakit/ RSGM  Bersama dengan dokter/ dokter gigi ybs
menandatangani berita acara yang berisi
rincian kewenangan klinik yang telah
disepakati berdasarkan rekomendasi
Komite Medis.
 Menerbitan Surat Penugasan Klinis
kepada Dokter Gigi Spesialis Bedah
Mulut dan Maksilofasial.
Dokter Gigi Spesialis Bedah Mulut,  Menyerahkan Surat Penugasan Klinis

Staf Medis ybs kepada Ketua SMF Bedah Mulut dan
Maksilofasial
9
3.2. Dokter baru yang telah bekerja di suatu rumah sakit
Dokter Gigi Spesialis, Staf Medis  Mengajukan Surat Lamaran ke Direktur
yang berangkutan Rumah Sakit/ RSGM dengan tembusan
ke Ketua Departemen/ SMF Bedah
Mulut dan Maksilofasial
 Membawa Surat Penempatan.
 Membuat surat tertulis rincian
kewenangan tindakan medis sesuai
dengan acuan Organisasi Profesi
Kedokteran Gigi dan Kolegium terkait.
Ketua Departemen/ SMF Bedah  Menyerahkan semua dokumen lamaran

Mulut dan Maksilofasial dan surat penempatan serta daftar rincian
kewenangan tindakan medis kepada
Komite Medis RS/ RSGM
Komite Medis RS/RSGM  Melakukan verifikasi dan validasi serta

Panitia Komite Kredensial evaluasi akhir semua dokumen dokter
gigi Spesialis Bedah Muliut dan
Maksilofasial yang bersangkutan.
 Memberi rekomendasi kepada Direktur
Rumah Sakit/ RSGM.
Direktur Rumah Sakit/ RSGM  Bersama dengan dokter/ dokter gigi ybs
menandatangani berita acara yang berisi
rincian kewenangan klinik yang telah
disepakati berdasarkan rekomendasi
Komite Medis.
 Menerbitan Surat Penugasan Klinis
kepada Dokter Gigi Spesialis Bedah
Mulut dan Maksilofasial.
Dokter Gigi Spesialis Bedah Mulut,  Menyerahkan Surat Penugasan Klinis

Staf Medis ybs kepada Ketua SMF Bedah Mulut dan
Maksilofasial
10
Penyangkalan atau Disclaimer
Buku Kewenangan Tindak Medik Dokter Gigi Spsialis Bedah Mulut dan
Maksilofasial Indonesia ini adalah merupakan rangkuman dari sejumlah tindakan medis
yang dapat dilakukan oleh Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial yang
dapat dipakai sebagai acuan atau pedoman oleh Rumah Sakit/ RSGM dalam hal ini
Direktur Rumah Sakit bersama Komite Medis Rumah Sakit/ RSGM dalam menerbitkan
Surat Penugasan Klinik kepada setiap Dokter Gigi Spesialis Bedah Mulut dan
Maksilofasial yang berada di Rumah Sakit/ RSGM tersebut.
Buku Kewenangan Tindakan Medik Dokter Gigi Spesialis Bedah Mulut dan
Maksilofasal Indonesia ini berisi informasi rincian secara lengkap tentang tindakan bedah
seorang Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial Indonesia. Setiap kasus/
penyakit bedah di bidang bedah mulut dan maksilofasial yang ditandatangani memerlukan
ketersediaan sarana dan fasilitas kesehatan maupun alat kesehatan pendukung, hal tersebut
dapat sangat bervariasi termasuk ketidaklengkapannya atau ketidaksempurnaannya.
Buku ini tidak menghilangkan hak Direktur Rumah Sakit/ RSGM untuk memberikan
penugasan klinik yang melebihi ataupun mengurangi dari daftar yang ada kepada staf
medis Rumah Sakit/ RSGM, tergantung dari situasi yang dihadapi oleh Rumah Sakit/
RSGM dalam pengadaan SDM Staf Medis, termasuk pemberian kewenangan klinis
tindakan pembedahan kepada Spesialis Bedah Mulut dan Maksilofasial. Beberapa tindakan
bedah mulut dan maksilofasial diperlukan suatu tindakan perawatan terpadu dan untuk hal
ini memerlukan kebijakan Direktur Rumah Sakit/ RSGM dalam hal memberikan
kewenangan tindakan.
Buku ini tidak memberi jaminan atas keberhasilan suatu tindakan operasi dengan
hasil yang baik, sempurna dan memuaskan bagi penderita karena tingkat kesulitan
penanganan diagnostik maupun terapi bedah setiap kasus bedah terutama pada kasus yang
memiliki kesulitan tinggi dan bervariasi. Untuk hal tersebut, maka disarankan diantara para
Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial yang terlibat dalam penanganan
suatu kasus bedah mulut dan maksilofasial yang sulit untuk dapat bekerja sama secara tim
dan atau melakukan konsultasidan rujukan (rujukan pasien, rujukan ilmu dan rujukan
dokter ahli), apabila Dokter Gigi Spesialis Bedah Mulut dan Maksilofasial yang
bersangkutan tidak menguasai atau mengalami keraguan dalam menegakkan diagnosis
maupun terapi bedah. Untuk melengkapi dan menyempurnakan mutu pelayanan kesehatan
kepada penderita bedah mulut dan maksilofasial diperlukan juga Pedoman Nasional
Praktek Dokter Gigi (PNPDG), Standar Pelayanan Medis, Panduan Praktek Klinik (PPK),
Standar Pelayanan Medis, Clinical Pathway, Clinical Guidelines,Standar Prosedur
Operasional (SPO) dan lain-lain.
Apabila terjadi suatu kejadian akibat tindakan seorang dokter, maka hal tersebut
merupakan tanggung jawab dokter yang bersangkutan dan Direktur Rumah Sakit/ RSGM.
11
KOLEGIUM
BEDAH MULUT DAN MAKSILOFASIAL INDONESIA
KEWENANGAN KLINIS
SPESIALIS BEDAH MULUT DAN MAKSILOFASIAL
INDONESIA
2017
KOLEGIUM
12
DAFTAR KOMPETENSI DAN KEWENANGAN KLINIS
SPESIALIS BEDAH MULUT DAN MAKSILOFASIAL INDONESIA
KEWENANGAN KLINIS SPESIALIS

ICD-10CM ICD-9 CM
Dimint Disetuju
Diagnose Procedure a i
Codes Codes
BEDAH DENTOALVEOLAR
K00. DISORDER OF TOOTH DEVELOPMENT AND ERUPTION

Supernumarary Teeth
K00.1 Includes : Supplementary teeth
Excludes : Impacted supernumerary teeth
Incisor and canine region
K00.10
Mesiodens
Premolar region K00.11
Molar region
Distomolar
K00.12
Paramolar
Fourth molar
Supernumerary teeth, unspecified K00.19
K00.2 Abnormalitiesof Size and Form of Teeth K00.20 - 29
K00.6 Disturbance in Tooth Eruption
Natal teeth K00.60
Neonatal teeth K00.61
Premature eruption (dentia praecox) K00.62
Retained (persistensi) primary (deciduous) teeth K00.63
Late eruption K00.64
Premature shedding of primary (deciduous)teeth K00.65
Other specified disturbances in tooth eruption K00.68
Disturbances in tooth eruption, unspecified K00.69
K01. EMBEDDED AND IMPACTED TEETH

K01.0 Embedded Teeth
K01.1 Impacted Teeth
Maxillary incisor K01.10
13
Mandibular incisor K01.11
Maxillary canine K01.12
Mandibular canine K01.13
Maxillary premolar K01.14
Mandibular premolar K01.15
Maxillary molar K01.16
Mandibular molar K01.17
Supernumerary tooth K01.18
Impacted tooth, unspecified K01.19
K03. OTHER DISEASES OF HARD TISSUES OF TEETH

K03.3 Pathological Resorption of Teeth
External K03.30
Internal (internal granuloma) K03.31
Pathological resorption of teeth, unspecified K03.39
Hypercementosis
K03.4
Excludes : Hypercementosis in Paget’s disease
K03.5 Ankylosis of Teeth
K03.60 - 66
K03.6 Deposits (accretions) on Teeth
K03.68 - 69
K04. DISEASES OF PULP AND PERIAPICAL TISSUE

K04.0 Pulpitis
Acute K04.01
Suppurative (pulpal abscess) K04.02
Chronic K04.03
Necrosis Pulp
K04.1
Pulpal gangrene
Acute Apical Periodontitis of Pulpal Origin
K04.4
Acute apical periodontitis NOS
Chronic Apical Periodontitis
K04.5
Apical granuloma
Periapical Abscess with Sinus
K04.6
Includes :Dental, dentoalveolar
Sinus to maxillary antrum K04.60
Sinus to nasal cavity K04.61
Sinus to oral cavity K04.62
Sinus to skin K04.63
14
Periapical abcess with sinus, unspecified K04.69
Periapical Abscess without Sinus
Dental abscess
K04.7 Dentoalveolar abscess
Periodontal abscess of pulpal origin
Periapical abscess with no reference to sinus
Radicular Cyst
K04.8
Includes : Apical periodontal, periapical
Apical and lateral K04.80
Residual K04.81
Inflamatory paradental
Excludes: Developmental lateral periodontal cyst K04.82
(K09.04)
Radicular cyst, unspecified K04.89
K04.9 Other and Unspecified Diseases of Pulp and Periapical
K05. GINGIVITIS AND PERIODONTAL DISEASES

K05.1 Chronic Gingivitis
Simple marginal K05.10
Hyperplastic K05.11
Ulcerative
Excludes : necrotizingulcerative gingivitis K05.12
(A69.10)
Desquamative K05.13
Other specified chronic gingivitis K05.18
Chronic gingivitis, unspecified K05.19
K05.2 Acute Periodontitis
 Periodontal abcess (paradontal abscess) of
gingival origin without sinus
 Periodontal abcess of gingival origin with no
reference to sinus
Excludes: K05.20
Acute apical periodontitis of pulpal origin
(K04.4)
Acute periapical abcess of pulpal origin
(K04.7)
Acute pericoronitis K05.22
Other specified acute periodontitis K05.28
Acute periodontitis, unspecified K05.29
K05.3 Chronic Periodontitis
Simplex K05.30
15
Complex K05.31
Chronic pericoronitis K05.32
Thickened follicle K05.33
Other specified chronic periodontitis K05.38
Chronic periodontitis, unspecified K05.39
Periodontitis
K05.4
Juvenile periodontitis
K05.5 Other Periodontal Diseases
OTHER DISORDER OF GINGIVA AND EDENTULOUS ALVEOLAR RIDGE

K06.
Excludes : Atrophy of edentulous alveolar ridge (K08.2) gingivitis (K05.0 - 1)
Gingival Recession
K06.0
Includes : Postinfective, postoperative
Localized K06.00
Generalized K06.01
Gingival recession, unspecified K06.09
Gingival Enlargement
K06.1
Includes : Tuberosity
Gingival fibromatosis K06.10
Other specified gingival enlargement K06.18
Gingival enlargement, unspecified K06.19
K06.2 Gingival and Edentulous Alveolar Ridge Lesions Associated with Trauma
Due to traumatic occlusion K06.20
Due to toothbrushing K06.21
Frictional(functional)keratosis K06.22
Irritativehyperplasia (denturehyperplasia) K06.23
Otherspecifiedgingivalandedentulousalveolar
K06.28
ridgelesions associated withtrauma
Unspecified gingival andedentulous
K06.29
alveolarridgelesionsassociated withtrauma
K06.8 OtherSpecifiedDisordersof GingivaandEdentulous AlveolarRidge
Gingivalcystof adult
K06.80
Excludes:Gingival cyst of newborn (K09.82)
Peripheralgiantcellgranuloma(giantcellepulis) K06.81
Fibrousepulis K06.82
Pyogenicgranuloma K06.83
Excludes:Pyogenic granulomaof site
otherthangingivaor edentulous alveolar
ridge (K13.40)
16
Flabby ridge K06.84
Other K06.88
K06.9 DisorderofGingiva andEdentulousAlveolarRidge, Unspecified
K07. DENTOFACIAL ANOMALIES (INCLUDING MALOCCLUSION)

Major Anomalies of Jaw Size
Excludes:
Acromegaly (E22.0)
K07.0 Hemifacial atrophy or hypertrophy (Q67.4)
Robin's syndrome (Q87.0)
Unilateral condylar hyperplasia (Kl0.81)
Unilateral condylar hypoplasia (K10.82)
Maxillary macrognathism (maxillary
K07.00
hyperplasia)
Mandibular macrognathism
K07.01
(mandibularhyperplasia)
Macrognathism,bothjaws K07.02
Maxillary micrognathism (maxillary hypoplasia) K07.03
Mandibular micrognathism (mandibular
K07.04
hypoplasia)
Micrognathism, both jaws K07.05
Other specified jaw size anomalies K07.08
Anomaly of jaw size, unspecified K07.09
K07.1 Anomalies of Jaw-Cranial Base Relationship
Asymmetries
Excludes:
Hemifacial atrophy (Q64.40)
K07.10
Hemifacial hypertrophy (Q67.41)
Unilateral coudyiar hyperplasia (K
10.81)Unilateralcondylar hypoplasia (K10.82)
Mandibular prognathism K07.11
Maxillary prognathism K07.12
Mandibular retrognathism K07.13
Maxillaryretrognathism K07.14
Other specified anomalies of jaw-cranial base
K07.18
relationship
Anomaly of jaw-cranial base relationship,
K07.19
unspecified
K07.2 Anomalies of Dental Arch Relationship
Disto-occlusion K07.20
17
Mesio-occlusion K07.21
Excessive overjet (horizontal overbite) K07.22
Excessive overbite (vertical overbite) K07.23
Openbite K07.24
Crossbite (anterior, posterior) K07.25
Midline deviation K07.26
Posterior lingual occlusion of mandibular teeth K07.27
Other specified anomalies of dental arch
K07.28
relationship
Anomaly of dental arch relationship,unspecified K07.29
K07.3 Anomalies of Tooth Position
Crowding
K07.30
Imbrication
Displacement K07.31
Rotation K07.32
Spacing
K07.33
Diastema
Transposition K07.34
Embedded or impacted teeth in abnormal
position
K07.35
Excludes: embedded or impacted teeth in normal
position (K01.0, K01.1)
Other specified anomalies of tooth position K07.38
Anomaly of tooth position, unspecified K07.39
K07.4 Malocclusion, Unspecified
DentofacialFunctional Abnormalities
K07.5
Excludes:bruxism (teeth-grinding)(F45.82)
Abnormal jaw closure K07.50
Malocclusion due to abnormal swallowing K07.51
Malocclusion due to mouth breathing K07.54
Malocclusion due to tongue, lip or finger habits K07.55
Other specified dentofacial functional
K07.58
abnormalities
Dentofacial functional abnormality, unspecified K07.59
K07.6 Temporomandibular Joint Disorders
Temporomandibular joint-pain-dysfunction
syndrome (Costen)
Excludes:Current temporomandibularjoint K07.60
dislocation(S03.0)and strain (S03.4)diseases
listed in Chapter XIII
Clicking (snapping) jaws K07.61
18
Recurrent dislocation and sublexation of
temporomandibular joint K07.62
Excludes: Current injury (S03.0)
Pain in temporomandibular joint, not
elsewhereclassified
K07.63
Excludes:Temporomandibular joint-pain-
dysfunctionsyndrome (Costen) (K07.60)
Stiffness of temporomandibular joint, not
K07.64
elsewhereclassified
Osteophyte of temporomandibular joint K07.65
Other specified temporomandibular joint
K07.68
disorders
Temporomandibular joint disorder, unspecified K07.69
K08. OTHER DISORDERS OF TEETH AND SUPPORTING STRUCTURES

Exfoliation of Teeth Due to Systemic Causes
K0.8.0
Excludes :Anodontia (K00.0)
Exfolation of teeth (attributable to diseases of
surrounding tissues, including systemic causes,
e.g. acrodynia (T56.1) hypophosphatasia (E83.3) K08.0X
Excludes :Premature shedding of primary
(deciduous) teeth (S03.2)
Loss of Teeth Due to Accident, Extraction or Local Periodontal Disease
K08.1
Excludes :Current accident (S03.2)
K08.2 Atrophy of Edentulous Alveolar Ridge
K08.3 Retained Dental Root
K08.8 Other Specified Disorders of Teeth and Supporting Structures
Toothache NOS K08.80
Irregular alveloar process K08.81
Enlargement of alveloar ridge NOS K08.82
Other K08.88
K08.9 Disorder of Teeth and Supporting Structures, Unspecified
CYSTS OF ORAL REGION, NOT ELSEWHERE CLASSIFIED

K09.
Excludes :Radicular cyst (K04.8), mucous cyst (K11.6)
K09.0 Developmental Odontogenic Cysts1
Eruption K09.00
Gingival K09.01
Keratocyst (primordial) K09.02
Follicular (dentigerous) K09.03
19
Lateral periodontal K09.04
Other specified developmental odontogenic cysts K09.08
Developmental odontogenic cyst, unspecified K09.09
Developmental (non-odontogenic) Cysts of Oral Region1
K09.1
Includes : ’’fissural’’ cysts
Globulomaxillary K09.10
Median palatal K09.11
Nasopalatine (incisive canal) K09.12
Palatine papilla K09.13
Other specified developmental cysts of oral
K09.18
region
Developmental cyst of oral region, unspecified K09.19
Other Cysts of Jaw 1
K09.2
Excludes :Latent bone cyst of jaw (K10.02), Stafne’s cyst (K10.02)
Aneurysmal bone cyst2 K09.20
Solitary bone (traumatic) (haemorrhagic) cyst K09.21
Epithelial jaw cysts not identifiable as
K09.22
odontogenic or non-odontogenic
Other specified cysts or jaw K09.28
Cyst of jaw, unspecified K09.29
K09.8 Other Cysts of Oral Region, Not Elsewhere Classified
Dermoid cyst K09.80
Epidermoid cyst K09.81
Gingival cyst of newborn
K09.82
Excludes:Gingival cyst of adult (K06.80)
Palatal cyst of newborn
K09.83
Epstein's pearl
Nasoalveolar (nasolabial) cyst K09.84
Lymphoepithelial cyst K09.85
Other specified cysts of oral region K09.88
K09.9 Cyst of Oral Region, Unspecified
K10. OTHER DISEASES OF JAWS

K10.00 Developmental Disorders of Jaws
Torus mandibularis K10.00
Torus palatinus K10.01
Latent bone cyst K10.02
Developmental bone defect in mandible
Stafne's cyst
20
Static bone cyst
Other specified developmental disordersof K10.08
jaws
Developmental disorder of jaws, unspecified K10.09
Giant Cell Granuloma, Central
K10.1 Giant cell granu]oma NOS
Excludes: peripheral (K06.81)
Inflammatory Conditions of Jaws
K10.2 Use additional external cause code (chapter XX), if desired, to identify radiation, if radiation-
induced
Osteitis of jaw
Excludes: Alveolar osteitis (K10.3), dry socket K10.20
(K10.3)
Osteomyelitis of jaw
Excludes:Neonatal osteomyelitis of maxilla K10.21
(neonatal maxillitis)(KI0.24)
Periostitis of jaw K10.22
Chronic periostitis of jaw
Hyalinemicroangiopathy K10.23
Pulse granuloma
Neonatal osteomyelitis of maxilla (neonatal
K10.24
maxillitis)
Squestrum K10.25
Osteoradionecrosis K10.26
Other specified inflammatory conditions of iaws K10.28
Inflammatory condition of jaws, unspecified K10.29
Alveolitis of Jaws
K10.3 Alveolar osteitis
Dry socket
Other Specified Diseases of Jaws
K10.8
Excludes:Fibrous dysplasia, polyostotic (Q78. 1)
Cherubism1 K10.80
Unilateral condylar hyperplasia of mandible K10.81
Unilateral condylar hypoplasia ofmandible K10.82
Fibrous dysplasia of jaw K10.83
Other specified diseases of jaws
K10.88
Exostosis of jaw
K10.9 Disease of Jaws, Unspecified
DISEASES OF SALIVARY GLANDS

K11.
Excludes:Salivary gland tumours (C07.-, C08.-, D10.-,D11.-)
21
K11.0 Atrophy of Salivary Gland
K11.1 Hypertrophy of SalivaryGland
Sialoadenitis
K11.2
Excludes:Epidemic parotitis (mumps)(B26.-), uveoparotid fever (Hccrfordt)(D86.8)
K11.3 Abscess of Salivary Gland
Fistula of Salivary Gland
K11.4
Excludes :Congenital fistula of salivary gland(Q38.43)
Sialolithiasis
K11.5
Calculus (stone) in salivary duct
Mucocele of Salivary Gland
K11.6
Ranula
Mucous retention cyst K11.60
Mucous extravasation cyst K11.61
Mucocele of salivary gland, unspecified K11.69
Disturbances of Salivary Secretion
K11.7
Excludes :Dry mouth NOS (R68.2), sicca syndrome (Sjogren) (M35.0)
Hyposecretion K11.70
Xerostomia K11.71
Hypersecretion (ptyausrn) K11.72
Other specified disturbances of salivary secretion K11.78
Disturbance of salivary secretion, unspecified K11.79
Other Diseases of Salivary Glands
K11.8
Excludes :Sicca syndrome (Sjogren)(M35.0)
Benign lymphoepithelial lesion of salivary gland K11.80
Mikuliczdisease K11.81
Stenosis (stricture) of salivary duct K11.82
Sialectasia K11.83
Sialosis K11.84
Necrotizing slatometaplasia K11.85
Other specified diseases of salivary glands K11.88
Disease of Salivary Gland, Unspecified
K11.9
SialoadenopathyNOS
STOMATITIS AND RELATED LESIONS

Excludes :Focal epithelial hyperplasia (B07.X2)
Herpangina (B08.5X)
K12.
Pyostomatitisvaginatus (L08.0X) stomatitis :
 Acutenecrotizing(A69.0)
 Allergic(L23.-)
22
 Candidal(B37.0)
 Cotton roll (K12.14)
 Coxsackievirus NOS (B34.1)
 Cpizootic(B08.8)
 Fusospirochactal (A69.0)
 Medicamentosa(T36- T50)
 Mycotic(B37.0)
 Nicotinic (K13.24)
 Vesicular with exanthem (B08.4)
 Streptococcal gingivostornatitis (K05.00)
 Vesicularstomatitis virus disease (Indiana fever)(A93.8X)
K12.0 Recurrent Oral Aphthae
Recurrent (minor) aphthae
Aphthous stomatitis
Canker sore
K12.00
Mikulicz’ aphthae
Minor aphthae
Recurrent aphthous ulcer
Periadenitis mucosa necrotica recurrens
Cicatrizing aphthous stomatitis
K12.01
Major aphthae
Sutton's aphthae
Stomatitis herpetiformis (herpetiform eruption)
Excludes :Dermatitis herpetiformis (L13.0X), K12.02
herpesviral gingivostomatitis (B00.2X)
Bednar's aphthae K12.03
Traumatic ulcer
Excludes :Traumatic ulcer of tongue K12.04
(K14.01),ulcers of tongue NOS (K14.09)
Other specified recurrent oral aphthae K12.08
Recurrent oral aphthae, unspecified K12.09
K12.1 Other Forms of Stomatitis
Stomatitis artifacta K12.10
Geographic stomatitis
K12.11
Excludes :Geographic tongue (K14.1)
Denture stomatitis
Excludes :Denture stomatitis due to candida K12.12
infection (B33.03),traumatic ulcer due to denture
(K12.04)
Papillary hyperplasia of palate K12.13
Contact stomatitis
K12.14
Cotton roll stomatitis
Other specified forms ofstomatitis K12.18
23
Stomatitis, unspecified K12.19
Cellulitis and Abscess of Mouth
Phlegmon
Submandibular abscess
Excludes :abscess (of):
K12.2  Periapical (K04.6-K04.7)
 Periodontal (K05.21)
 Peritonsillar (J36)
 Salivary gland(K11.3)
 Tongue(K14.00)
OTHER DISEASES OF LIP AND ORAL MUCOSA

Includes :Epithelial disturbances of tongue
Excludes :Certain disorders of gingiva and edentulous alveolar ridge (K05.-K06.)
K13.
Cysts of oral region (K09.)
Diseases of tongue (K14.)
Stomatitis and related lesions (K12.)
Diseases of Lips
K13.0 Excludes : Actinic cheilitis (L56.8X)
Ariboflavinosis (E53.0)
Angular cheilitis
Angular cheolosis
Perleche NEC
K13.00
Excludes : Perleche due to :
 candidiasis (B37.0)
 riboflavin deficiency (E53.0)
Cheilitis glandularis apostematosa K13.01
Cheilitis, exfoliative K13.02
Cheilitis NOS K13.03
Cheilodynia K13.04
Other specified diseases of lips K13.08
Disease of lips,unspecified K13.09
K13.1 Cheek and lip biting
Leukoplakia And Other Disturbances Of Oral Epithelium Including Tongue
Excludes : Candinal leukoplakia (B37.02)
Focal epthelial hyperplasia (B07.X2)
K13.21
Frictional keratosis (K06.22)
Functional keratosis (K06.22)
Hairy leukoplakia (K13.3)
Leukoplakia, idiopathic K13.20
Leukoplakia, tobacco-associated K13.21
24
Excludes :Leukokeratosis nicotina palati
(K13.24), Smoker’s palate (K13.24)
Erythroplakia K13.22
Leukoedema K13.23
Smoker's palate [leukokeratosis nicotina palati]
K13.24
[nicotinic stomatitis]
Other K13.28
Unspecified
K13.29
Leukoplakia NOS
K13.3 Hairy Leukoplakia
K13.4 Granuloma And Granuloma-Like Lesions Of Oral Mucosa
Pyogenic granuloma
K13.40
Excludes:gingiva (K06.83)
Eosinophilic granuloma of oral mucosa
Exciudes:eosinophilic granuloma of bone K13.41
(D76.00) , histiocytosis X (D76. -)
Verrucous xanthoma [histiocytosis Y] K13.42
Other specified granuloma and granuloma-like
K13.48
lesions of oral mucosa
Granuloma and granuloma-like lesions cf oral
K13.49
mucosa, unspecified
K13.5 Oral Submucous Fibrosis
Irritative Hyperplasia Of Oral Mucosa
K13.6
Excludes:irritative hyperplasia [denture hyperplasia) of edcntulous alveolar ridge (K06.23)
K13.7 Other And Unspecified Lesions Of Oral Mucosa
Excessive melanin pigmentation
K13.70
Mclanoplakia
Oral fistula
K13.71
Excludes: oroantral fistula (T81.8)
Deliberate tattoo
K13.72
Excludes:amalgam tattoo (T81.50)
Focal oral mucinosis K13.72
Other specified lesions of oral mucosa
K13.78
Linea alba
Lesion of oral mucosa. Unspecified K13.79
DISEASES OF TONGUE
Excludes :Erythroplakia of tongue (K13.22)
K14. Focal epithelialhyperplasia (B07.X2)
Hairy leukoplakia (K13.3)
Leukoedema of tongue (K13.3)
25
Leukoplakia of tongue (K13.2)
Macroglossia (congenital) (Q38.2X)
Submucous fibrosisi of tongue (K13.5)
Glossitis
K14.0
Excludes: atrophicglossiris(K14.42)
Abscessof tongue K14.00
Traumaticulcerationof tongue K14.01
Otherspecifiedglossitis K14.08
Glossitis.Unspecified
K14.09
Ulcer of tongue NOS
GeographicTongue
K14.1 Benignmigratoryglossitis
Glossitisareata exfoliative
K14.2 MedianRhomboidGlossitis
HypertrophyOfTonguePapillae
Coatedtongue K14.30
Hairytongue
Blackhairytongue
Lingua villosa nigra K14.31
Excludes : hairyleukoplakia(K 13.3)
hairytonguedueto antibiotics(K14.38)
Hypertrophyof foliatepapillae K14.32
Otherspecifiedhypertrophyof tongue papillae
K14.38
Hairytongueduetoantibiotics
Hypertrophyoftonguepapillae,unspecified K14.39
Plicated Tongue
Fissured Tongue
K14.5 Furrowed Tongue
Scrotal Tongue
Excludes :fissuredtongue,congenital(Q38.33)
Glossodynia
Excludes :abnormalitiesof taste(R43,-)
Glossopyrosis[burningtongue] K14.60
Glossodynia[painfultongue] K14.61
Otherspecifiedglossodynia K14.68
Glossodynia. Unspecified K14.69
K14.8 OtherDiseasesOf Tongue
Crenatedtongue[linguaindentata] K14.80
Hypertrophyoftongue
Hemihypcrtrophyof tongue K14.81
Excludes:macroglossia (congenital) (Q38.2X)
26
Atrophy of tongue
Hemia trophy of tongue K14.82
Excludes: atrophy of tongue papillae (K14.4)
Other specified diseases of tongue
K14.88
Disease of lingual tonsil
K14.9 Disease Of Tongue, Unspecified
K50. CROHN’S DISEASE (REGIONAL ENTERITIS)

Oral manifestations K50.8X
Prosthetic dental implant 23.6

Apicoectomy and root canal therapy 23.7
Root canal therapy with apicoectomy 23.72
Apicoectomy 23.73
Other Other surgical extraction of tooth 23.19
(Root Resection/ Hemisection)
 Resection of Upper Tooth, Single, Open
Approach
 Resection of Upper Tooth, Multiple, Open
Approach
 Resection of Upper Tooth, All, Open
Approach
 Resection of Lower Tooth, Single, Open
Approach
 Resection of Lower Tooth, Multiple, Open
Approach
 Resection of Lower Tooth, All, Open
Approach
 Resection of Upper Tooth, Single, Open
Approach
 Resection of Upper Tooth, Multiple, Open
Approach
 Resection of Upper Tooth, All, Open
Approach
Disertai
 Transfer Upper Gingiva, Open Approach
 Transfer Upper Gingiva, External Approach
Scenario 2
 Resection of Lower Tooth, Single, Open
Approach
 Resection of Lower Tooth, Multiple, Open
27
Approach
 Resection of Lower Tooth, All, Open
Approach
Disertai
 Transfer Lower Gingiva, Open Approach
 Transfer Lower Gingiva, External Approach
Exposure of tooth 24.6
Application of orthodontic appliance 24.7
Oro-Antral Fistula Closure 528.3
Closure of nasal sinus fistula 22.71
 Repair Right Maxillary Sinus, Open Approach
 Repair Right Maxillary Sinus, Percutaneous
Approach
22.79
 Repair Right Maxillary Sinus, Percutaneous
Endoscopic Approach
 Repair Buccal Mucosa, Open Approach
 Repair Buccal Mucosa, Percutaneous
Approach 22.71
 Repair Buccal Mucosa, External Approach
CORPUS ALENIUM SINUS MAKSILARIS

Other external maxillary antrotomy
 Extirpation of Matter from Right Maxillary
Sinus, Open Approach
 Extirpation of Matter from Right Maxillary 22.39
Sinus, Percutaneous Approach
 Extirpation of Matter from Left Maxillary
Sinus, Open Approach
PREPROSTHETIC SURGERY
Alveoloplasty
(Alveolectomy (interradicular) (intraseptal) 24.5
(radical) (simple) (with graft or implant)
Extension or deepening of buccolabial or lingual
sulcus (Vestibuloplasty)
 Release Buccal Mucosa, Open Approach 0CN40ZZ
24.91
 Release Buccal Mucosa, Percutaneous
0CN43ZZ
Approach
 Release Buccal Mucosa, External Approach 0CN4XZZ
Exostosis of the Jaw M27.8 526.81
28
Jaw (bone)
Torus:
Mandibularis
Palatinus
Enlargement : Hypertrophy alveolar processus or
525.8
ridge
Free skin graft: Split Skin Graft 86.6
29
DENTAL IMPLANT TOOTH-ROOT MANDIBULAR IMPLANTS
Mandibular Implant (Dental)
Tooth root(s) Z96.5
Implanted Device (artificial)(functional)
DENTAL IMPLANT FAILURE

Osseointegration failure of dental implant M27.61 525.71
Post-osseointegration biological failure of dental
M27.62 525.72
implant
Post-osseointegration mechanical failure of
M27.63 525.73
dental implant
Other endosseous dental implant failure M27.69 525.79
Disebabkan karena:
infection
M27.61 525.71
Poor Bone quality poor bone quality
Lack of attached gingiva
Occlusal trauma (caused by poor prosthetic
design)
Parafunctional habits M27.62 525.72
Periodontal infection (peri-implantitis)
Poor oral hygiene
Unintentional loading
Endosseous NEC M27.69 525.79
Mechanical M27.63 525.63
Disebabkan karena:
M27.61
Iatrogenic
Post-osseointegration:
525.72
biological failure
M27.62
iatrogenic
due to complications of systemic disease
pre-osseointegration M27.61 525.71
30
INFLAMMATORY CONDITIONS OF JAWS
Open wound of tooth (broken) (fractured) (due to
ttrauma), without mention of compiIcation
S02.5XXA
 Fracture of tooth (traumatic), initial encounter
for closed fracture
S02.5XXB
for open fracture
Tooth (broken) (fractured) (due to trauma), 873.63
Complicated
S02.5XXA
for closed fracture
S02.5XXB
for open fracture
Avulsion (traumatic) tooth
S03.2
Avulsion traumatic complicated 873.73
PERIODONTIC SURGERY
Operations On Teeth, Gums, And Alveoli 24
Incision of gum or alveolar bone
Drainage of Upper Gingiva with Drainage
0C9500Z
Device, Open Approach
Drainage of Upper Gingiva, Open Approach 0C950ZZ
24.0
0C9530Z
Device, Percutaneous Approach
Drainage of Upper Gingiva, Percutaneous
0C953ZZ
Approach
0C950ZX 24.11
Drainage of Upper Gingiva with Drainage 24.0
0C95X0Z
Device, External Approach
Drainage of Upper Gingiva, External Approach 0C95XZZ
Drainage of Lower Gingiva with Drainage
0C9600Z
Drainage of Lower Gingiva, Open Approach 0C960ZZ
Drainage of Lower Gingiva with Drainage
0C9630Z
Drainage of Lower Gingiva, Percutaneous
0C963ZZ
Approach
Drainage of Lower Gingiva with Drainage 0C96X0Z
Device, External Approach
31
Drainage of Lower Gingiva, External Approach 0C96XZZ
Extirpation of Matter from Upper Gingiva, Open
0CC50ZZ
Approach
Extirpation of Matter from Upper Gingiva,
Percutaneous Approach
Extirpation of Matter from Lower Gingiva, Open
Approach
Extirpation of Matter from Lower Gingiva,
Drainage of Right Maxilla with Drainage
Drainage of Right Maxilla, Open Approach 0N9R0ZZ
0N9R30Z
Drainage of Right Maxilla, Percutaneous
0N9R3ZZ
Approach
0N9R40Z
Device, Percutaneous Endoscopic Approach
Drainage of Right Maxilla, Percutaneous
0N9R4ZZ
Endoscopic Approach
Drainage of Left Maxilla with Drainage Device,
0N9S00Z
Open Approach
Drainage of Left Maxilla, Open Approach 0N9S0ZZ
0N9S30Z
Drainage of Left Maxilla, Percutaneous
0N9S3ZZ
Approach
0N9S3ZZ
Percutaneous Endoscopic Approach
Drainage of Left Maxilla, Percutaneous
0N9S40Z
Endoscopic Approach
Drainage of Right Mandible with Drainage 24.0
0N9T00Z
Drainage of Right Mandible, Open Approach 0N9T0ZZ
Drainage of Right Mandible with Drainage
0N9T30Z
Drainage of Right Mandible, Percutaneous
0N9T3ZZ
Approach
Drainage of Right Mandible with Drainage
0N9T40Z
Device, Percutaneous Endoscopic Approac
Drainage of Right Mandible, Percutaneous
0N9T4ZZ
Endoscopic Approach
Drainage of Right Mandible with Drainage 0N974ZZ
32
Drainage of Left Mandible with Drainage
0N9V00Z
Drainage of Left Mandible, Open Approach 0N9V0ZZ
0N9V30Z
Drainage of Left Mandible, Percutaneous
0N9V3ZZ
Approach
0N9V3ZZ
Drainage of Left Mandible, Percutaneous
0N9V4ZZ
Endoscopic Approach
Extirpation of Matter from Right Maxilla, Open
0NCR0ZZ
Approach
Extirpation of Matter from Right Maxilla,
0NCR3ZZ
Extirpation of Matter from Right Maxilla,
0NCR4ZZ
Extirpation of Matter from Left Maxilla, Open
0NCS0ZZ
Approach
Extirpation of Matter from Left Maxilla,
0NCS3ZZ
Extirpation of Matter from Left Maxilla,
0NCS4ZZ
Extirpation of Matter from Right Mandible,
0NCT0ZZ
Open Approach
0NCT3ZZ
0NCT4ZZ
Extirpation of Matter from Left Mandible, Open
0NCV0ZZ
Approach
Extirpation of Matter from Left Mandible,
0NCV3ZZ
24.0
Extirpation of Matter from Left Mandible,
ONCV4ZZ
Diagnostic Procedures On Teeth, Gums, and
24.1
Alveoli
Exposure of Tooth 24.6
Biopsi of Gum 24.11
Biopsi of Alveolus 24.12
Other diagnostic procedure on teeth, gums and
24.19
alveoli
33
Gingivoplasty
 Replacement of Upper Gingiva with
0CR507Z
Autologous Tissue Substitute, Open Approach
 Replacement of Upper Gingiva with Synthetic
0CR50JZ
Substitute, Open Approach
Nonautologous Tissue Substitute, Open 0CR50KZ
Approach
Autologous Tissue Substitute, Percutaneous 0CR537Z
Approach
0CR53JZ
Substitute, Percutaneous Approach
Nonautologous Tissue Substitute, 0CR53KZ
Percutaneous Approach 24.2
Autologous Tissue Substitute, External 0CR5X7Z
Approach
0CR5XJZ
Substitute, External Approach
Nonautologous Tissue Substitute, External 0CR5XKZ
Approach
 Replacement of Lower Gingiva with
0CR607Z
Autologous Tissue Substitute, Open Approach
 Replacement of Lower Gingiva with Synthetic
0CR60JZ
Nonautologous Tissue Substitute, Open
Approach
 Replacement of Lower Gingiva with 24.2
Autologous Tissue Substitute, Percutaneous
Approach
Nonautologous Tissue Substitute,
Autologous Tissue Substitute, External
Approach
34
Nonautologous Tissue Substitute, External
Approach
 Supplement Upper Gingiva with Autologous
Tissue Substitute, Open Approach
 Supplement Upper Gingiva with Synthetic
 Supplement Upper Gingiva with
Approach
Tissue Substitute, Percutaneous Approach
Tissue Substitute, External Approach
Approach
 Supplement Lower Gingiva with Autologous
Tissue Substitute, Open Approach
 Supplement Lower Gingiva with Synthetic
 Supplement Lower Gingiva with
Approach
Tissue Substitute, Percutaneous Approach
24.2
Tissue Substitute, External Approach
Approach
35
Other Operations On Gum 24.3
Excision of dental lesion of jaw 24.4
Biopsy of gum 24.11
Biopsy of alveolus 24.12
Other diagnostic procedures on teeth, gums, and 24.19
alveoli
Excision of lesion or tissue of gum 24.31
Suture of laceration of gum 24.32
Other operations on gum 24.39
Excision of dental lesion of jaw 24.4
Other dental operations 24.99
Calculus, calculi, calculous
K03.6
dental (subgingival) (supragingival)
Gingival enlargement
K06.1
Gingival fibromatosis
Gingival and edentulous alveolar ridge lesions
associated with trauma
K06.2
Irritative hyperplasia of edentulous ridge
(denture hyperplasia)
Other specified disorders of gingiva and
edentulous alveolar ridge
Fibrous epulis
Flabby ridge K06.8
Giant cell epulis
Peripheral giant cell granuloma
Pyogenic granuloma of gingiva
Disorder of gingiva and edentulous alveolar
K06.9
ridge, unspecified
Bleeding gums K05.5
Cyst (mucus) (retention) (serous) (simple)
J34.1 527.6
gingiva
Oral Mucocele (mucous retention, mucous 527.6 ;
K11.6
extravasasion, mucous cyst of oral mucosa) 528.9
Other Cyst of Oral Region K09.8
Elephantiasis (nonfilarial) gingival
Enlargement, enlarged - see also Hypertrophy
gingival K06.1
Epulis (giant cell) (gingiva)
Fibromatosis gingival
Other Periodontal diseases K05.5 523.8
Gingival Enlargement K06.1
36
K06.2
Fissuratum (gum) Giant cell (central) (jaw)
K05.5
(reparative)
K06.1
Peripheral (gingiva
K05.5
Hemorrhage, hemorrhagic (nontraumatic)
gingiva
R58
gum
mouth
Hypertrophy, hypertrophic K06.1
gingiva
gum (mucous membrane) K06.1
mucous membrane
alveolar process K06.2
Converts approximately to:
Unspecified lesions of oral mucosa (Bleeding K13.70
mouth)
Other lesions of oral mucosa K13.79
Macrogingivae :
K05.5
Other periodontal diseases
Gingival enlargement K06.1
Occlusion K06.2
Gingiva, traumatic
Periodontal, traumatic
Leukoplakia of gingiva K13.21
Periodontal, due to traumaticocclusion K05.5
A disorder in the gingival tissue around the teeth K05.6
Occluded traumaticperiodontal K05.5
Gingival and edentulous alveolar ridge lesions K06.2
Traumaticgingival and edentulous alveolar ridge
lesions.
Traumatic:
dentulous (alveolar)
gingiva
Hyperplasia, hyperplastic denture
irritative, edentulous (alveolar)
Hypertrophy, hypertrophic mucous membrane
alveolar ridge
Lesion (s) (nontraumatic) edentulous (alveolar)
37
gingiva, associated with trauma
Occlusion, occluded gingiva, traumatic
Traumatic edentulous (alveolar) gingival
Polyp, polypus
gingiva
K06.1
gum
Pyogenic granuloma of oral mucosa
PENGELOLAAN KOMPLIKASI BEDAH DENTOALVEOLAR

Disturbances of skin sensation:
R20
Anaesthesia of skin
R20.0
Hypoaesthesia of skin
R20.1
Parasthesia of skin
R20.2
Hyperaesthesia
R20.3
Other and unspecified distrubances of skin
R20.8
sensation
Dry socket (Alveolitis of jaw)/ Sicca Dolorosa K10.3
Prophylactic drug therapy use of antibiotics
 Antibiotic given for prevention of subacute
bacterial endocarditis 99.21
 Antibiotic given for prevention of subacute
bacterial endocarditis (situation)
Excessive bleeding (hemorrhage) R58
Abnormal involuntary movements
R25.9
Trismus
Osteitis (Lihat Osteomyelitis) K10.2
Aveolar Process K10.2
Periostitis (circumscribed) (diffuse) (infective) K10.2
Suppuration, suppurative - Lihat Juga:
M27.8
Dental periosteum
Osteomyelitis
Acute haematogenous osteomyelitis M86
Other acute osteomyelitis M86.1
Subacute osteomyelitis M86.2
Chronic multifocal osteomyelitis M86.3
Chronic osteomyelitis with draining sinus M86.4
Other chronic haematogenous osteomyelitis M86.5
Other osteomyelitis M86.6
Osteomyelitis, unspecified M86.8
 Infection of bone M86.9
 Periostitis without mention of osteomyelitis
Ulcer, ulcerated, ulcerating, ulceration, L98.499
38
ulcerative
alveolar process M27.3
ORAL AND MAXILLOFACIAL MANAGEMENT

Abscess (acute) (chronic) (infectional)
(lymphangitic) (metastatic) (multiple) (pyogenic) L03.90
(septic) (with lymphangitis)
Cellulitis and abscess of atau soft tissues K12.2
Inflammatory conditions of jaw: M27.2
Abscess of hard palate
Abscess of jaw
Abscess of mandible
Abscess of maxilla
Acute nonsuppurative osteitis of jaw
Acute osteitis of jaw
Acute osteomyelitis of jaw
Acute periostitis of jaw
Acute suppurative alveolar periostitis
Chronic abscess of jaw
Chronic abscess of mandible
Chronic abscess of maxilla
Chronic nonsuppurative osteitis of jaw
Chronic ossifying alveolar periostitis
Chronic osteitis of jaw
Chronic osteomyelitis of jaw
Chronic periostitis of jaw
Giant cell hyaline angiopathy
Inflammatory disorder of jaw
Neonatal osteomyelitis of jaw
Nonsuppurative osteitis of jaw
Osteomyelitis of jaw
Periostitis of jaw
Sequestrum of jaw bone
Sequestrum of the mandible
Sequestrum of the maxilla
Suppurative osteomyelitis of jaw
Suppurative periostitis of jaw
Acute apical periodontitis of pulpal origin
K04.4
Acute apical periodontitis NOS
Chronic apical periodontitis
Apical or periapical granuloma K04.5
Apical periodontitis NOS
Periapical abscess with sinus K04.6
39
Dental Abcess with sinus
Dentoalveolare Abcess with sinus
Periapical abscess without sinus
Dental Abceses
K04.7
Dentoalveolar Abcess NOS
Periapical Abcess NOS
Other and unspecified diseases of pulp and
K04.9
periapical tissues
Osteomyelitis (general) (infective) (localized)
(neonatal) (purulent) (septic) (staphylococcal) M86.9
(streptococcal) (suppurative) (with periostitis)
Jaw (acute) (chronic) (lower) (neonatal)
M27.8
(suppurative) (upper)
Jaw acute osteomyelitis M86.10
Osteomyelitis mandible M27.2
Hematogenous
chronic (or old) M86.00
chronic (or old) mandible
Osteomyelitis chronic (or old) mandible with
M86.40
draining sinus
Specified type NEC - see also subcategory Other
M86.8
osteomyelitis
Jaw subacute Sub-acute osteomyelitis M86.20
Subacute osteomyelitis
M27.2
Mandible
Osteoradionecrosis, jaw (acute) (chronic) (lower)
K10.2
(suppurative) (upper)
Periostitis (albuminosa)(circumscribed)(diffuse)
(infective)(monomelic - see also M27.2
Osteomyelitisjaw (lower) (upper)
 Sequestrum
dental
jaw bone
 Suppuration, suppurative - see also condition
maxilla, maxillary
Garré's M27.2
 disease (see also Osteomyelitis)
 osteitis (sclerosing) (see also Osteomyelitis)
 osteomyelitis (see also Osteomyelitis)
Chronic osteomyelitis
Sequestrum
Pyogenic granuloma of oral mucosa, ilic or
K06.8 528.9
eosinophopyogenic
40
Alveolar osteitis M27.3
Osteonecrosis of jaw M87.08
CELLULITIS AND ABCESS OF FACE

Cellulitis and abscess of mouth
K12.2
Cellulitis and abscess of oral soft tissues
Cellulitis and abcess of face L03.211
Acute lymphangitis of face L03.212
Abscess (acute) (chronic) (infectional)
(lymphangitic) (metastatic) (multiple) (pyogenic)
(septic) (with lymphangitis) (see also Cellulitis)
cheek, external K12.2
Cheek, inner
Chin
face (any part, except eye) L03.212
forehead L03.213
Jaw (bone) (lower) (upper) M27.2
nose (septum) J34.0
jaw (bone) (lower) (upper) M27.2
skin K12.2
nose (septum) external J34.0
submandibular (region) (space) (triangle) K12.2
Submandibular gland K11.3
Submaxillary (region) L03.213
Submaxillary gland K11.3
Submental (pyogenic) K12.2
Submentalgland K11.3
Temporal region L03.213
Cellulitis (diffuse) (with lymphangitis) (see also L03.90
Abscess) 730.1
Submandibular (region) (space) (triangle) 730.1
Submental (pyogenic) Gland K11.3
Sialoadenitis K11.20
Salivary gland abscess K11.3
Cellulitis (diffuse) (with lymphangitis) (SEE L03.90
ALSO) Abscess)
submandibular (region) (space) (triangle) K11.3
gland K11.3
submaxillary gland K11.3
submental (pyogenic) gland K11.3
Osteomyelitis (general) (infective) (localized) M27.2
41
(neonatal) (purulent) (pyogenic) (septic)
(staphylococcal) (streptococcal) (suppurative)
(with periostitis)
 chronic or old
 Garré's
 nonsuppurating
 sclerosing, nonsuppurative
 sicca
Acute osteomyelitis M86.10
Chronic osteomyelitis
M27.2
Garré's osteomyelitis
Periostitis without mention of osteomyelitis M27.3
Necrosis of jaw M87.08
ODONTOGENIC AND NON ODONTOGENIC CYST

Other cysts of jaws :
Synonyms
Aneurysmal cyst of jaw
Cyst of jaw
Hemorrhagic cyst of jaw
K09.2
Maxillary cyst
Median mandibular cyst
Non-odontogenic developmental cyst of jaw
Stafne idiopathic bone cavity of mandible
Traumatic cyst of jaw
Alveolar process (jaw bone) M27.49
Cyst of bone (localized), unspecified / bone
K09
(local)
Aneurysmal Bone Cyst of jaw K09.2
Fissural
(Globulomaxillary Cyst)
globulomaxillary K09.1
incisive canal
median arteri or maxillary
median palatal
nasopalatine of papilla
Latent bone cyst of jaw M27.8
Solitary bone cyst
M85.40
Unicameral bone cyst
Jaw bone cyst (aneurysmal) (extravasation)
K09.2
(hemorrhagic) (traumatic)
Developmental (odontogenic) cyst K09.0
42
Fissural bone cyst K09.1
Alveolar process (jaw bone)
Cyst of bone (localized), unspecified M85.60
Aneurysmal bone cyst M85.50
Fissural Cyst
Incisive canal cyst
K09
Median anterior maxillary cyst
Median palatal cyst
Nasopalatine palatine of papilla
K09.1
Globulomaxillary cyst
Other specified diseases of the jaws
Diperuntukkan untuk:
Cherubism
Fibrous dysplasia of jaw(s)
M27.2
Latent bone cyst of jaw(s)
Osteradionecrosis of jaw(s)
Unilateral condylar hyperplasia or hypoplasia of
mandible
Unspecified Cyst of Jaw
Applicable to:
 Cyst of jaw NOS M27.49
 Aneurysmal cyst of jaw
 HemAtaurhagic cyst of jaw
 Traumatic cyst of jaw
Developmental (odontogenic)
K09.0
Dentigerous Cyst
Fissural Cyst K09.9
Mandible Cyst
M27.40
Maxilla Cyst
Radicular Cyst K04.8
Other and unspecified diseases of pulp and
K04.9
periapical tissues
Ranula
K11.6
Mucocele
Sialolithiasis
Other specified diseases of the jaws: M27.8
Cherubism with gingival fibromatosis
Fibro-osseous lesion of jaw
Fibrous dysplasia of jaw
Fistula of hard palate
Hyperplasia of mandibular condyle
Hypoplasia of mandibular condyle
43
Latent bone cyst of jaw
Odontogenic cyst
Osteoradionecrosis of bone of skull
Osteoradionecrosis of jaw
Osteoradionecrosis of the mandible
Osteoradionecrosis of the maxilla
Resorption of mandible
Unilateral condylar hyperplasia of mandible
Unilateral condylar mandibular hypoplasia
Unilateral coronoid hyperplasia of mandible
Salivary gland atrophy
Atrophy of salivary gland
Atrophy, atrophic
parotid gland K11.0
salivary duct or gland 527.0
sublingual gland
submaxillary gland
Hypertrophy of salivary gland
Disease, diseased - SEE ALSO Syndrome
glassblowers'
Mikulicz's (dryness of mouth, absent or K11.1
decreased lacrimation) 527.1
Glassblowers' disease
Hyperplasia, hyperplastic
salivary gland (any)
Congenital malformations of salivary glands and K11.1
ducts
Congenian Hypoplasia, hypoplastic parotid Q38.4
Fistula of salivary gland K11.4
Atrophy of salivary gland K11.0
Hypertrophy of salivary gland K11.1
Sialoadenitis K11.2
Abscess of salivary gland K11.3
Fistula of salivary gland K11.4
Mucocele of salivary gland K11.6
Disturbance of salivary secretion K11.7
Other specified diseases of the salivary glands K11.8
Unspecified disease of the salivary glands K11.9
Developmental odontogenic cysts:
References found for the code 526.0 in the Index K09.0
of Diseases and Injuries: 733.20
Cyst (mucus) (retention) (serous) (simple)
bone (local)
jaw 526.2
44
mandible
maxilla
jaw (bone) (aneurysmal) (extravasation)
dental 522.8
developmental (odontogenic)
developmental
eruption
lateral periodontal
primordial (keratocyst)
mandible
maxilla
eruption
dentigerous
526.0
pericoronal
periodontal
lateral
primordial (jaw)
Dentigerous cyst
Keratocyst (dental)
Odontoma
Follicular
upper jaw (bone)
follicular (atretic) (ovarian) 620.0
Fissural cysts of jaw

This is the 2014 version of the ICD-9-CM K09.1
diagnosis code 526.1
References found for the code 526.1 in the Index
of Diseases and Injuries:
bone (local) 733.20
jaw
jaw (bone) (aneurysmal) (extravasation) 526.2
Cyst (mucus) (retention) (serous) (simple) 526.1
anterior nasopalatine
fissural
fissural (oral region)
globulomaxillary
incisor, incisive canal
fissural
median
anterior maxillary
palatal
45
nasopalatine (duct)
anterior
palatal papilla (jaw)
palate
fissural
median (fissural)
palatine, of papilla
Short Description: Cysts of jaws NEC
Long Description: Other cysts of jaws
This is the 2014 version of the ICD-9-CM
diagnosis code 526.2
Synonyms
Aneurysmal cyst of jaw
Cyst of jaw M27.49 526.2
Hemorrhagic cyst of jaw
Maxillary cyst
Median mandibular cyst
Non-odontogenic developmental cyst of jaw
Stafne idiopathic bone cavity of mandible
Traumatic cyst of jaw
NEOPLASMA
Central giant cell (reparative) granuloma M27.1
References found for the code 526.3 in the Index
of Diseases and Injuries: L98.0
Granuloma NEC 686.1
gingiva M27.1
523.8
peripheral (gingiva)
giant cell (central) (jaw) (reparative) K05.5
jaw (bone) K05.5
M27.1 526.3
reparative giant cell
mandible M27.1
MALIGNANT NEOPLASMA BIBIR, RONGGA MULUT DAN PHARYNX

Malignant neoplasm of lip
A primary Atau metastatic malignantneoplasm CC00.0
involving the lip
Malignant neoplasm of lip C00.0
Malignant neoplasm of upper lip, vermilion
bAtauder C00.1
Malignant neoplasm of external lower lip C00.1
46
Malignant neoplasm of upper lip, inner aspect C00.3
Malignant neoplasm of lower lip, inner aspect C00.4
Malignant neoplasm of lip, unspecified, inner
C00.5
aspect
Malignant neoplasm of commissure of lip C00.6
Malignant neoplasm of other sites of lip C00.8
Malignant neoplasm of lip, unspecified,
C00.9
vermilion border
Malignant Neoplasm of The Tounge C02.9
Malignant Neoplasm of Gum C03.9
Malignant Neoplasm of floor of mouth
Malignant neoplasm of anterior portion of floor
CM C04.0
of mouth
Malignant neoplasm of lateral portion of floor of
C04.1
mouth
Malignant neoplasm of other sites of floor of
C04.8
mouth
Malignant neoplasm of floor of mouth, part
C04.9
unspecified
MALIGNANT NEOPLASMA OF OTHER AND UNSPESIFIED PART OF MOUTH

Cheek Mucosa C06.0
Vestibulae of mouth C06.1
Hard Palate C05.0
Soft Palate C05.1
Uvula C05.2
Palate, unspecified C05.9
Retromolar area C06.2
Malignant neoplasm of overlapping sites of other
C06.89
parts of mouth
Malignant neoplasm of salivary gland,
C08.9
unspecified
Operations on tongue
Diagnostic procedures on tongue 25.0
Closed [needle] biopsy of tongue 25.01
Open biopsy of tongue
25.02
Wedge biopsy
Other diagnostic procedures on tongue 25.09
Partial glossectomy 25.2
Complete glossectomy 25.3
47
Glossectomy NOS
Code also any neck dissection (40.40-40.42)
Radical glossectomy
Code also any:
25.4
Neck dissection (40.40-40.42)
Tracheostomy (31.1-31.29)
Repair of tongue and glossoplasty 25.5
Suture of laceration of tongue 25.51
Other repair and plastic operations on tongue
25.59
Fascial sling of tongue
Fusion of tongue (to lip)
Graft of mucosa atau skin to tongue
25.93
Tidak termasuk: lysis of adhesions of tongue
Other operations on tongue 25.9
Lingual frenotomy
25.91
Tidak termasuk: labial frenotomy
Lingual frenectomy
25.92
Tidak termasuk: labial frenectomy
Lysis of adhesions of tongue 25.93
Other glossotomy 25.94
Other 25.99
LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUE

 Leukokeratosis - see also
 Leukoplakia mouth
 oral mucosa
 tongue
 Leukoplakia buccal
 gingiva K13.21
 lip
 mouth
 oral epithelium, including tongue (mucosa)
 palate
 tongue
Leukokeratosis of oral mucosa · Leukoplakia of
K13.3
gingiva, lips, tongue · hairy leukoplakia
leukokeratosis nicotina palati (K13.24) K13.24
Operations on salivary glands and ducts 26
Includes: operations on:
lesser salivary gland and duct
parotid gland and duct
sublingual gland and duct
submaxillary gland and duct
48
Code also any neck dissection (40.40-40.42)
26.0 Incision of salivary gland or duct
Tidak termasuk: 26.0
x-ray of salivary gland (87.09)
Diagnostic procedures on salivary glands and
26.1
ducts
Closed [needle] biopsy of salivary gland Atau
26.11
duct
Open biopsy of salivary gland atau duct 26.12
Other diagnostic procedures on salivary glands
and ducts 26.19
Tidak termasuk: x-ray of salivary gland (87.09)
Excision of lesion of salivary gland 26.2
Marsupialization of salivary gland cyst 26.1
Other excision of salivary gland lesion 26.29
Tidak termasuk: biopsy of salivary gland
salivary fistulectomy (26.42) 26.42
Other operations on mouth and face
27
Includes: operations on:
lips
palate
soft tissue of face and mouth, except tongue and
gingiva
Excludes: operations on:
gingiva (24.0-24.99)
tongue
Drainage of face and flour of mouth

27.0
Drainage of:
facial region (abscess)
fascial compartment of face
Ludwig's angina
Excludes: drainage of thyroglossal tract (06.09)
Incision of palate
Diagnostic procedures on Ataual cavity
27.1
Biopsy of bony palate
27.2
Biopsy of uvula and soft palate
27.21
Biopsy of lip
27.22
Biopsy of mouth, unspecified structure
27.23
Other diagnostic procedures on Ataual cavity
27.29
Excludes: soft tissue x-ray (87.09)
49
ORTHOGNATIC SURGERY
Mayor anomali of Jaw size M26.0
Unspecified anomaly M26.00
Maxillary hyperplasia M26.01
Mandibular hyperplasia M26.03
Maxillary hypoplasia M26.02
Mandibular hypoplasia M26.04
Macrogenia M26.05
Microgenia M26.06
Excessive tuberosity of jaw M26.07
Other specified anomaly M26.09
Anomalies of relationship of jaw to cranial base M26.1
Dentofacial anomalies [including malocclusion]
Major anomalies of jaw size
Hyperplasia, hypoplasia: M26.0
mandibular
maxillary
Macrognathism (mandibular)(maxillary)
Micrognathism (mandibular)(maxillary)
Anomalies of jaw-cranial baserelationship: M26.00
Asymmetry of jaw
Prognathism (mandibular)(maxillary)
Retrognathism (mandibular)(maxillary)
Anomalies of dental arch relationship: K07.1
Crossbite (anterior)(posterior)
Disto-occlusion
Mesio-occlusion
Midline deviation of dental arch
Openbite (anterior)(posterior)
Overbite (excessive): K07.2
deep
horizontal
vertical
Overjet
Posterior lingual occlusion of mandibular teeth
Operations on facial bones and joints 76.1 76
Other facial bone repair and orthognathic surgery 76.6
Code also any synchronous:
76.91
bone graft
synthetic implant
76.92
Excludes:
50
Closed osteoplasty [osteotomy] of mandibular
ramus 76.61
Gigli saw osteotomy
Open osteoplasty [osteotomy] of mandibular
76.62
ramus
Osteoplasty [osteotomy] of body of mandible 76.63
Other orthognathic surgery on mandible
Mandibular osteoplasty NOS 76.64
Segmental or subapical osteotomy
Segmental osteoplasty [osteotomy] of maxilla
76.65
Maxillary osteoplasty NOS
Total osteoplasty [osteotomy] of maxilla 76.66
Reduction genioplasty
76.67
Reduction mentoplasty
Augmentation genioplasty
Mentoplasty:
76.68
NOS
with graft or implant
Other facial bone repair
76.69
Osteoplasty of facial bone NOS
CONGENITAL MALFORMATION
Macrostomia Q18.4
Microstomia Q18.5
Cleft palate and cleft lip
Cleft Lip
Cleft lip, unspecified Q35.9
Cleft Palate
Cleft palate, unilateral
Q35.7
(Cleft
Uvula)
Cleft palate, unilateral incomplate
Q35.9
(Cleft Palate
unspecified)
Cleft palate, bilateral, complete
Q35.9
Cleft palate, bilateral, incomplete
Cleft lip, unilateral, complete
Q36.9
Cleft lip, unilateral, incomplete
Cleft lip, bilateral, complete Q36.0
51
Cleft lip, bilateral, incomplete
Cleft palate with cleft lip
Cleft palate with cleft lip, unspecified
Cleft palate with cleft lip, unilateral, complete Q37.9
Cleft palate with cleft lip, unilateral, incomplete
Cleft palate with cleft lip, bilateral, complete
Q37.8
Cleft palate with cleft lip, bilateral, incomplete
Other combinations of cleft palate with cleft lip Q37.9
CONGENITAL MUSCULOSKELETAL DEFORMITIES OF SKULL, FACE AND JAW

Congenital facial asymmetry Q67.0
Other congenital deformities of skull, face and
Q67.4
jaw
Facial Palsy (loss of control over facial
G51.0
expressions)
Facial Cleft Q67.4
Chin deformities(misalnya mirognathia) atau
K07.0
(macrognathia) kongenital
Chin deformity mity acquired M95.2
Upper Jaw (Maxillary) deformities - excess bone
of the upper jaw, the face appears long, the chin M26.9
is recessed and the nose large in the profile view.
Lower Jaw (Mandibular) deformities - There are
two most common mandibular deformities;
K07.9
mandibular excess (protrusion) and mandibular
deficiency (retrusion).
Mandibular hypoplasi M26.04
Hemifacial Microsomia - In this Face Defect, the
soft tissues and bones of the ear, mouth and jaw
Q67.4
areas on one side of the face are under
developed.
Other congenital anomalies of upper alimentary
tract :
Tongue tie
Q38.1
Ankyloglossia
Other anomalies of tongue Q38.3
Anomalies of tongue, unspecified
Anomalies of tongue, unspecified
Aglossia
Congenital adhesions of tongue
Fissure of tongue
52
Macroglossia
Microglossia
Hypoplasia of tongue
FACIAL BONES AND JOINTS SURGERY

(Operations on Facial Bones and Joints)
Incision of Facial Bone without Division 76.0
Sequestrectomy of facial bone 76.01
Diagnostic Procedures On Facial Bones And
76.1
Joints
Other incision of facial bone 76.09
Biopsy of facial bone 76.11
Other diagnostic procedures on facial bones and
76.19
joints
Local excision or destruction of lesion of facial
76.2
bone
Partial Ostectomy Of Facial Bone 76.3
Partial mandibulectomy 76.31
Partial ostectomy of other facial bone 76.39
Excision And Reconstruction Of Facial Bones 76.4
Total mandibulectomy with synchronous
76.41
reconstruction
Other total mandibulectomy 76.42
Total ostectomy of other facial bone with
76.44
synchronous reconstruction
Other total ostectomy of other facial bone 76.45
Other reconstruction of other facial bone 76.46
Temporomandibular arthroplasty 76.5
Other Facial Bone Repair And Orthognathic
76.6
Surgery
Closed osteoplasty [osteotomy] of mandibular
76.61
ramus
Open osteoplasty [osteotomy] of mandibular
76.62
ramus
Osteoplasty [osteotomy] of body of mandible 76.63
Other orthognathic surgery on mandible 76.64
Segmental osteoplasty [osteotomy] of maxilla 76.65
Total osteoplasty [osteotomy] of maxilla 76.66
Reduction genioplasty 76.67
Augmentation genioplasty 76.68
53
Other facial bone repair 76.69
Reduction Of Facial Fracture 76.7
Reduction of facial fracture, not otherwise
76.70
specified
Closed reduction of malar and zygomatic 76.71
fracture
Open reduction of malar and zygomatic fracture 76.72
Closed reduction of maxillary fracture 76.73
Open reduction of maxillary fracture 76.74
Closed reduction of mandibular fracture 76.75
Open reduction of mandibular fracture 76.76
Open reduction of alveolar fracture 76.77
Other closed reduction of facial fracture 76.78
Other open reduction of facial fracture 76.79
Other Operations On Facial Bones And Joints 76.9
Bone graft to facial bone 76.91
Insertion of synthetic implant in facial bone 76.92
Closed reduction of temporomandibular 76.93
dislocation
Open reduction of temporomandibular 76.94
dislocation
Other manipulation of temporomandibular joint 76.95
Injection of therapeutic substance into 76.96
temporomandibular joint
Removal of internal fixation device from facial 76.97
bone
Other operations on facial bones and joints 76.99
Dislocation of jaw S03.0
Dislocation of jaw, initial encounter S03.00XA
Dislocation of jaw, subsequent encounter S03.00XD
Dislocation of jaw, sequel S03.00XS
Dislocation of jaw, unspecified side S03.00
Dislocation of jaw right side S03.01
Dislocation of jaw left side S03.02
Dislocation of jaw bilateral S03.03
Temporomandibular strain S03.4
Costen’s complex or syndrome
M26.69
Derangement of temporomandibular joint
Snapping jaw
Temporomandibular joint-pain-dysfunction
M26.69
syndrome
Sprain of jaw S03.4
Sprain of jaw unspecified side S03.40
54
Sprain of jaw right side S03.41
Sprain of jaw left side S03.42
Sprain of jaw bilateral S03.43
Temporomandibular joint disorder unspecified:
26.60
Temporomandibular arthroplasty
BONE AND SKIN TRANSPLANT

Bone replaced by transplant Z94.6
Bone transplant status :
 Bone Z94.6
 Marrow Z94.81
Skin transplant Z94.5
Medical Policy
Subject: Mandibular/Maxillary (Orthognathic) Surgery

Policy #: SURG.00049 Current Effective Date: 01/01/2017
Status: Reviewed Last Review Date: 08/04/2016
Description/Scope
This document addresses medically necessary, reconstructive and cosmetic procedures

involving the mandible, maxilla or both, with the exception of orthognathic surgery for the
treatment of temporomandibular disorders or obstructive sleep apnea. This document does
not apply to orthodontia (braces) services.
Note: Please see the following related documents for additional information:
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep
Apnea or Snoring
CG-SURG-09 Temporomandibular Disorders
Medically Necessary: In this document, procedures are considered medically necessary if

there is a significant physical functional impairment AND the procedure can be reasonably
expected to improve the physical functional impairment.
Reconstructive: In this document, procedures are considered reconstructive when

intended to address a significant variation from normal related to accidental injury, disease,
trauma, treatment of a disease or congenital defect.Note: Not all benefit
contracts/certificates include benefits for reconstructive services as defined by this
document. Benefit language supersedes this document.
Cosmetic: In this document, procedures are considered cosmetic when intended to change
a physical appearance that would be considered within normal human anatomic variation.
55
Cosmetic services are often described as those which are primarily intended to preserve or
improve appearance.
Position Statement
Medically Necessary:
Mandibular/Maxillary (orthognathic) surgery is considered medically necessary to treat a

significant physical functional impairment when the procedure can be reasonably expected
to improve the physical functional impairment. Significant physical functional impairment
includes anyone of the following:
Dysphagia when all of the following criteria (1, 2 and 3) are met:
Symptoms related to difficulty chewing such as: choking due to incomplete mastication, or
difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on
liquid food; and
Symptoms must be documented in the medical record, must be significant and must persist
for at least 4 months; and
Other causes of swallowing or choking problems have been ruled out by history, physical
exam and appropriate diagnostic studies.
or
Speech abnormalities determined by a speech pathologist or therapist to be due to a
malocclusion and not helped by orthodontia or at least 6 months of speech therapy.
or
Intra-oral trauma while chewing related to malocclusion (for example, loss of food
through the lips during mastication, causing recurrent damage to the soft tissues of the
mouth during mastication).
or
Masticatory dysfunction or malocclusion when criteria 1, 2, and 2 below are met:
Completion of skeletal growth with long bone x-ray or serial cephalometrics showing no
change in facial bone relationships over the last 3- to 6-month period (Class II
malocclusions and individuals age 18 and over do not require this documentation); and
Documentation of malocclusion with either intra-oral casts (if applicable), bilateral lateral
x-rays, cephalometric radiograph with measurements, panoramic radiograph or
tomograms; and
any one of the following described in a, b, d or d is documented:
Anteroposterior discrepancies defined as either of the following:
Maxillary/Mandibular incisor relationship (established norm = 2 mm) defined as one of the
following:
Horizontal overjet of 5mm or more, or
Horizontal overjet of zero to a negative value. (Note: Overjet up to 5mm may be treatable
with routineorthodontic therapy); or
Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more
(norm 0 to 1mm).
Vertical discrepancies defined as any of the following:
Presence of a vertical facial skeletal deformity which is two or more standard deviations
from published norms for accepted skeletal landmarks; or
Open bite (defined as one of the following):
No vertical overlap of anterior teeth; or
Unilateral or bilateral posterior open bite greater than 2mm; or
56
Deep overbite with impingement or irritation of buccal or lingual soft tissues of the
opposing arch; or
Supra-eruption of a dentoalveolar segment due to lack of occlusion.
Transverse discrepancies defined as either of the following:
Presence of a transverse skeletal discrepancy which is two or more standard deviations
from published norms; or
Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater,
or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the
posterior teeth.
Asymmetries defined as the following:
Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant
occlusal asymmetry.
When the condition involves treatment of skeletal deformity, the deformity must be
documented either by computed tomography (CT), magnetic resonance imaging (MRI), or
x-ray.
Reconstructive:
Mandibular/maxillary (orthognathic) surgery is considered reconstructive when intended

to address a significant variation from normal related to accidental injury, disease, trauma,
or treatment of a disease or congenital defect.
Cosmetic and Not Medically Necessary:
Mandibular/Maxillary (orthognathic) surgery is considered cosmetic and not medically

necessary when intended to change a physical appearance that would be considered within
normal human anatomic variation.
A genioplasty (or anterior mandibular osteotomy) is considered cosmetic and not

medically necessary when not associated with masticatory malocclusion.
Rationale
There is convincing evidence of the relationship between facial skeletal abnormalities and
malocclusions, including Class II, Class III, asymmetry and open bite deformities. A strong
correlation has been demonstrated between the state of the individual's occlusion and his or
her chewing efficiency, bite forces, and restricted mandibular excursions. Orthognathic
surgery has resulted in significant improvement in skeletal deformities that contribute to
chewing, breathing and swallowing dysfunction and where the severity of the deformity
cannot be corrected through dental therapeutics or orthodontics. Studies have shown that
individuals with skeletal malocclusions suffer from a variety of functional impairments,
including diminished bite forces, restricted mandibular excursions, and abnormal chewing
patterns. The evidence in the peer-reviewed literature to support this conclusion includes
non-randomized controlled trials and case series studies.
Clinical practice guidance has been published by the American Association of Oral and
Maxillofacial Surgeons on criteria for orthognathic surgery (2013). The guidance states
that facial skeletal deformities which are two or more standard deviations (SD) from
published norms is an indication for orthognathic surgery. For instance, according to
Franchi (1998), amongst a sample of 100 North Americans, the cephalometric mean of the
57
SNA (sella–nasion–A point angle) and SNB (sella–nasion–B point angle) using Steiner's
analysis were found to be 82.98 and 80.37 with a SD of 3.46 and 3.21, respectively. It is
important to note that the mean values for cephalometric measurements vary significantly
between different ethnic groups (Celebi, 2013; Connor, 1985; Flynn 1989).
Background/Overview
Orthognathic surgery is the surgical correction of skeletal anomalies or malformations

involving the mandible (lower jaw) or the maxilla (upper jaw). These malformations may
be present at birth or they may become evident as the individual grows and develops.
Orthognathic surgery can be performed to correct malocclusion, which cannot be improved
with routine orthodontic therapy and where the functional impairments are directly caused
by the malocclusion. The overall goal of treatment is to improve function through
correction of the underlying skeletal deformity.
Maxillary advancement is a type of orthognathic surgery that may be necessary to improve

the facial contour and normalize dental occlusion when there is a relative deficiency of the
midface region. This is done by surgically moving the maxilla with sophisticated bone
mobilization techniques and fixing it securely into place.
Depending on the soft tissue profile of the face or the severity of an occlusal discrepancy,
problems with the lower face may require surgery of the mandible. This can be performed
in conjunction with or separate from maxillary surgery. The mandible can be advanced, set
back, tilted or augmented with bone grafts. A combination of these procedures may be
necessary. Following any significant surgical movement of the mandible, fixation may be
accomplished with mini-plates and screws or with a combination of interosseous wires and
intermaxillary fixation (IMF). Rigid fixation (screws and plates) has the advantage of
needing limited or no IMF. However, if interosseous wiring is used, IMF is maintained for
approximately 6 weeks.
Definitions
Anomaly: Deviation from normal.
Anteroposterior: From front to back.
Asymmetry: The lack of balance or symmetry.
Cephalometric: A scientific measurement of the head.
Cephalometrics: The interpretation of lateral skull x-rays taken under standardized

conditions. Two of the more popular methods of analysis used in orthodontology are the
Steiner analysis and the McNamara analysis.
Class I occlusion: Exists with the teeth in a normal relationship when the mesial-buccal
cusp of the maxillary first permanent molar coincides with the buccal groove of the
mandibular first molar.
Class II malocclusion: Occurs when the mandibular teeth are distal or behind the normal
relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an
58
excess of the upper jaw, and therefore, presents two types: (1) Division I is when the
mandibular arch is behind the upper jaw with a consequential protrusion of the upper front
teeth. (2) Division II exists when the mandibular teeth are behind the upper teeth, with a
retrusion of the maxillary front teeth. Both of these malocclusions have a tendency toward
a deep bite because of the uncontrolled migration of the lower front teeth upwards.
Commonly referred to as an overbite.
Class III malocclusion:Occurs when the lower dental arch is in front of (mesial to) the
upper dental arch. People with this type of occlusion usually have a strong or protrusive
chin, which can be due to either horizontal mandibular excess or horizontal maxillary
deficiency. Commonly referred to as an under bite.
Dentoalveolar: Relating to a tooth and the part of the alveolar bone that immediately
surrounds it.
Dysphagia: Difficulty swallowing.
Genioplasty: Plastic surgery of the chin.
Malformation: An abnormal shape or structure.
Malocclusion: Imperfect contact with the mandibular and maxillary teeth.
Mandible: The horseshoe-shaped bone forming the lower jaw.
Mastication: Biting and grinding food in the mouth so it becomes soft enough to swallow.
Maxilla: A paired bone that forms the skeletal base of the upper face, roof of the mouth,
sides of the nasal cavity and floor of the orbit (contains the eye); the upper jaw.
McNamara analysis: One of the most popular methods of cephalometric analyses. It

combines the anterior reference plane with a description of the length of the individual's
jaw and the relationship between them.
Occlusion: Bringing the opposing surfaces of the teeth of the two jaws (mandible and
maxilla) into contact with each other.
Orthodontics: The division of dentistry dealing with the prevention and correction of
abnormally positioned or aligned teeth.
Panoramic radiograph: Radiograph of the maxilla and mandible extending from the left to
right glenoid fossa. An x-ray image of a curved body surface, such as the upper and lower
jaws, on a single film.
Radiograph: X-ray.
Skeletal discrepancies: An orthodontic term used to describe the nature of a malocclusion

as being a malrelationship of the bony base rather than merely of the teeth; often assessed
via cephalometrics.
59
Steiner analysis: One of the most commonly used cephalometric analysis methods. Utilizes
the SNA angle to assess the anteroposterior position of the maxilla in regard to the cranial
base. Steiner's Analysis follows the belief that the most important measurements in his
analysis were the ANB angle, which is formed by the difference between SNA and SNB
angles.
Supraeruption: The occurrence of a tooth continuing to grow out of the gum if the
opposing tooth in the opposite jaw is missing.
Tomogram: An image of a tissue section produced by tomography.
Tomography: Imaging by sections or sectioning, through the use of any kind of penetrating
wave.
Coding
The following codes for treatments and procedures applicable to this document are
included below for informational purposes. Inclusion or exclusion of a procedure,
diagnosis or device code(s) does not constitute or imply member coverage or provider
reimbursement policy. Please refer to the member's contract benefits in effect at the time of
service to determine coverage or non-coverage of these services as it applies to an
individual member.
When services may be Medically Necessary when criteria are met:

CPT
21120-21123 Genioplasty [includes codes 21120, 21121, 21122, 21123]
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft, onlay or
interpositional (includes obtaining autograft)
21141-21147 Reconstruction midface, LeFort I [includes codes 21141, 21142,
21143, 21145, 21146, 21147]
21150-21151 Reconstruction midface, LeFort II
21154-21155 Reconstruction midface, LeFort III
21188 Reconstruction midface, osteotomies (other than LeFort type) and
bone grafts (includes obtaining autografts)
21193-21196 Reconstruction of mandibular rami [includes codes 21193, 21194,
21195, 21196]
21198 Osteotomy, mandible, segmental
21199 Osteotomy, mandible, segmental; with genioglossus advancement
21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or
prosthetic implant)
21209 Osteoplasty, facial bones; reduction
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21215 Graft, bone; mandible (includes obtaining graft)
21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg,
mandibular staple bone plate)
21245-21246 Reconstruction of mandible or maxilla, subperiosteal implant
21247 Reconstruction of mandibular condyle with bone and cartilage
autografts (includes obtaining grafts)(e.g., for hemifacial microsomia)

HCPCS
60
D7940 Osteoplasty, for orthognathic deformities
D7941 Osteotomy; mandibular rami
D7943 Osteotomy; mandibular rami with bone graft; includes obtaining the
graft
D7944 Osteotomy; segmented or subapical
D7945 Osteotomy; body of mandible
D7946-D7947 LeFort I (maxilla, total/segmented)
D7948-D7949 LeFort II or LeFort III (osteoplasty of facial bones for midface
hypoplasia or retrusion); without/with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla,
autogenous or nonautogenous, by report
D7995 Synthetic graft, mandible or facial bones, by report
D7996 Implant, mandible for augmentation purposes (excluding alveolar
ridge), by report

ICD-10 Procedure
0NBR0ZZ- Excision of maxilla, open approach [right or left; includes codes
0NBS0ZZ 0NBR0ZZ, 0NBS0ZZ]
0NBT0ZZ- Excision of mandible, open approach [right or left; includes codes
0NBV0ZZ 0NBT0ZZ, 0NBV0ZZ
0NQR0ZZ- Repair maxilla, open approach [right or left; includes codes
0NQS0ZZ 0NQR0ZZ, 0NQS0ZZ]
0NQT0ZZ- Repair mandible, open approach [right or left; includes codes
0NQV0ZZ 0NQT0ZZ, 0NQV0ZZ]
0NUR07Z- Supplement maxilla, open approach [right or left with autologous
0NUS0KZ tissue, synthetic or nonautologous tissue substitute; includes codes
0NUR07Z, 0NUR0JZ, 0NUR0KZ, 0NUS07Z, 0NUS0JZ, 0NUS0KZ]
0NUT07Z- Supplement mandible, open approach [right or left with autologous
0NUV0KZ tissue, synthetic, nonautologous tissue substitute; includes codes
0NUT07Z, 0NUT0JZ, 0NUT0KZ, 0NUV07Z, 0NUV0JZ,
0NUV0KZ]
0W0407Z- Alteration of jaw, open approach [upper or lower with autologous
0W050ZZ tissue, synthetic, nonautologous tissue or no substitute; includes codes
0W0407Z, 0W040JZ, 0W040KZ, 0W040ZZ, 0W0507Z, 0W050JZ,
0W050KZ, 0W050ZZ]
0WU407Z- Supplement jaw, open approach [upper or lower with autologous
0WU50KZ tissue, synthetic or nonautologous tissue substitute; includes codes
0WU407Z, 0WU40JZ, 0WU40KZ, 0WU507Z, 0WU50JZ,
0WU50KZ]

ICD-10 Diagnosis
All diagnoses
When Services may be Reconstructive when criteria are met:

For the procedure codes listed above when reconstructive criteria are met; or when the
code describes a procedure indicated in the Position Statement section as reconstructive.
When services are Cosmetic and Not Medically Necessary:

For the procedure codes listed above when criteria are not met or when the code describes
a procedure indicated in the Position Statement section as cosmetic and not medically
necessary.
61
References
Peer Reviewed Publications:
Aghabeigi B, Hiranaka D, Keith DA, et al. Effect of orthognathic surgery on the

temporomandibular joint in patients with anterior open bite. Int J Adult Orthodon
Orthognath Surg. 2001; 16(2):153-160.
Ahn SJ, Kim JT, Nahm DS. Cephalometric markers to consider in the treatment of Class II
Division 1 malocclusion with the bionator. Am J Orthod Dentofacial Orthop. 2001;
119(6):578-586.
Celebi AA, Tan E, Gelgor IE, et al. Comparison of soft tissue cephalometric norms
between Turkish and European-American adults. ScientificWorldJournal. 2013;
2013:806203.
Cheung LK, Lo J. The long-term clinical morbidity of mandibular step osteotomy. Int J
Adult Orthod Orthognath Surg. 2002; 17(4):283-290.
Connor AM, Moshiri F. Orthognathic surgery norms for American black patients. Am J
Orthod. 1985; 87(2):119-134.
Flynn TR, Ambrogio RI, Zeichner SJ. Cephalometric norms for orthognathic surgery in
black American adults. J Oral Maxillofac Surg. 1989; 47(1):30-39.
Han H, Davidson WM. A useful insight into 2 occlusal indexes: HLD(Md) and
HLD(CalMod). Am J Orthod Dentofacial Orthop. 2001; 120(3):247-253.
Huang CS, Hsu SS, Chen YR. Systematic review of the surgery-first approach in
orthognathic surgery. Biomed J. 2014; 37(4):184-190.
Incisivo V, Silvestri A. The reliability and variability of SN and PFH reference planes in
cephalometric diagnosis and therapeutic planning of dentomaxillofacial malformations. J
Craniofacial Surg. 2000; 11(1):31-38.
Kim JC, Mascarenhas AK, Joo BH, et al. Cephalometric variables as predictors of Class II
treatment outcome. Am J Orthod Dentofacial Orthop. 2000; 118(6):636-640.
Mihalik CA, Profitt WR, Phillps C. Long-term follow-up of Class II adults treated with
orthodontic camouflage: a comparison with orthognathic surgery outcomes. Am J Orthod
Dentofacial Orthop. 2003; 123(3):266-278.
Nickel JC, Yao P, Spalding PM, Iwasaki LR. Validated numerical modeling of the effects
of combined orthodontic and orthognathic surgical treatment on TMJ loads and muscle
forces. Am J Orthod Dentofacial Orthop. 2002; 121(1):73-83.
Oguri Y, Yamada K, Fukui T, et al. Mandibular movement and frontal craniofacial
morphology in orthognathic surgery patients with mandibular deviation and protrusion. J
Oral Rehabil. 2003; 30(4):392-400.
Oomens MA, Verlinden CR, Goey Y, Forouzanfar T. Prescribing antibiotic prophylaxis in
orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg. 2014; 43(6):725-
731.
Park JE, Baik SH. Classification of angle Class III malocclusion and its treatment
modalities. Int J Adult Orthod Orthognath Surg. 2001; 16(1):19-29.
Ruf S, Pancherz H. Orthognathic surgery and dentofacial orthopedics in adult Class II
Division 1 treatment: mandibular sagittal split osteotomy versus Herbst appliance. Am J
Orthod Dentofacial Orthop. 2004; 126(2):140-152.
Stellzig-Eisenhauser A, Lux CJ, Schuster G. Treatment decision in adult patients with
Class III malocclusion: orthodontic therapy or orthognathic surgery? Am J Orthod
Dentofacial Orthop. 2002; 122(1):27-38.
62
Wolford LM, Karras S, Mehra P. Concomitant temporomandibular joint and orthognathic
surgery: a preliminary report. J Oral Maxillofac Surg. 2002; 60(4):356-362.
Wolford LM, Karras SC, Mehra P. Consideration for orthognathic surgery during growth,
part 1: mandibular deformities. Am J Orthod Dentofacial Orthop. 2001; 119(2):95-101.
Wolford LM, Karras SC, Mehra P. Consideration for orthognathic surgery during growth,
part 2: maxillary deformities. Am J Orthod Dentofacial Orthop. 2001; 119(2):102-105.
Yamada K, Hanada K, Hayashi T, Ito J. Condylar bony change, disk displacement, and
signs and symptoms of TMJ disorders in orthognathic surgery patients. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2001; 91(5):603-610.
Government Agency, Medical Society, and Other Authoritative Publications:
American Academy of Pediatric Dentistry. Guideline on Management of the Developing

Dentition and Occlusion in Pediatric Dentistry. (2014) Available at:
http://www.aapd.org/media/policies_guidelines/g_developdentition.pdf. Accessed on July
11, 2016.
American Association of Oral and Maxillofacial Surgeons. Criteria for Orthognathic
Surgery. (2013). Available at:
http://www.aaoms.org/images/uploads/pdfs/ortho_criteria.pdf. Accessed on July 11, 2016.
American Association of Oral and Maxillofacial Surgeons. Guidelines to the evaluation of
impairment of the oral and maxillofacial region. (2008). Available at:
http://www.aaoms.org/images/uploads/pdfs/impairment_guidelines.pdf. Accessed on July
11, 2016.
American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical
Practice Guidelines for Oral and Maxillofacial Surgery (2012). Available at:
http://www.aaoms.org/images/uploads/pdfs/parcare_assessment.pdf. Accessed on July 11,
2016.
Index
Anteroposterior Discrepancies
Asymmetries
Cleft Palate
LeFort Procedure
Malocclusion: Class I, Class II, and Class III
Mandibular/Maxillary Surgery
Maxillofacial Surgery
Orthognathic Surgery
Transverse Discrepancies
Vertical Discrepancies
Document History
Status Date Action

01/01/2017 Updated Coding section to remove codes 21248, 21249, not
applicable for orthognathic surgery.
Reviewed 08/04/2016 Medical Policy & Technology Assessment Committee
63
(MPTAC) review. Updated formatting in Position Statement,
Rationale, Definitions, and References sections. Removed
ICD-9 codes from Coding section.
Revised 08/06/2015 Medical Policy & Technology Assessment Committee
(MPTAC) review. Reformatted Criteria. Updated Reference
section.
Reviewed 08/14/2014 MPTAC review. Updated Rationale, Background, and
Reference sections.
Revised 08/08/2013 MPTAC review. Clarification to Position Statements.
Updated Rationale and References.
Revised 08/09/2012 MPTAC review. Updated Description/Scope, Coding and
Reference sections. Clarification to Position Statements.
Reviewed 08/18/2011 MPTAC review. Updated Rationale, Background/Overview
and Definitions.
Revised 08/19/2010 MPTAC review. Clarification to medically necessary
statement that individuals age 18 and over do not require
documentation of completion of skeletal growth. Updated
Definitions. Updated Coding section with 10/01/2010 ICD-9
changes.
Revised 08/27/2009 MPTAC review. Updated Definitions, Coding and
References. Clarification of Medically Necessary statement
about dysphagia.
02/24/2009 Formatting edited for clarity.
Reviewed 08/28/2008 MPTAC review. Updated References, Coding.
04/01/2008 A NOTE was added after the Reconstructive Definition to
clarify that not all benefit contracts include a reconstructive
services benefit.
02/21/2008 The phrase "cosmetic/not medically necessary" was clarified
to read "cosmetic and not medically necessary." This change
was approved at the November 29, 2007 MPTAC meeting.
Reviewed 08/23/2007 MPTAC review. References and Coding updated. Minor
formatting changes.
01/01/2007 Updated Coding section with 01/01/2007 CPT/HCPCS
changes.
Reviewed 09/14/2006 MPTAC review. References and Coding updated. Minor
grammatical changes.
Revised 09/22/2005 MPTAC review. Revision based on Pre-merger Anthem and
Pre-merger WellPoint Harmonization.
Pre-Merger Last ReviewDocument Title

Organizations Date Number
Anthem, Inc. 04/28/2005 SURG.00049 Orthognathic Surgery
WellPoint Health04/28/2005 3.03.03 Mandibular/Maxillary
Networks, Inc. (Orthognathic) Surgery
64
04/28/2005 Clinical Mandibular/Maxillary
Guideline (Orthognathic) Surgery
Federal and State law, as well as contract language, including definitions and specific
contract provisions/exclusions, take precedence over Medical Policy and must be
considered first in determining eligibility for coverage. The member’s contract benefits in
effect on the date that services are rendered must be used. Medical Policy, which addresses
medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update
Medical Policy periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted,

in any form or by any means, electronic, mechanical, photocopying, or otherwise, without
permission from the health plan.
POLICY . . . . . . . . PG-0226 MEDICAL POLICY

EFFECTIVE . . . . . .03/15/09 Orthognathic Surgery
LAST REVIEW . . . 05/27/16
65
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by
each individual policyholder contract. Paramount applies coding edits to all medical claims
through coding logic software to evaluate the accuracy and adherence to accepted national
standards. This guideline is solely for explaining correct procedure reporting and does not
imply coverage and reimbursement.
DESCRIPTION
Orthognathic surgery is the revision by ostectomy, osteotomy or osteoplasty of the upper
jaw (maxilla) and/or the lower jaw (mandible) intended to alter the relationship of the jaws
and teeth. These surgical procedures are intended to correct skeletal jaw and cranio-facial
deformities that may be associated with significant functional impairment, and to
reposition the jaws when conventional orthodontic therapy alone is unable to provide a
satisfactory, functional dental occlusion within the limits of the available alveolar bone.
Congenital or developmental defects can interfere with the normal development of the face
and jaws. These birth defects may interfere with the ability to chew properly, and may also
affect speech and swallowing. In addition, trauma to the face and jaws may create skeletal
deformities that cause significant functional impairment. Functional deficits addressed by
this type of surgery are those that affect the skeletal masticatory apparatus such that
chewing, speaking and/or swallowing are impaired.
POLICY Orthognathic surgery (21120-21123, 21125, 21127, 21141-21143, 21145-
21147, 21150, 21151, 21154, 21155, 21159, 21160, 21181-21184, 21188, 21193-21196,
21198, 21199, 21206, 21208-21210, 21215, 21230, 21240, 21244-21249, 21255, 21270,
21275, 21295, 21296) requires prior authorization.
Procedure code 21235 does not require a prior authorization.
REVIEW SPECIFICS
Procedures performed with the primary purpose of improving physical appearance or to
treat psychological symptomatology or psychosocial complaints are cosmetic in nature and
not medically necessary. A Medical Director/Associate Medical Director will review
medical and dental records (including study models, x-rays, photographs) to determine if
the surgery is cosmetic or reconstructive in nature. The review focus is to evaluate the
degree of spatial asymmetry and presence of resultant medical problem due to asymmetry.
Information may be submitted for evaluation to an oral surgery specialist for final
determination.
TERMS THAT MAY BE USED IN THESE CASES INCLUDE:

 Maxillofacial surgery
 Facial plastic surgery
 Mandibular surgery
 Maxillary surgery
 Osteotomy or osteoplasty (bone removal or addition)
 Craniofacial surgery
 Mentoplasty (chin surgery)
 LeForte I, II, or III procedures
HMO, PPO, Individual Marketplace, Elite, Advantage
Paramount covers orthognathic surgery with prior authorization for the following
indications:
1. The procedure is being done to restore bodily function or, initially, to rebuild lost
function from a congenital abnormality; OR
66
2. For jaw and craniofacial deformities that cause significant functional impairment for
repair or correction of a congenital anomaly that is present at birth, such as cleft palate,
Crouzon’s syndrome or Treacher Collins dysostosis; OR
3. For initial and immediate surgery to repair a covered accidental injury or cancerous
growth: OR
4. To correct jaw and craniofacial deformities related to severe or handicapping
malocclusion.
5. Severe or handicapping malocclusion is defined as a deformity where the patient has
difficulty in swallowing or in the ability to chew only soft food or intake liquids. For these
patients, there should be evidence of significant and persistent symptoms and other causes
of swallowing and oral problems should have been evaluated. Paramount will require
clinical evidence, such as weight loss or malnutrition.
6. Severe malocclusion as evidenced by anteroposterior, transverse or lateral asymmetry
(spatial mismatch) of the jaws with clinical evidence of:
 speech abnormalities
 swallowing difficulties
 obstructive sleep apnea
 difficulty chewing
Orthognathic surgery is considered cosmetic and therefore NOT COVERED in the

following instances:
1. When no functional impairment is present; OR
2. When there is no change in spatial or functional relationship of the jaws; OR
3. To address psychological issues of asymmetry or anatomic variation (appearance); OR
4. For familial chin deformities (“weak chin”); OR
5. For the purposes of improved outcome of orthodontia. Orthodontia is not covered under
the Commercial HMO and Elite medical/dental benefits.
6. Bone grafting done for the purpose of dental implants, not related to post-traumatic
reconstruction or post-surgical (tumor resection) reconstruction.
CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage.
Codes that are covered may have selection criteria that must be met. Payment for
supplies may be included in payment for other services rendered. CPT CODES
21120 GENIOPLASTY; AUGMENTATION
67
21121 GENIOPLASTY; SLIDING OSTEOTOMY
21122 GENIOPLASTY; SLIDING OSTEOTOMIES
21123 GENIOPLASTY; SLIDING AUGMENTATION
21125 AUGMENTATION MANDIBULAR BODY; PROSTHETIC MAT
21127 AUGMENTATION MANDIBULAR BODY; W/ BONE GRAFT
21141 LEFORT I RECON; SINGLE PIECE W/OUT BONE GRAFT
21142 LEFORT I RECON; TWO PIECES W/OUT BONE GRAFT
21143 LEFORT I RECON; THREE OR MORE W/OUT BONE GRAFT
21145 LEFORT I RECON; SINGLE PIECE W/ BONE GRAFT
21146 LEFORT I RECON; TWO PIECES W/ BONE GRAFT
21147 LEFORT I RECON; THREE OR MORE W/ BONE GRAFT
21150 LEFORT II RECON; ANTERIOR INTRUSTION
21151 LEFORT II RECON; ANY DIRECTION W/ GRAFTS
21154 LEFORT III RECON; W/ BONE GRAFTS W/OUT LEFORT I
21155 LEFORT III RECON; W/ BONE GRAFTS W/ LEFORT I
21159 LEFORT III RECON; W/ FOREHEAD ADV W/OUT LEFORT I
21160 LEFORT III RECON; W/ FOREHEAD ADV W/OUT LEFORT I
21181 RECON BY CONTOURING OF CRANIAL BONES
21182 RECON ORBITAL RIMS/FOREHEAD; W/GRAFTS LESS 40 CM
21183 RECON ORBITAL RIMS/FOREHEAD; W/GRAFTS 40-80 CM
21184 RECON ORBITAL RIMS/FOREHEAD; W/GRAFTS 80 OR MORE
21188 RECON MIDFACE OSTEOTOMIES AND BONE GRAFTS
21193 MANDIBULAR RECONSTRUCTION; W/OUT BONE GRAFT
21194 MANDIBULAR RECONSTRUCTION; W/ BONE GRAFT
21195 MANDIBULAR RECONSTRUCTION; W/OUT INT FIXATION
21196 MANDIBULAR RECONSTRUCTION; W/ INT FIXATION
21198 OSTEOTOMY MANDIBLE; SEGMENTAL
21199 OSTEOTOMY MANDIBLE; W/ ADVANCEMENT
21206 SEGMENTAL OSTEOTOMY
21208 FACIAL OSTEOPLASTY
21209 FACIAL OSTEOPLASTY REDUCTION
21210 NASAL BONE GRAFT
21215 NASAL BONE GRAFT
21230 AUTOGENOUS GRAFT RIB TO FACE
21235 AUTOGENOUS GRAFT EAR TO FACE
21240 ARTHROPLASTY,TEMPOROMANDIBULAR JOINT
\
LAMPIRAN:
Kewenangan Klinis di bidang Emergency Bedah Mulut dan Maksilofasial

ICD-9 Codes that meet Emergency Criteria
68
ICD-9
No DESCREPTION
CODE
1 042 Human immunodefieciency virus (hiv) disease ~ acquired immune defic
2 920 contusion of face, scalp, and neck except eye(s)
3 990 Effects of radiation, unspecified
Hemorrhage, hemorrhagic (nontraumatic) 459.0 (gingiva 523.8; gum
4 459.0
523.8, mouth 528.9)
5 2680 Hemophilia
6 2861 Congenital factor ix disorder
7 2862 Congenital factor xi deficiency
8 2863 Congenital deficiency of other clotting factors
9 2864 Von willebrand's disease
10 2865 Hemorrhagic disorder due to intrinsic circulating anticoagulants
11 2870 Allergic purpura
12 2878 Other specified hemorrhagic conditions
13 2879 Unspecified hemorrhagic conditions
14 3501 Trigeminal neuralgia
15 3510 Bells palsy ~ seventh nerve
16 4200 Acute pericarditis in diseases classified elsewhere
17 4210 4210 acute and subacute bacterial endocarditis
18 4211 Acute and subacute infective endocarditis in diseases classified
19 4219 Acute endocarditis, unspecified
20 4220 Acute myocarditis in diseases classified elsewhere
21 4275 Cardiac arrest
22 5192 Mediastinitis
23 5224 Acute apical periodontitis of pulpal origin
24 5225 Abscess: tooth or teeth
25 5227 Periapical abscess with sinus
26 5253 Retained dental root
27 5271 Hypertrophy of salivary gland
28 5272 5272 sialoadenitis ~ parotitis
29 6819 Paronychia ~ subungual abscess
30 6820 Cellulitis and abscess of face
31 6821 Cellulitis and abscess of neck
32 7817 Tetany
33 7825 Cyanosis
34 7827 Spontaneous ecchymosis
35 7861 Stridor
36 7981 Instantaneous death ~ doa
37 7982 Death occurring in less than 24 hours from onset of symptoms, not
38 7989 Unattended death
39 7991 Respiratory arrest {excludes cardiac arrest 4275 failure of peripheral
40 8020 Closed fracture of nasal bones
41 8021 Open fracture of nasal bones
42 8024 closed fracture of malar and maxillary bones
43 8025 Open fracture of malar and maxillary bones
44 8026 Closed fracture of orbital floor (blow-out)
45 8027 Open fracture of orbital floor (blow-out)
46 8028 Closed fracture orbit
69
47 8029 Open fracture of other facial bones
48 8029 Open fracture of other facial bones
49 8300 Closed dislocation of jaw
50 8301 Open dislocation of jaw
51 9056 Late effect of dislocation
52 9060 late effect of open wound of head, neck, and trunk
53 9092 late effect of radiation
54 9093 late effect of complications of surgical and medical care
55 9095 late effect of adverse effect of drug ~ medicinal ~ or bilogical
56 9107 superficial foreign body (splinter) of face, neck, and scalp except eye
57 9108 other and unspecified superficial injury of face, neck, and scalp
58 9109 other and unspecified superficial injury of face, neck, and scalp, infec
59 9251 crushing injury of face and scalp
60 9252 crushing injury of neck
61 9350 foreign body in mouth
9600 POISONING BY PENICILLINS

9601 POISONING BY ANTIFUNGAL ANTIBIOTICS
9602 POISONING BY CHLORAMPHENICOL GROUP
9603 POISONING BY ERYTHROMYCIN AND OTHER MACROLIDES
9604 POISONING BY TETRACYCLINE GROUP
9605 POISONING OF CEPHALOSPORIN GROUP
9606 POISONING OF ANTIMYCOBACTERIAL ANTIBIOTICS
9607 POISONING BY ANTINEOPLASTIC ANTIBIOTICS
9608 POISONING BY OTHER SPECIFIED ANTIBIOTICS
9609 POISONING BY UNSPECIFIED ANTIBIOTIC
9610 POISONING BY SULFONAMIDES
9613 POISONING BY QUINOLINE AND HYDROXYQUINOLINE DERIVATIVES
9617 POISONING BY ANTIVIRAL DRUGS
9618 POISONING BY OTHER ANTIMYCOBACTERIAL DRUGS
9619 POISONING BY OTHER AND UNSPECIFIED ANTI-INFECTIVES
9620 POISONING BY ADRENAL CORTICAL STEROIDS
9635 POISONING BY VITAMINS, NOT ELSEWHERE CLASSIFIED
9638 POISONING BY OTHER SPECIFIED SYSTEMIC AGENTS
9639 POISONING BY UNSPECIFIED SYSTEMIC AGENT
9640 POISONING BY IRON AND ITS COMPOUNDS
9642 POISONING BY ANTICOAGULANTS
9643 POISONING BY VITAMIN K (PHYTONADIONE)
9644 POISONING BY FIBRINOLYSIS-AFFECTING DRUGS
9645 POISONING BY ANTICOAGULANT ANTAGONISTS AND OTHER
COAGULANTS
9647 POISONING BY NATURAL BLOOD AND BLOOD PRODUCTS
9648 POISONING BY OTHER SPECIFIED AGENTS AFFECTING BLOOD
CONSTITUENTS
9649 POISONING BY UNSPECIFIED AGENT AFFECTING BLOOD
CONSTITUENTS
9651 POISONING BY SALICYLATES
9654 POISONING BY AROMATIC ANALGESICS, NOT ELSEWHERE CLASSIFIED
9657 POISONING BY OTHER NON-NARCOTIC ANALGESICS
9658 POISONING BY OTHER SPECIFIED ANALGESICS AND ANTIPYRETICS
70
9685 POISONING BY SURFACE (TOPICAL) AND INFILTRATION ANESTHETICS
9686 POISONING BY PERIPHERAL NERVE- AND PLEXUS-BLOCKING
ANESTHETICS
9689 POISONING BY OTHER AND UNSPECIFIED LOCAL ANESTHETICS
9751 POISONING BY SMOOTH MUSCLE RELAXANTS
9752 POISONING BY SKELETAL MUSCLE RELAXANTS
9753 POISONING BY OTHER AND UNSPECIFIED DRUGS ACTING ON MUSCLES
9754 POISONING BY ANTITUSSIVES
9755 POISONING BY EXPECTORANTS
9756 POISONING BY ANTI-COMMON COLD DRUGS
9757 POISONING BY ANTIASTHMATICS
9758 POISONING BY OTHER AND UNSPECIFIED RESPIRATORY DRUGS
9760 POISONING BY LOCAL ANTI-INFECTIVES AND ANTI-INFLAMMATORY
DRUGS
9761 POISONING BY ANTIPRURITICS
9762 POISONING BY LOCAL ASTRINGENTS AND LOCAL DETERGENTS
9766 POISONING BY ANTI-INFECTIVES AND OTHER DRUGS AND
PREPARATIONS F
9767 POISONING BY DENTAL DRUGS TOPICALLY APPLIED
9768 POISONING BY OTHER AGENTS PRIMARILY AFFECTING SKIN AND
MUCOUS MEMBRANE
9769 POISONING BY UNSPECIFIED AGENT PRIMARILY AFFECTING SKIN AND
MUCOUS MEMBRANE
9773 POISONING BY ALCOHOL DETERRENTS
9774 POISONING BY PHARMACEUTICAL EXCIPIENTS
9778 POISONING BY OTHER SPECIFIED DRUGS AND MEDICINAL
SUBSTANCES
9779 POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE ~
OVERDOSE
9850 TOXIC EFFECT OF MERCURY AND ITS COMPOUNDS
09851 GONOCOCCAL SYNOVITIS AND TENOSYNOVITIS
9851 TOXIC EFFECT OF ARSENIC AND ITS COMPOUNDS
9872 TOXIC EFFECT OF NITROGEN OXIDES
9878 TOXIC EFFECT OF OTHER SPECIFIED GASES, FUMES, OR VAPORS
9879 INHALATION SMOKE ~ STEAM ~ GAS ~ FUMES ~ VAPOR
9918 OTHER SPECIFIED EFFECTS OF REDUCED TEMPERATURE
9919 UNSPECIFIED EFFECT OF REDUCED TEMPERATURE
9920 HEAT STROKE AND SUNSTROKE
9921 HEAT SYNCOPE
9922 HEAT CRAMPS
9950 ANAPHYLACTIC SHOCK, NOT ELSEWHERE CLASSIFIED
9951 ANGIONEUROTIC EDEMA, NOT ELSEWHERE CLASSIFIED
9952 INVALID REQUIRES 5TH DIGIT EFF 10/1/06 - OTHER AND UNSPECIFIED
ADVERSE
9953 ALLERGY, UNSPECIFIED, NOT ELSEWHERE CLASSIFIED
9954 SHOCK DUE TO ANESTHESIA, NOT ELSEWHERE CLASSIFIED
9980 POSTOPERATIVE SHOCK, NOT ELSEWHERE CLASSIFIED
9982 ACCIDENTAL PUNCTURE OR LACERATION DURING A PROCEDURE, NOT
ELSEWHERE CL
9983 DISRUPTION OF OPERATION WOUND, NOT ELSEWHERE CLASSIFIED
DEHISCENSE
71
9984 FOREIGN BODY ACCIDENTALLY LEFT DURING A PROCEDURE, NOT
ELSEWHERE
9987 ACUTE REACTION TO FOREIGN SUBSTANCE ACCIDENTALLY LEFT
DURING A PROCES
9991 AIR EMBOLISM AS A COMPLICATION OF MEDICAL CARE, NOT
ELSEWHERE CLAS
9992 OTHER VASCULAR COMPLICATIONS OF MEDICAL CARE, NOT
ELSEWHERE CLASSIFIE
9994 ANAPHYLACTIC SHOCK DUE TO SERUM, NOT ELSEWHERE CLASSIFIED
9995 OTHER SERUM REACTION, NOT ELSEWHERE CLASSIFIED
9996 ABO INCOMPATIBILITY REACTION, NOT ELSEWHERE CLASSIFIED
9997 RH INCOMPATIBILITY REACTION, NOT ELSEWHERE CLASSIFIED
9998 OTHER TRANSFUSION REACTION, NOT ELSEWHERE CLASSIFIED
27541 HYPOCALCEMIA
27542 HYPERCALCEMIA
27650 VOLUME DEPLETION, UNSPECIFIED
27651 DEHYDRATION
27652 HYPOVOLEMIA
47822 PARAPHARYNGEAL ABSCESS
47824 RETROPHARYNGEAL ABSCESS
ICD-9 Codes that meet Emergency CriteriaCD-

78601 HYPERVENTILATION
78602 ORTHOPNEA
78603 APNEA
78605 SHORTNESS OF BREATH
78606 TACHYPNEA
78607 WHEEZING
78609 SHORTNESS OF BREATH SOB
79091 ABNORMAL ARTERIAL BLOOD GASES
79092 ABNORMAL COAGULATION PROFILE
80220 CLOSED FRACTURE OF UNSPECIFIED SITE OF MANDIBLE

80221 CLOSED FRACTURE OF CONDYLAR PROCESS OF MANDIBLE
80222 CLOSED FRACTURE OF SUBCONDYLAR PROCESS OF MANDIBLE
80223 CLOSED FRACTURE OF CORONOID PROCESS OF MANDIBLE
80224 CLOSED FRACTURE OF UNSPECIFIED PART OF RAMUS OF MANDIBLE
80225 CLOSED FRACTURE OF ANGLE OF JAW
80226 CLOSED FRACTURE OF SYMPHYSIS OF BODY OF MANDIBLE
80227 CLOSED FRACTURE OF ALVEOLAR BORDER OF BODY OF MANDIBLE
80228 CLOSED FRACTURE OF OTHER AND UNSPECIFIED PART OF BODY OF
MANDIBLE
80229 CLOSED FRACTURE OF MULTIPLE SITES OF MANDIBLE
80230 OPEN FRACTURE OF UNSPECIFIED SITE OF MANDIBLE
80231 OPEN FRACTURE OF CONDYLAR PROCESS OF MANDIBLE
80232 OPEN FRACTURE OF SUBCONDYLAR PROCESS OF MANDIBLE
80233 OPEN FRACTURE OF CORONOID PROCESS OF MANDIBLE
80234 OPEN FRACTURE OF UNSPECIFIED PART OF RAMUS OF MANDIBLE
80235 OPEN FRACTURE OF ANGLE OF JAW
80236 OPEN FRACTURE OF SYMPHYSIS OF BODY OF MANDIBLE
80237 OPEN FRACTURE OF ALVEOLAR BORDER OF BODY OF MANDIBLE
72
80238 OPEN FRACTURE OF OTHER AND UNSPECIFIED PART OF BODY OF
MANDIBLE
80239 OPEN FRACTURE OF MULTIPLE SITES OF MANDIBLE
87321 OPEN WOUND OF NASAL SEPTUM, UNCOMPLICATED
87322 OPEN WOUND OF NASAL CAVITY, UNCOMPLICATED
87323 OPEN WOUND OF NASAL SINUS, UNCOMPLICATED
87329 OPEN WOUND OF MULTIPLE SITES, UNCOMPLICATED
87330 OPEN WOUND OF NOSE, UNSPECIFIED SITE, COMPLICATED
ICD-9 Codes that

87340 OPEN WOUND OF FACE, UNSPECIFIED SITE, UNCOMPLICATED
87341 OPEN WOUND OF CHEEK, UNCOMPLICATED
87342 OPEN WOUND OF FOREHEAD, EYEBROW UNCOMPLICATED
87343 OPEN WOUND OF LIP, UNCOMPLICATED
87344 OPEN WOUND OF JAW, UNCOMPLICATED ~ CHIN
87349 OPEN WOUND OF OTHER AND MULTIPLE SITES, UNCOMPLICATED
87350 OPEN WOUND OF FACE, UNSPECIFIED SITE, COMPLICATED
87351 OPEN WOUND OF CHEEK, COMPLICATED
87353 OPEN WOUND OF LIP, COMPLICATED
87354 OPEN WOUND OF JAW, COMPLICATED
87359 OPEN WOUND OF OTHER AND MULTIPLE SITES, COMPLICATED
87360 OPEN WOUND OF MOUTH, UNSPECIFIED SITE, UNCOMPLICATED
87361 OPEN WOUND OF BUCCAL MUCOSA, UNCOMPLICATED
87362 OPEN WOUND OF GUM (ALVEOLAR PROCESS), UNCOMPLICATED
87363 TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA)
87364 OPEN WOUND OF TONGUE AND FLOOR OF MOUTH, UNCOMPLICATED
87365 OPEN WOUND OF PALATE, UNCOMPLICATED
87369 OPEN WOUND OF OTHER AND MULTIPLE SITES, UNCOMPLICATED
87370 OPEN WOUND OF MOUTH, UNSPECIFIED SITE, COMPLICATED
87371 OPEN WOUND OF BUCCAL MUCOSA, COMPLICATED
87372 OPEN WOUND OF GUM (ALVEOLAR PROCESS), COMPLICATED
87373 TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA)
87374 OPEN WOUND OF TONGUE AND FLOOR OF MOUTH, COMPLICATED
87375 OPEN WOUND OF PALATE, COMPLICATED
99552 CHILD NEGLECT NUTRITIONAL
99553 CHILD SEXUAL ABUSE
99554 CHILD PHYSICAL ABUSE
99555 SHAKEN INFANT SYNDROME
99559 OTHER CHILD ABUSE AND NEGLECT
99560 ANAPHYLACTIC SHOCK DUE TO UNSPECIFIED FOOD
99561 ANAPHYLACTIC SHOCK DUE TO PEANUTS
99562 ANAPHYLACTIC SHOCK DUE TO CRUSTACEANS
99563 ANAPHYLACTIC SHOCK DUE TO FRUITS AND VEGETABLES
99564 ANAPHYLACTIC SHOCK DUE TO TREE NUTS AND SEEDS
99565 ANAPHYLACTIC SHOCK DUE TO FISH
99566 ANAPHYLACTIC SHOCK DUE TO FOOD ADDITIVES
99567 ANAPHYLACTIC SHOCK DUE TO MILK PRODUCTS
99568 ANAPHYLACTIC SHOCK DUE TO EGGS
99569 ANAPHYLACTIC SHOCK DUE TO OTHER SPECIFIED FOOD
99580 ADULT MALTREATMENT UNSPECIFIED
99581 ADULT MALTREATMENT SYNDROME
73
99582 ADULT EMOTIONAL/PSYCHOLOGICAL ABUSE
99583 ADULT SEXUAL ABUSE
99584 ADULT NEGLECT NUTRITIONAL
99585 OTHER ADULT ABUSE AND NEGLECT
99586 MALIGNANT HYPERTHERMIA
99589 OTHER SPECIFIED ADVERSE EFFECTS, NOT ELSEWHERE CLASSIFIED
99590 SYSTEMIC INFLAMMATORY RESPONSE SYNDROME, UNSPECIFIED
99591 SEPSIS
99592 SEVERE SEPSIS
99593 SYSTEMIC INFLAMMATORY RESPONSE SYNDROME DUE TO
NONINFECTIOUS PROCESS
99594 SYSTEMIC INFLAMMATORY RESPONSE SYNDROME DUE TO
NONINFECTIOUSPROCESS
99600 MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE,
IMPLANT, AND G
99601 MECHANICAL COMPLICATION DUE TO CARDIAC PACEMAKER
(ELECTRODE)
99602 MECHANICAL COMPLICATION DUE TO HEART VALVE PROSTHESIS
99603 MECHANICAL COMPLICATION DUE TO CORONARY BYPASS GRAFT
(EXCLUDES AT
99604 DUE TO AUTOMATIC IMPLANTABLE CARDIAC DEFIVRILLATOR
99609 OTHER MECHANICAL COMPLICATION OF CARDIAC DEVICE, IMPLANT,
AND GRAFT
99630 MECHANICAL COMPLICATION OF UNSPECIFIED GENITOURINARY
DEVICE, IMPLANT,
99631 MECHANICAL COMPLICATION DUE TO URETHRAL (INDWELLING)
CATHETER
99655 MECHANICAL COMPLICATIONS DUE TO ARTIFICIAL SKIN GRAFT AND
99656 MECHANICAL COMPLICATIONS DUE TO PERITONEAL DIALYSIS
CATHETER
99659MECHANICAL COMPLICATION OF OTHER SPECIFIED PROSTHETIC
DEVICE IMPLANT
99685 BONE MARROW
ICD-9 Codes that meet Emergency Criteria
ICD-9
Code Description
74

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Kewenangan Tindakan Medik

Tim Editor Coen Pramono D. (Ketua)

1. Ketua PP PABMI : Safrudin Haq

Pengurus Pusat PABMI

Surabaya, 16 Januari 2017

Selamat bekerja dan mengabdi.

Surabaya, 16 Januari 2017

Tim Edit Editor dan Kontributor

Kata Pengantar Tim Editor Buku KTM

Kata Pengantar Ketua Kolegium PABMI

Sambutan Ketua PP PABMI

Sambutan Ketua Umum Persatuan Dokter Gigi Indonesia

Sambutan Ketua Konsil Kedokteran Gigi Indonesia

Penyangkalan atau Discalaimer

Lampiran 2. Contoh Surat Penugasan Klinis (SPK)/ Clinical Appointment untuk

Lampiran 3. Contoh Modifikasi Rincian Kewenangan Klinis (RKK)

Lampiran 4. Contoh Formulir Saran, Keluhan dan Laporan Pengaduan Kelalaian

1.Kerangka dasar pembuatan Surat Penugasan Klinis

2. Kewenangan Tindak Medik Dokter Gigi Spesialis Kedokteran Gigi

3. Bagan alur pengajuan pembuatan Surat Penugasan Klinik (White Paper)

Ketua Departemen/ SMF Bedah  Melakukan penelitian kebenaran

Komite Medis RS/RSGM  Melakukan verifikasi dan validasi serta

Dokter Gigi Spesialis Bedah Mulut,  Menyerahkan Surat Penugasan Klinis

Ketua Departemen/ SMF Bedah  Menyerahkan semua dokumen lamaran

Komite Medis RS/RSGM  Melakukan verifikasi dan validasi serta

Dokter Gigi Spesialis Bedah Mulut,  Menyerahkan Surat Penugasan Klinis

KEWENANGAN KLINIS SPESIALIS

K00. DISORDER OF TOOTH DEVELOPMENT AND ERUPTION

K01. EMBEDDED AND IMPACTED TEETH

K03. OTHER DISEASES OF HARD TISSUES OF TEETH

K04. DISEASES OF PULP AND PERIAPICAL TISSUE

K05. GINGIVITIS AND PERIODONTAL DISEASES

OTHER DISORDER OF GINGIVA AND EDENTULOUS ALVEOLAR RIDGE

K07. DENTOFACIAL ANOMALIES (INCLUDING MALOCCLUSION)

K08. OTHER DISORDERS OF TEETH AND SUPPORTING STRUCTURES

CYSTS OF ORAL REGION, NOT ELSEWHERE CLASSIFIED

K10. OTHER DISEASES OF JAWS

DISEASES OF SALIVARY GLANDS

STOMATITIS AND RELATED LESIONS

OTHER DISEASES OF LIP AND ORAL MUCOSA

K50. CROHN’S DISEASE (REGIONAL ENTERITIS)

Prosthetic dental implant 23.6

CORPUS ALENIUM SINUS MAKSILARIS

DENTAL IMPLANT FAILURE

PENGELOLAAN KOMPLIKASI BEDAH DENTOALVEOLAR

ORAL AND MAXILLOFACIAL MANAGEMENT

CELLULITIS AND ABCESS OF FACE

ODONTOGENIC AND NON ODONTOGENIC CYST

follicular (atretic) (ovarian) 620.0

Fissural cysts of jaw

MALIGNANT NEOPLASMA BIBIR, RONGGA MULUT DAN PHARYNX

MALIGNANT NEOPLASMA OF OTHER AND UNSPESIFIED PART OF MOUTH

LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUE

Drainage of face and flour of mouth

CONGENITAL MUSCULOSKELETAL DEFORMITIES OF SKULL, FACE AND JAW

FACIAL BONES AND JOINTS SURGERY

BONE AND SKIN TRANSPLANT

Subject: Mandibular/Maxillary (Orthognathic) Surgery

This document addresses medically necessary, reconstructive and cosmetic procedures

Medically Necessary: In this document, procedures are considered medically necessary if

Reconstructive: In this document, procedures are considered reconstructive when

Mandibular/Maxillary (orthognathic) surgery is considered medically necessary to treat a

Mandibular/maxillary (orthognathic) surgery is considered reconstructive when intended