KODING ICD 9 CM

Dr. Endang Suparniati, M.Kes

 DEFINISI PROSEDUR

• Adalah : Intervensi medis atau bedah yang

dilakukan terhadap pasien dengan tujuan
untuk diagnostik ataupun terapetik.

• Meliputi :
• Radiologi eksplorasi fungsional
• Intervensi bedah
• Prosedur umum untuk tujuan diagnostik /
terapetik
 PROSEDUR UTAMA

• Adakah prosedur tindakan yang paling

banyak menghabiskan sumber daya atau
yang menyebabkan hari rawatan paling
lama dan biasanya berhubungan erat
dengan diagnosis utama
 PROSEDUR SEKUNDER

• Adalah seluruh prosedur tindakan yang

signifikan yang dilakukan pada pasien
rawat inap atau rawat jalan,
membutuhkan peralatan spesial atau
dikerjakan oleh staf terlatih dan
berpengalaman.
 Prosedur Operasi

Prosedur non-operasi
 PROSEDUR OPERASI
• setiap prosedur terapetik atau
diagnostik utama
• dengan menggunakan berbagai
instrumen
• atau dengan memanipulasi bagian
• atau beberapa bagian dari tubuh
• dan pada umumnya dilakukan
dengan bantuan anastetik.
 PROSEDUR NON-OPERASI

Prosedur investigatif dan terapetik

lain yang tidak melibatkan bedah,
Misalnya:
• radiologi;
• laboratorium;
• fisik;
• psikologik;
• dan sebagainya.
 0 00 Procedures and interventions, not elsewhere classified
1 01-05 Operations on the nervous system
2 06-07 Operations on the endocrine system
3 08-16 Operations on the eye
4 18-20 Operations on the ear
5 21-29 Operations on the nose, mouth, and pharynx
6 30-34 Operations on the respiratory system
7 35-39 Operations on the cardiovascular system
8 40-41 Operations on the hemic and lymphatic system
9 42-54 Operations on the digestive system
10 55-59 Operations on the urinary system
11 60-64 Operations on the male genital organs
12 65-71 Operations on the female genital organs
13 72-75 Obstetrical procedures
14 76-84 Operations on the musculoskeletal system
15 85-86 Operations on the integumentary system
16 87-99 Miscellaneous diagnostic and therapeutic procedures
 MULTI AXIAL CLASSIFICATION
ICD 9 CM

• ANATOMICAL SITE AXIS

LEVEL 1

• PROCEDUR AXIS
LEVEL 2

• SITE/PROCEDURE/TECHNICAL AXIS
LEVEL 3
Chapter I - Operations on the
nervous system (01-05) (1st axis)
PRIMARY
Incision & excision of skull, AXIS
01 brain and cerebral meninges
(1st axis)
SECONDARY
01.0 Cranial puncture (2nd axis)
AXIS
01.01 Cisternal puncture (3rd axis)
Ventriculopuncture thru
01.02 previouslyimplanted catheter TERTIARY
(3rd axis) AXIS
Other cranial puncture (3rd
01.09 axis) 01.09 Other cranial
puncture (3rd axis)
Chapter VI – Operations on the
respiratory system (30-34) (1st axis) PRIMARY
32 Excision of lung and bronchus AXIS
(1st axis)
32.0 Local excision or destruction
SECONDARY
of lesion or tissue of bronchus
AXIS
(2nd axis)
32.01 Endoscopic excision or
destruction of lesion or tissue
of bronchus (3rd axis) TERTIARY
32.09 Other local excision or AXIS
destruction of lesion or tissue
of bronchus (3rd axis)
KONVENSI DALAM
KODING ICD-9-CM
 NEC (NOT ELSEWHERE CLASSIFIABLE :

tidak ada informasi yang lebih spesifik

untuk menentukan kodingnya

Contoh:
16.9 Other operations on orbit and eyeball
Excludes: irrigation of eye (96.51)
prescription and fitting of low vision
aids (95.31-95.33)
removal of:
eye prosthesis NEC (97.31)
nonpenetrating foreign body from
eye without incision (98.21)
 NOS (NOT OTHERWISE SPECIFIED)

Singkatan ini setara dengan “unspecified”

26.4 Repair of salivary gland or duct

26.41 Suture of laceration of salivary gland
26.42 Closure of salivary fistula
26.49 Other repair and plastic operations
on salivary gland or duct
• Fistulization of salivary gland
• Plastic repair of salivary gland or
duct NOS
• Transplantation of salivary duct
opening
[ ] Brackets
Digunakan untuk :
• mengurung persamaan kata atau sinonim
(synonyms),
• kata sebutan alternatif (alternative words),
• dan frasa penjelasan (explanatoryphrases)

50.1 Diagnostic procedures on liver

50.11 Closed (percutaneous) [needle]
biopsy of liver Diagnostic aspiration of
liver
50.12 Open biopsy of liver Wedge biopsy
 () PARENTHESES

• digunakan untuk melampirkan kata tambahan yang

mungkin ada atau tidak ada dalam pernyataan penyakit
atau prosedur tanpa mempengaruhi nomor kode yang
ditugaskan.

55.03 Percutaneous nephrostomy without fragmentation

Nephrostolithotomy, percutaneous (nephroscopic)
Percutaneous removal of kidney stone(s) by:
basket extraction
forceps extraction (nephroscopic)
Pyelostolithotomy, percutaneous (nephroscopic)
With placement of catheter down ureter
Excludes: percutaneous removal by fragmentation
(55.04)
repeat nephroscopic removal during current
episode (55.92)
 : COLON

• Menambahkan istilah yang tidak lengkap.

• Dengan menambahkan satu atau lebih modifier
untuk bisa ditetapkan kedalam kategori tertentu.

40.24 Excision of inguinal lymph node

40.29 Simple excision of other lymphatic structure
Excision of :
cystic hygroma
lymphangioma
Simple lymphadenectomy
 Includes

Istilah yang muncul di bawah judul pada digit 3 untuk

menjelaskan lebih detail atau memberikan contoh kategori
tsb

57.7 Total cystectomy

Includes: total cystectomy with urethrectomy
57.71 Radical cystectomy
Pelvic exenteration in male
Removal of bladder, prostate, seminal vesicles,
and fat
Removal of bladder, urethra, and fat in a female
Code also any:
lymph node dissection (40.3, 40.5)
urinary diversion (56.51- 56.79)
Excludes: that as part of pelvic exenteration in female
(68.8)
57.79 Other total cystectomy
 Excludes
Bila pernyataan tindakan sesuai dengan pernyataan
yang ada di baris “exclude”, maka harus dikode
sesuai dengan petunjuk dalam “exclude”

57.7 Total cystectomy

Includes: total cystectomy with urethrectomy
57.71 Radical cystectomy
Pelvic exenteration in male
Removal of bladder, prostate, seminal vesicles, and
fat
Removal of bladder, urethra, and fat in a female
Code also any:
lymph node dissection (40.3, 40.5)
urinary diversion (56.51- 56.79)
Excludes: that as part of pelvic exenteration in female
(68.8)
57.79 Other total cystectomy
 “omit code”(tidak dikoding)
Merupakan bagian dari prosedur utama.
Jika ada pernyataan omit code pada Indeks Alfabet maka
prosedur tersebut adalah bagian dari kode prosedur lain yang
berhubungan dan tidak dikode.

Laparotomy NEC 54.19 54.19 Other laparotomy

– as operative approach
--omit code
– exploratory (pelvic)
54.11
– reopening of recent
operative site (for
control of hemorrhage)
(for exploration) (for
incision of hematoma)
54.12
Drainage of intraperitoneal abscess or
hematoma
Excludes: culdocentesis (70.0)
drainage of appendiceal abscess
(47.2)
exploration incidental to intra
abdominal surgery --omit code
Ladd operation (54.95)
percutaneous drainage of abdomen
(54.91)
removal of foreign body (54.92)
 “omit code”(tidak dikoding)
Berdasarkan Teknik yang digunakan
• Jika ada pernyataan omit code terkait dengan teknik yang
dilakukan maka tidak dikode. Tetapi jika dilakukan dengan
instrument (tajam) maka bukan termasuk omit code.

Lysis
adhesions
NOTE: blunt --omit code
digital --omit code
manual --omit code
mechanical --omit code
without instrumentation --omit code
abdominal 54.59
laparoscopic 54.51
appendiceal 54.59
laparoscopic 54.51
 KATA “code also”
(dikoding juga)
Jika ada pernyataan code also dibawah
pernyataan tindakan/prosedur maka
harus dikoding.

55.4 Partial nephrectomy

Calycectomy
Wedge resection of kidney
Code also any synchronous resection of ureter
(56.40-56.42)
 KATA –”see”, “see also”
(lihat juga)

Jika ada pernyataan (see, see also) di belakang

pernyataan tindakan/prosedur, maka harus melihat
juga pernyataan tindakan yang dimaksud.

Atherectomy coronary Catheterization –see also

Atherectomy Insertion,
- Cerebrovasculas –see Angioplasty - Catheter arteriovenous 39.93
- Coronary –see Angioplasty - Artery 38.91
coronary 36.09

Maka harus dilihat juga

Dikode Angioplasty coronary 36.09 Insertion.
LANGKAH PENGKODEAN
PROSEDUR
 LEAD TERM:

Menggunakan terminologi tindakan /

kata biasa
• contoh: bisa Herniorraphy atau Repair
of Hernia
CONTOH:
Appendicitis akut dengan appendicectomy
Lead term : Appendicectomy
Alphabetic index : Appendicectomy (with drainage) 47.0
incidental 47.1
Tabular list :
47 Operations on appendix
Includes: appendiceal stump
47.0 Appendectomy
Exclude: incidental appendectomy,described
laparoscopic (47.11)
other (47.19)
47.1 Incidental appendectomy
47.2 Drainage of appendiceal abscess
Excludes: that with appendectomy (47.0)
CONTOH:
CRF dengan hemodialysis
Lead term : Hemodialysis

Alphabetic index: Hemodialysis (extracorporeal) 39.95

Tabular list : 39 Other operations on vessels

39.95 Hemodialysis
Artificial kidney Hemofiltration
Hemodiafiltration Renal dialysis

Excludes: Peritoneal dialysis (54.98)

CONTOH:
Lower Segment Cesarean Section (Fetal Distress)
Lead term : Cesarean
Alphabetic index : Cesarean section 74.99
classical 74.0
fundal 74.0
lower uterine segment 74.1
upper uterine segment 74.0

Tabular list : 74 Cesarean section and removal of fetus

74.1 Low cervical cesarean section
Lower uterine segment cesarean section
SACHSE  URETHROTOMY INTERNAL
SACHSE  URETHROTOMY INTERNAL
BNO - IVP
BNO - IVP
MARI BERLATIH