KLASIFIKASI
TINDAKAN
(Procedure
Classification)
Oleh : Sis Wuryanto
Klasifikasi Tindakan
ICOPIM
(
ICD-9-CM Volume 3
CPT
ICHI
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
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
Poisoning
and Contact
Histor
y
3 volumes:
2.
3.
4.
5.
6.
7.
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
Medical statistic
Medical care review
Reimbursement
Abbreviations
NEC (Not elsewhere classifiable) :
Lack of the necessary information to code more
specific term
Instructional Notations
Includes
Excludes
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
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.
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
Operation
Explore with
splenectomy
415 Splenectomy
Dx : FB (Foreign body) in
Tx : esophagus Operation :
Esophagoscope and FB
Removal
Root of operation
Bypass
Drainage
Reattachment
Control
Excision
Repair
Creation
Extirpation
Reposition
Destruction
Extraction
Resection
Detachmaent
Fragmentation
Revision
Dilation
Fusion
Transfer
Division
Occlusion
Transplantation
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
Endometriosis
Operation : TAH + BSO
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
Kode tidak
valid
kode
valid
valid
code
Site
code
valid
code
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
Warrens Shunt
Splenal vein , Renal vein
Bypass
Bypass
Vascular
Splenorenal 39.1
Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
1.
Colonoscopy 45.23
with biopsy 45.25 rectum 48.24
Colonoscopy 45.23
Colonoscopy with biopsy 45.25
Colonoscopy rectum 48.24
8-52
53
54
Coder must be
careful!!!
Never code
directly from the
Index
No.
No.
No.
No
SOAL LATIHAN
1.
Semoga bermanfaat
Sis Wuryanto
08122742787,
085742225553
sis.wuryanto.hw@gmai