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PELATIHAN CODING

DPD PORMIKI KALBAR 2016

KLASIFIKASI
TINDAKAN
(Procedure
Classification)
Oleh : Sis Wuryanto

Klasifikasi Tindakan
ICOPIM
(

International Classification of Procedures in Medicine)

ICD-9-CM Volume 3

(International Classification of Diseases 9 th Revision Clinical Modification)

CPT

(Current Procedure Terminology)

ICHI

(International Classification of Health Intervention)

KW@PPB

SUFFIXES OPERASI
SuffixArti Contoh
-desis
ikat, fiksasi
arthrodesis, spondylodesis
-ectomy
operasi mengangkat,
(cut and removal)
eksisi appendectomy,
nephrectomy
-pexy
bedah fiksasi
hyeteropexy,
orchidopexy
-plasty
bedah koreksi,
angioplasty, dermatoplasty
perbaikan
-(r)rhaphy
suture (jahit)herniorrhaphy,epatorrhaphy
-(o)stomy
membuat lobang
baru
colostomy, ileostomy
-(o)tomy
insisi ke dalam
craniotomy,
tympanotomy
-tripsymenghancurkan
lithotripsy
4

The International Classification


of Diseases, 9th Revision, Clinical
Modification
(ICD 9-CM)
Volume 3

Procedure Classification

KW@PPB

Histor
y
ICD 9 (1975)
Volume 1 Tabular List
E Code supplementary classification of
external causes of Injury and
V Code supplementary classification of
Factors Influencing Health Status
with Health Services

Volume 2 Alphabetic Index

Poisoning
and Contact

Histor
y

ICD 9-CM (1978)


- Introduced by US (Commission of Professional &
Hospital Activities)

3 volumes:

Volume 1 Diseases : TABULAR LIST


Volume 2 Diseases : ALPHABETICAL LIST
Volume 3 PROCEDURES:
TABULAR and ALPHABETICAL LIST

ICD 9-CM Procedure


Classification:
1.

2.
3.
4.
5.
6.
7.

Published in its own volume containing both


A. Tabular List and
B. Alphabetic Index.
Modification of Fascicle V Surgical Procedures of ICD-9 dan
ICOPIM (International Classification of Procedures in Medicine)
Surgical procedures are group in rubrics 01-86
Non-surgical procedures are confined to rubrics 87-99
Structure of the classification is based on anatomy rather than
surgical specialty.
Numeric only
Based on 2-digit structure with 2 decimal digits where necessary
(expansion from 3 digits in ICD 9 to 4 digits in ICD 9-CM)

Hubungan Antara
ICD-10 dan ICD-9-CM
Dalam Implementasi INA CBGs

ICD-10

Kode
Diagnosis
ICD-9-CM vol.3
Kode Tindakan
(Procedures)

6
8
19

ICD-9-CM
Therapeutic diagnostic procedures
Structure of the classification is based on anatomy rather than surgical
specialty.
01-86 Procedures Organ system
87-99 Miscellaneous (Non OR) procedures
Radiology
Laboratory exam
Interview, evaluation, consultation & examination
Nuclear medicine
Rehabilitation
Procedures related to the psyche
Non - operative intubation & irrigation

TUJUAN KODE TINDAKAN


(Procedures)

Medical statistic
Medical care review
Reimbursement

Abbreviations
NEC (Not elsewhere classifiable) :
Lack of the necessary information to code more
specific term

NOS (Not otherwise specified) :


The equivalent of Unspecified

Instructional Notations
Includes
Excludes

42.6 Antesternal anastomosis of


esophagus
Code also any synchronous
Esophagectomy (42.40-42.42)
Gastrostomy (43.1)
39.21 Caval-pulmonary artery
anastomosis
Code also cardiopulmonary bypass
13.71 Insertion of IOL at time of cataract
(39.61)
extraction, one stage
Code also synchronous extraction of
cataract (13.11-13.69)

Definitio
n
Operative procedure
Non-Operative procedure

Operative procedure
An operation - defined as any therapeutic or
major diagnostic procedure which involves the
use of instruments or the manipulation of part or
parts of the body and generally takes place under
O.T conditions. Any procedure undertaken in the
O.T and/or under G.A, other than the normal
delivery of an obstetric patient, is to be included.
Principle Operation performed to treat the condition
selected as the principle diagnosis

Non-Operative
procedure
Other investigative and therapeutic procedures
which does not involves operation such as
radiological, laboratory, physical,
psychological and other procedures.

Site
code

TABULAR LIST ICD-9-CM


1.Operations on the
2.Operations on the
3.Operations on the
4.Operations on the
5.Operations on the
(21-29)
6.Operations on the
7.Operations on the
39)
8.Operations on the
system (40-41)

nervous system (01-05)


endocrine system (06-07)
eye (08-16)
ear (18-20)
nose,mouth and pharynx
respiratory system (30-34)
cardiovascular system (35hemic and lymphatic

ICD-9-CM
9.Operations on the digestive system (42-54)
10.Operations on the urinary system (55-59)
11.Operations on the male genital organs (60-64)
12.Operations on the female genital oorgans (65-71)
13.Obstetrical procedures (72-75)
14.Operations on the musculoskeletal system (76-84)
15.Operations on the integumentary system (85-86)
16.Miscellaneous diagnostic, therapeutic
procedures (87-99)

ICD-9-CM
Surgical procedures (01-86)
Non-surgical procedures (87-99)
96.71 Continuous mechanical ventilation
for less than 96 consecutive hours
99.25 Injection or infusion of cancer
chemotherapeutic substance
87.03 Computerized axial tomography
of head

Ex. Pregnancy with low forceps delivery


PDx. O81.0 Low forceps delivery
Proc. 72.1 Low forceps operation with episiotom

Ex. Term pregnancy delivered of dead fetus


2800 gO36.4 Maternal care for intrauterine death
PDx. O80.9 Single spontaneous delivery,unspeci
73.59 Assisted spontaneous delivery
Proc.

Ex.
Acute renal failure on hemodialysis
PDx. N17.0 Acute renal failure with tubular necro
Proc. 39.95 hemodialysis

Craniotomy
Craniectomy
Thoracotomy
Explore Laparotomy
Laminectomy
Arthrotomy

Craniotomy with clot


removal of subdural
hematoma
01.24 Other craniotomy
01.31 Incision of cerebral meninges
Drainage of subdural hematoma

Operation
Explore with
splenectomy

415 Splenectomy

5411 Exploratory laparotomy

Dx : FB (Foreign body) in
Tx : esophagus Operation :
Esophagoscope and FB
Removal

98.02 FB removal from


esophagus
Remove FB
42.23 Other Esophagoscopy

Root of operation
Bypass

Drainage

Reattachment

Control

Excision

Repair

Creation

Extirpation

Reposition

Destruction

Extraction

Resection

Detachmaent

Fragmentation

Revision

Dilation

Fusion

Transfer

Division

Occlusion

Transplantation

Stop Bleeding from superior thyroid


artery
Control hemorrage thyroid
Total Stitches Of
Removal Suture
Shunt or Anastomosis
Bypass
Caldwells operation Caldwell

1.Craniotomy to drain subdural hematom


01.31 Incision of cerebral meninges
Drainage of : Subdural empyema

2. Repair sclera + cornea


12.89
11.59
11.51
16.82

Repair sclera
Repair cornea, NEC
Suture cornea
Repair multiple structure of eye

Operation
Cesarean section with
appendectomy
741 Low cervical cesarean section
47.19 Other incidental appendectomy

47.0 Appendectomy

Excludes : incidental appendectomy,so described(47.11,4

47.01 Laparoscopic appendectomy


47.09 Other appendectomy

Endometriosis
Operation : TAH + BSO

PDx. N80.3 Endometriosis of pelvic


peritonium
68.4 Total abdominal hyterectomy
Code also removal of tube and ovary(65.3-65
Proc.
65.61 Other removal of both ovaries and
tubes at same operative
episode

CA larynx
Total laryngectomy
+ Radical neck dissection +
Total thyroidectomy +
tracheostomy
30.3
40.41
06.4
31.29

Complete laryngectomy
Radical neck dissection, unilateral
Complete thyroidectomy
Other permanent tracheostomy

Total laryngectomy with


radical neck dissection
30.4 Radical laryngectomy
Complete ( total)
laryngectomy with radical
neck dissection (with
thyroidectomy)(with
synchronous tracheostomy)

Kode tidak
valid

kode
valid
valid
code

Site
code

valid
code

Fracture shaft of femur


Operation : ORIF with
plate
79.35 Open reductionfemur
of
fracture with internal fixation

Operation related to Dx.


(Diagnosis)

Incision & Drainage


27.0 Drainage of face & floor of
mouth : facial abscess, fascial
compartment of face
28.0 Incision and drainage of
tonsil and peritonsillar structures
86.04 Other incision with drainage
of skin & subcut. tissue

Deep neck abscess


Operation : I&D

PDx. L02.1 Cutaneous abscess of neck


Proc. 86.04 Other incision with drainage of
skin & subcut. tissue

PDx. K12.2 Cellulitis & abscess of


mouth
Proc. 27.0 Drainage of face&floor
of
mouth : facial abscess,
fascial compartment of face

Alternate XT
Operation : Recession&Resection
of muscle muscle
of extraocular
PDx. H50.1 Exotropia
(alternating)
15.3
83.45Operation
Muscle resection
of two or more
Proc.extraocular muscles involving
temporary detachment,one or both
eyes
Extraocular muscle resection 15.13
Resection of one extraocular muscle 15.13
Recession of one extraocular muscle 15.11

Functional Endoscopic Sinus


Surgery ( FESS )

21.31 Local excision or destruction


of intranasal lesion
22.63 Ethmoidectomy
22.52 Sphenoidotomy

Warrens Shunt
Splenal vein , Renal vein
Bypass
Bypass
Vascular
Splenorenal 39.1

39.1 Intra-abdominal venous shunt


Anastomosis : splenic and renal vein

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

1.

Coding Procedures Using ICD-9-CM Vol


Find the key words (lead3term) in the physicians
notes.
For example: Colonoscopy flexible, proximal to splenic flexure;
with removal of tumor(s) by snare technique

2. Find those key words in the Alphabetic Index of ICD9-CM, Volume 3.


For example:
\

Colonoscopy 45.23
with biopsy 45.25 rectum 48.24
Colonoscopy 45.23
Colonoscopy with biopsy 45.25
Colonoscopy rectum 48.24

3. Look up the code choices in the numerical listings.

8-52

Pengkodean Diagnosis dalam implementasi


INA-CBGs
SistemINA-CBGstelah diterapkan di rumah
sakit di seluruh Indonesia. Tarif sistemINACBGsdiharapkan akan lebih efisien.
Namun pelaksanaanINA-CBGsmasih banyak
menghadapi kendala, salah satunya mengenai
penggantian biaya operasional RS, berkisar
pada paketINA-CBGs ternyata beberapa ada
yang berada di bawah tarif RS.

53

Dalam pelaksanaan Case Mix INA-CBGs,


pengkodean sangat menentukan
Logic software yang digunakan untuk
menentukan tarif adalah pedoman ICD 10
yaitu utk menentukan diagnosis (perlu Diag.
utama, komorbid/komplikasi, sekunder). ICD
9 CM untuk tindakan atau prosedur.
Besar kecilnya tarif yang muncul dalam
software INA-CBGs ditentukan oleh Kode
diagnosis dan prosedur (tindakan).
Kesalahan penulisan diagnosis
ketidaktepatan code ICD akan
mempengaruhi tarif !!

54

Coder must be
careful!!!

Never code
directly from the
Index

Underline the Lead Term

1.Lower segment caesarean section secondary to Fetal Distress

2.Mid forceps delivery with episiotomy

No.

3.Herniotomy for indirect inguinal hernia No


4.Ritual Circumcision

No.

5.Computerized Tomography Scan of Brain

No.

6.Total Abdominal Hysterectomy & Bilateral Salpingo-oophorectomy No.

7.Debridement of Sequestrum of Tibia

No

8.Termination of pregnancy by aspiration curettage No


9.Ultrasonography Uterus No
10.Closed reduction of fractured humerus No.

SOAL LATIHAN
1.

Appendicitis acut dengan Operasi pengangkatan appendix

2. Kanker rahim dilakukan pengangkatan rahim


3. Ibu melahirkan bayi tunggal dengan sectio cesarean
4. Fractur humerus dilakukan pemasangan pen
5. Sterilisasi pada pria
6. Pengangkatan kedua tuba falopian
7. Herniotomy
8. Pengangkatan tonsil dengan adenoidectomy
9. Insisi dan drainase sinus cranial
10. Pengambilan benda asing yang masuk ke bronchus tanpa
insisi.

Semoga bermanfaat
Sis Wuryanto
08122742787,
085742225553
sis.wuryanto.hw@gmai

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