TATA CARA KODING ICD-10

Lily Kresnowati

KODING
Translasi dari suatu diagnosis, prosedur,
jasa maupun pelayanan ke dalam kode
numerik dan/atau alfanumerik untuk tujuan
pelaporan statistik dan reimbursement.
Membutuhkan pengetahuan tentang
terminologi medis menyangkut diagnosis,
dan prosedur untuk dapat mengalokasikan
kode secara akurat
Bahasa Inggris yang memadai, terutama
terkait letak anatomik dan istilah2 medis

PROSEDUR KODING
1. Persiapan koding :
Alat bantu koding (Buku ICD-10 Vol.1 & 3,
Kamus kedokteran/ Bhs Inggris)
Dokumen Rekam Medis (RM) lengkap
(post-assembled)

2. Analisis dokumen RM untuk

menentukan item yang harus di-kode
3. Koding

VOLUME 1,2,3

DAFTAR
TABULASI

MANUAL
INSTRUKSI

INDEKS
ALFABETIK

VOLUME 1
Bagian terbesar memuat klasifikasi utama,
terdiri dari kategori tiga-karakter dan
subkategori empat karakter dalam 22 Bab
Tanda Baca ; inclusion, exclusion, NOS,
NEC, dll
Morfologi neoplasma
Daftar tabulasi khusus (special tabulation
lists)
Definisi
Regulasi nomenklatur

VOLUME 2
deskripsi tentang sejarah ICD
struktur dan prinsip klasifikasi
aturan-aturan koding morbiditas dan
mortalitas
presentasi statistik
petunjuk praktis bagi pengguna ICD
agar dapat memanfaatkan klasifikasi
sebaik-baiknya.

VOLUME 3
SUSUNAN : terdiri dari 3 bagian (section)
Sect I : Diseases & nature of injury
Sect II : External causes of injury
Sect III : Table of drugs & chemicals
STRUKTUR : berisikan daftar lead term,
modifiers, perkiraan kode ( crosscheck dg volume 1)
TANDA BACA : parentheses, NEC dan
cross-references (see dan see also)

ANALISIS DOKUMEN
REKAM MEDIS

Tujuan : agar kode terpilih dapat

merepresentasikan dengan tepat
diagnosis
Bagian RM yang dianalisis :

Resume (Anamnesis, Pem. Fisik,

Diagnosis, Terapi, Follow-up)

Pemeriksaan Penunjang (Patologi

Klinik, Patologi Anatomi, Radiologi, dll)

Laporan lain (Operasi, Fisioterapi, dll)

PEDOMAN SEDERHANA DALAM

KODING

1. Identifikasi tipe pernyataan

yang akan di-kode

2. Lihat lead term Vol 3
3. Baca seksama & ikuti petunjuk
catatan yang muncul di bawah
lead term

PENGGUNAAN Volume 3
(ALPHABETICAL INDEX)

1.Perhatikan struktur diagnosis

lead term
2.Tentukan penggolongan lead
term dalam bagian yg sesuai
(Vol.3)
3.Perhatikan catatan & crossreference (Vol.3)

PEDOMAN SEDERHANA DALAM

KODING
4. Baca istilah yg terdapat dlm tanda kurung
( ) sesudah lead term
5. Ikuti secara hati-hati setiap cross
-references dan perhatikan see & seealso yg ada dlm indeks
6. Lihat daftar tabulasi (Vol.1) untuk melihat
kode yg paling tepat. Bila ada .- cari
karakter ke-4
7. Ikuti inclusion dan exclusion Kode

Apakah Lead term ?

Lead Term atau Main Term adalah kata
kunci yang menjadi acuan pencarian
kode pada indeks alfabetik.
Di Indeks dicetak tebal di sisi kiri
Merupakan masalah (diagnosis,
cedera, dll) utama pada pasien.
Umumnya merupakan kelainan,
kondisi, gangguan

Letak Anatomik bukan lead

term
Jika kita tetap menjadikan letak anatomik
sebagai lead term maka akan muncul
istilah see condition yang berarti coder
harus merujuk pada kondisi si pasien dan
bukan letak anatomiknya.
Indeks alfabetik telah disusun sedemikian
sehingga coder dapat mengalokasikan
kode yang tepat dengan mencari lead
term dari berbagai istilah yang berbeda

LEAD TERM
Contoh : Congestive Heart Failure akan dapat
dirujuk menggunakan istilah congestive
ataupun failure dan menemukan kode yang
sama yaitu I50.0
Di bawah lead term akan disusun (list) sub term
sub term yang menjelaskan kondisi pasien
lebih jauh. Umumnya berisikan ;
- Etiology (causa)
- Lokasi /site anatomik
- Tipe kelainan/penyakit
- Keterangan lebih lanjut ttg penyakitnya

Congestive Heart Failure

Failure, failed
- cardiac (see also Failure, heart) I50.9
- congestive (see also Failure, heart, congestive) I50.0
- heart (acute) (sudden) I50.9
- - with
- - - acute pulmonary edema see Failure,
ventricular, left
- - - decompensation (see also Failure, heart,
congestive) I50.9
- - congestive I50.0
Extracted from ICD-10 Second Edition, 2005, F.

Congestion, congestive (chronic) (passive)

- bladder N32.8
- bowel K63.8
- general R68.8
- glottis J37.0
- heart (see also Failure, heart, congestive)
I50.0
- hepatic K76.1

Extracted from ICD-10 Second Edition, 2005, C.

I50 Heart failure

Excludes:
complicating:
abortion or ectopic or molar pregnancy (O00O07, O08.8)
obstetric surgery and procedures (O75.4)
due to hypertension (I11.0)
with renal disease (I13.-)
following cardiac surgery or due to presence of cardiac
prosthesis (I97.1)
neonatal cardiac failure (P29.0)

I50.0 Congestive heart failure

Congestive heart disease
Right ventricular failure (secondary to left heart failure)

Extracted from ICD-10 Second Edition, 2005, Diseases of the circulatory

system.

Cara Menggunakan ICD10

Kode
Penyakit

Diagnosis
Utama
(Lead
Term)

Volume
3 ICD10

Volume
1 ICD10
s
o
r
C

ck
e
h
C
s

INGAT KONVENSI TANDA

BACA

Inclusion term
Exclusion term
Glossary descriptions
Tanda kurung/ Parentheses ( )
Kurung besar/ Square brackets [ ]
NOS (Not Otherwise Specified)
NEC (Not Elsewhere Classified)
And & Point Dash (.-)
Kode rangkap : Dagger (+) & Asterisk
(*)

TERMS
INCLUSION

EXCLUSION

Pernyataan diagnostik
yang diklasifikasikan
dlm kelompok tsb.
Dpt dipakai untuk
kondisi yg berbeda atau
sinonimnya

Kondisi yang seolah

terklasifikasi dlm kateg.
ybs, namun ternyata
terklasifikasi di tempat
lain/ kode ditempat lain
Kode yg benar adl yg
diberi tanda dalam
kurung yg mengikuti
istilah tsb

Contoh Inclusion
Diagnosis : CALCULUS OF TONSIL
INDEX ALFABETIK SECTION I
Calculus, calculi, calculous
- ampulla of Vater (see also Choledocholithiasis) K80.5
- - Stensen's duct K11.5
- stomach K31.8
- sublingual duct or gland K11.5
- - congenital Q38.4
- submandibular duct, gland or region K11.5
- suburethral N21.8
- tonsil J35.8
Extracted from ICD-10 Second Edition, 2005, C.

Contoh Inclusion
TABULAR LIST VOL. 1

J35.8
and

Other chronic diseases of tonsils

adenoids
Adenoid vegetations
Amygdalolith
Cicatrix of tonsil (and adenoid)
Tonsillar tag
Ulcer of tonsil

Extracted from ICD-10 Second Edition, 2005, Diseases

of the respiratory system.

Contoh Inclusion
INDEKS ALFABETIK
Amygdalolith J35.8
Extracted from ICD-10 Second Edition, 2005, A.

Contoh Inclusion
L05 Pilonidal cyst
Includes: fistula coccygeal or pilonidal
sinus
L05.0
Pilonidal cyst with abscess
L05.9
Pilonidal cyst without abscess
Pilonidal cyst NOS
Extracted from ICD-10 Second Edition, 2005, Diseases of the skin and
subcutaneous tissue.

J12

Viral pneumonia, not elsewhere classified

Includes: bronchopneumonia due to viruses other than

influenza viruses
Excludes: congenital rubella pneumonitis (P35.0)
pneumonia:
- aspiration (due to):
-NOS (J69.0)
-anaesthesia during:
-labour and delivery (O74.0)
-pregnancy (O29.0)
-puerperium (O89.0)
-neonatal (P24.9)
-solids and liquids (J69.-)
- congenital (P23.0)
- in influenza (J10.0, J11.0)
- Interstitial NOS (J84.9)
- lipid (J69.1)
severe acute respiratory syndrome [SARS] (U04.9)
Extracted from ICD-10 Second Edition, 2005, Diseases of the respiratory system.

Contoh Exclusion
Q66 Congenital deformities of
feet
Excludes:

reduction defects of feet (Q72.-)

valgus deformities (acquired) (M21.0)
varus deformities (acquired) (M21.1)

Q66.0 Talipes equinovarus

Q66.1 Talipes calcaneovarus
Q66.2 Metatarsus varus
Q66.3 Other congenital varus deformities of feet
Hallux varus, congenital
Extracted from ICD-10 Second Edition, 2005, Congenital
malformations, deformations and chromosomal abnormalities.

KEKHUSUSAN BAB ICD10

Setiap Bab dalam ICD-10 memiliki kekhususan
berupa catatan-catatan yang perlu
diperhatikan dalam menentukan kode
penyakit.
Umumnya catatan tersebut berupa tata cara
pengalokasian kode, atau tambahan
subklasifikasi.
Dapat pula berupa keterangan mengenai kode
tambahan opsional yang dapat diberikan
terkait klasifikasi tertentu dalam bab tersebut.

Contoh Kekhususan Bab

Certain infectious and parasitic diseases
(A00B99)
Includes: diseases generally recognized as communicable or transmissible
Excludes: carrier or suspected carrier of infectious disease (Z22.-)
certain localized infections see body system-related chapters
infectious and parasitic diseases complicating pregnancy, childbirth
and the puerperium [except obstetrical tetanus and human
immunodeficiency virus [HIV] disease] (O98.-)
infectious and parasitic diseases specific to the perinatal period
[except tetanus neonatorum, congenital syphilis, perinatal
gonococcal infection and perinatal human immunodeficiency
virus [HIV] disease] (P35P39)
influenza and other acute respiratory infections (J00J22)
Extracted from ICD-10 Second Edition, 2005, Certain infectious and parasitic diseases.

Factors influencing health status and

contact with health services (Z00Z99)
Note: This chapter should not be used for international
comparison or for primary mortality coding.
Categories Z00Z99 are provided for occasions when circumstances other
than a disease, injury or external cause classifiable to categories A00Y89 are
recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
(a) When a person who may or may not be sick encounters the health
services for some specific purpose, such as to receive limited care or service
for a current condition, to donate an organ or tissue, to receive prophylactic
vaccination or to discuss a problem which is in itself not a disease or injury.
(b) When some circumstance or problem is present which influences the
person's health status but is not in itself a current illness or injury. Such
factors may be elicited during population surveys, when the person may or
may not be currently sick, or be recorded as an additional factor to be borne
in mind when the person is receiving care for some illness or injury.
Extracted from ICD-10 Second Edition, 2005, Factors influencing health status and contact with health services.

G81

Hemiplegia

Note:For primary coding, this category is to be used only

when hemiplegia (complete) (incomplete) is
reported without further specification, or is stated to be
old or longstanding but of unspecified cause. The
category is also for use in multiple coding to identify
these types of hemiplegia resulting from any cause.

Excludes: congenital and infantile cerebral palsy

(G80.-)
G81.0 Flaccid hemiplegia
G81.1 Spastic hemiplegia
G81.9 Hemiplegia, unspecified
Extracted from ICD-10 Second Edition, 2005, Diseases of the nervous
system.

Delivery
(O80O84)
Note: Codes O80-O84 are provided for
morbidity coding purposes. Codes from
this block should be used for primary
morbidity coding only if no other
condition classifiable to Chapter XV is
recorded. For use of these categories
reference should be made to the
morbidity coding rules and guidelines in
Volume 2.

Extracted from ICD-10 Second Edition, 2005, Pregnancy, childbirth

and the puerperium.

Diabetes mellitus
(E10E14)
Use additional external cause code (Chapter XX), if
desired, to identify drug, if drug-induced.

The following fourth-character subdivisions

are for use with categories E10-E14:
.0 With coma

Diabetic:
coma with or without ketoacidosis
hyperosmolar coma
hypoglycaemic coma
Hyperglycaemic coma NOS

Diabetes mellitus
(E10E14)
The following fourth-character subdivisions are for use
with categories E10-E14:
.1 With ketoacidosis

Diabetic:
acidosis } without mention of coma
ketoacidosis }

.2 With renal complications

Diabetic nephropathy (N08.3*)
Intracapillary glomerulonephrosis (N08.3*)
Kimmelstiel-Wilson syndrome (N08.3*)
Extracted from ICD-10 Second Edition, 2005, Endocrine, nutritional and
metabolic diseases.

S52 Fracture of forearm

The following subdivisions are provided for
optional use in a supplementary character
position where it is not possible or not desired
to use multiple coding to identify fracture and
open wound; a fracture not indicated as
closed or open should be classified as closed.
0 closed
1 open
Extracted from ICD-10 Second Edition, 2005, Injury,
poisoning and certain other consequences of external
causes.

Fracture including:
Fracture:
closed:
comminuted }
depressed }
elevated
}
fissured }
greenstick }
impacted } with or without delayed healing
linear }
march }
simple }
slipped epiphysis }
spiral }
dislocated
}
displaced }
Fracture:
open:
compound }
infected }
missile } with or without delayed healing
puncture }
with foreign body }
Excludes: fracture:
pathological (M84.4):
with osteoporosis (M80.-)
stress (M84.3-)
malunion of fracture (M84.0)
nonunion of fracture [pseudoarthrosis] (M84.1)
Extracted from ICD-10 Second Edition, 2005, Injury, poisoning and certain other consequences of external causes.

SEKIAN

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