UR RS TIPE C Dan D

UTILIZATION REVIEWS
RS PRASETYA HUSADA
RS Bala Keselamatan Bokor
RS Mitra Delima
RSI GONDANGLEGI
RSUI MADINAH KASEMBON
RS PRIMA HUSADA
RS LAWANG MEDIKA
RS BEN MARI
RUMKITBAN 05.08.04 LAWANG
RS ISLAM UNISMA
RS PURI BUNDA
RS PERMATA BUNDA
RUMKITBAN 05.08.02 MALANG
RS BHAYANGKARA HASTA BRATA
RS MELATI HUSADA
RS. ABD. SALEH
RS PANTI NIRMALA
RS. UMM
RSIA Muhammadiyah Malang
Dr. Ardi Andriatno

Kepala Unit Manajemen Pelayanan Kesehatan Rujukan
Best Western (OJ) Hotel

10 Juni 2015
Utilization Reviews
Pendahuluan
Rawat Jalan
Rawat Inap
Update Regulasi
Penutup
• Utilization Reviews : kegiatan evaluasi pada
Fasilitas Kesehatan Tingkat Lanjutan dalam upaya
pengendalian biaya pelayanan kesehatan dan
tercapainya utilisasi pelayanan kesehatan yang
rasional
• Outcome :
– Biaya pelayanan kesehatan terkendali.
– Utilisasi pelayanan kesehatan rasional sesuai standar
yang ditetapkan.
– Memastikan terwujud persepsi yang sama antara BPJS
Kesehatan dengan Faskes Tingkat Lanjutan terhadap
kebijakan pelayanan rujukan dan pengendalian
pelayanan kesehatan.
TOTAL KASUS RJTL TOTAL BIAYA RJTL U.C TOTAL RJTL
NO. NAMA RS
OKT'14 s/d Apr'15 OKT'14 s/d Apr'15 Des'14 s/d Apr'15
1 RS PANTI NIRMALA 3.284 1.114.982.900 339.520
2 RSIA Muhammadiyah Malang 473 133.488.400 282.216
3 RS PURI BUNDA 2.269 606.391.800 267.251
4 RS BEN MARI 609 125.699.100 206.402
5 RS MELATI HUSADA 8.573 1.653.610.700 192.886
6 RS. UMM 1.625 309.691.300 190.579
7 RUMKITBAN 05.08.04 LAWANG 615 117.184.000 190.543
8 RS PERMATA BUNDA 1.168 211.364.900 180.963
9 RS ISLAM UNISMA 8.075 1.374.799.600 170.254
10 RS Mitra Delima 2.553 429.790.600 168.347
11 RS. ABD. SALEH 2.007 332.383.600 165.612
12 RSI GONDANGLEGI 3.742 554.053.600 148.063
13 RS Bala Keselamatan Bokor 3.907 574.264.800 146.984
14 RS PRASETYA HUSADA 6.516 955.631.000 146.659
15 RUMKITBAN 05.08.02 MALANG 426 62.124.600 145.832
16 RS PRIMA HUSADA 7.911 1.152.445.100 145.676
17 RS BHAYANGKARA HASTA BRATA 599 86.933.800 145.132
18 RS LAWANG MEDIKA 857 120.022.772 140.050
19 RSUI MADINAH KASEMBON 5.475 762.813.300 139.327
TOTAL KASUS RITL TOTAL BIAYA RITL U.C TOTAL RITL
NO. NAMA RS
OKT'14 s/d Apr'15 OKT'14 s/d Apr'15 Des'14 s/d Apr'15
1 RS PANTI NIRMALA 658 3.621.002.800 5.503.044
2 RS ISLAM UNISMA 1.438 7.319.441.900 5.090.015
3 RS. UMM 590 2.939.013.100 4.981.378
4 RS LAWANG MEDIKA 334 1.576.523.661 4.720.131
5 RS MELATI HUSADA 2.146 9.741.543.500 4.539.396
6 RS PURI BUNDA 1.125 4.556.133.300 4.049.896
7 RS BEN MARI 520 2.034.300.200 3.912.116
8 RS BHAYANGKARA HASTA BRATA 463 1.809.033.200 3.907.199
9 RSI GONDANGLEGI 804 3.073.591.500 3.822.875
10 RUMKITBAN 05.08.04 LAWANG 438 1.608.425.900 3.672.205
11 RS PRIMA HUSADA 1.672 5.905.964.913 3.532.276
12 RSIA Muhammadiyah Malang 213 725.014.400 3.403.823
13 RUMKITBAN 05.08.02 MALANG 100 337.928.500 3.379.285
14 RS PRASETYA HUSADA 1.583 5.311.668.400 3.355.444
15 RS PERMATA BUNDA 567 1.738.092.100 3.065.418
16 RSUI MADINAH KASEMBON 1.313 3.992.721.000 3.040.915
17 RS Bala Keselamatan Bokor 760 2.269.098.900 2.985.656
18 RS Mitra Delima 1.273 3.458.333.200 2.716.680
19 RS. ABD. SALEH 579 696.690.400 1.203.265
RS Unisma
Peringk
at RJTL RITL
Kasus Terbesar Biaya Terbesar Kasus Terbesar Biaya Terbesar
Follow-up exam after other
Follow-up exam after other Dengue fever [classical
treatment for other Pneumonia, unspecified
1 treatment for other conditions dengue]
conditions
Follow-up examination Diarrhoea and
Follow-up examination after Dengue fever [classical
after surgery for other gastroenteritis of presumed
2 surgery for other conditions
infectious origin
dengue]
conditions
Essential (primary) Essential (primary)
Senile incipient cataract Senile incipient cataract
3 hypertension hypertension
Supervision of other normal Supervision of other
4 Typhoid fever Senile incipient cataract
pregnancy normal pregnancy
5 Presbyopia Presbyopia Dengue haemorrhagic fever Fracture of shaft of tibia
6 Necrosis of pulp Necrosis of pulp Pneumonia, unspecified Typhoid fever

Bronchopneumonia, Bronchopneumonia,
7 Heart failure, unspecified Heart failure, unspecified
unspecified unspecified
Diarrhoea and
Hepatitis a without hepatic
Astigmatism Astigmatism gastroenteritis of presumed
8 coma
infectious origin
Essential (primary) Essential (primary) Fracture of shaft of femur,
9 hypertension hypertension
Dyspepsia
closed
Fracture of femur, part
10 Other senile cataract Other senile cataract Senile incipient cataract
unspecified, closed
RS Puri Bunda
Peringk
at RJTL RITL
Supervision of normal Supervision of normal Maternal care due to uterine Maternal care due to uterine
1 pregnancy, unspecified pregnancy, unspecified scar from previous surgery scar from previous surgery
Follow-up examination
Follow-up examination after Other single spontaneous Other single spontaneous
after surgery for other
2 surgery for other conditions delivery delivery
conditions
Maternal care due to
Maternal care due to uterine Delivery by caesarean Delivery by caesarean
uterine scar from previous
3 scar from previous surgery section, unspecified section, unspecified
surgery
Supervision of very young Supervision of very young Maternal care for high head Maternal care for high head
4 at term
primigravida primigravida at term
Other and unspecified ovarian Other and unspecified Maternal care for Maternal care for
5 disproportion of other origin disproportion of other origin
cysts ovarian cysts
Abnormal uterine and Diarrhoea and Diarrhoea and
Abnormal uterine and vaginal
vaginal bleeding, gastroenteritis of presumed gastroenteritis of presumed
6 bleeding, unspecified
infectious origin
unspecified infectious origin
Maternal care for breech Maternal care for breech
7 presentation
Typhoid fever Typhoid fever
presentation
Acute pharyngitis, Blighted ovum and Blighted ovum and
Acute pharyngitis, unspecified
8 unspecified nonhydatidiform mole nonhydatidiform mole
9 Prolonged pregnancy Prolonged pregnancy Prolonged pregnancy Prolonged pregnancy

Supervision of other high-risk Supervision of other high-
10 pregnancies risk pregnancies
Fever, unspecified Fever, unspecified
RS Panti Nirmala
Peringk
at RJTL RITL
Follow-up exam after other Chemotherapy session for
Extracorporeal dialysis Other cerebral infarction
1 treatment for other conditions neoplasm
Extracorporeal dialysis End-stage renal disease Typhoid fever Typhoid fever

2
Chemotherapy session for
End-stage renal disease treatment for other Other cerebral infarction
3 neoplasm
conditions
Non-insulin-dependent
Non-insulin-dependent diabetes Dengue fever [classical
diabetes mellitus with renal Congestive heart failure
4 mellitus with renal comps dengue]
comps
Supervision of other high- Hypertensive renal disease
5 Myopia
with renal failure
Pneumonia, unspecified
risk pregnancies
Care involving use of other Hypertensive renal disease
6 rehabilitation procedures
Myopia End-stage renal disease
with renal failure
Care involving use of Cerebral infarction due to Hypertensive heart disease
Care involving use of other
rehabilitation procedure, thrombosis of cerebral with (congestive) heart
7 unspecified
rehabilitation procedures
arteries failure
Care involving use of Cerebral infarction due to
Asthma, unspecified rehabilitation procedure, Dengue haemorrhagic fever thrombosis of cerebral
8
unspecified arteries
Supervision of other high-risk
9 pregnancies
Asthma, unspecified Pneumonia, unspecified End-stage renal disease
Dengue fever [classical
10 Other cerebral infarction Other cerebral infarction Congestive heart failure
dengue]
RS Melati Husada
Peringk
at RJTL RITL
Follow-up exam after other Single spontaneous delivery, Single spontaneous delivery,
treatment for other
1 treatment for other conditions unspecified unspecified
conditions
Supervision of pregnancy
Mild and moderate birth Mild and moderate birth
Atherosclerotic heart disease with hist insuffic antenatal
2 asphyxia asphyxia
care
Supervision of pregnancy with Atherosclerotic heart Delivery by caesarean Delivery by caesarean
3 hist insuffic antenatal care disease section, unspecified section, unspecified
Routine postpartum Maternal care due to uterine Maternal care due to uterine
4 Routine postpartum follow-up
scar from previous surgery scar from previous surgery
follow-up
Unspecified diabetes mellitus Other specified Infection specific to the Infection specific to the
5 without complications postsurgical states perinatal period, unspecified perinatal period, unspecified
Other specified postsurgical Leiomyoma of uterus, Leiomyoma of uterus,
6 states
Heart failure, unspecified
Essential (primary) Delivery by emergency Delivery by emergency
7 hypertension
Palpitations
caesarean section caesarean section
Unspecified diabetes
Neonatal jaundice due to Neonatal jaundice due to
Heart failure, unspecified mellitus without
8 infection infection
complications
Essential (primary)
9 Palpitations
hypertension
Prolonged pregnancy Prolonged pregnancy
Other and unspecified Other and unspecified
10 Cholecystitis, unspecified Cholecystitis, unspecified
ovarian cysts ovarian cysts
RS UMM
Peringk
at RJTL RITL
Follow-up exam after
Follow-up exam after unspec
unspec treatment for other Typhoid fever Typhoid fever
1 treatment for other conditions
conditions
Other specified surgical follow- Other specified surgical Hepatitis a without hepatic Hepatitis a without hepatic
2 up care follow-up care coma coma
Follow-up examination after Acute appendicitis,
after surgery for other Dengue haemorrhagic fever
3 surgery for other conditions unspecified
conditions
Orthopaedic follow-up care, Orthopaedic follow-up Acute appendicitis,
4 unspecified
unspecified care, unspecified
Supervision of other high-
5 Astigmatism
risk pregnancies
Angina pectoris, unspecified Other cholelithiasis
Other specified orthopaedic
6 follow-up care
Astigmatism Pneumonia, unspecified Angina pectoris, unspecified
Diarrhoea and Hypertens heart and renal
Essential (primary) Other specified
gastroenteritis of presumed dis with (conges) heart
7 hypertension orthopaedic follow-up care
infectious origin failure
Hypertens heart and renal
Stroke, not specified as Acute appendicitis with
Arthritis, unspecified dis with (conges) heart
8 haemorrhage or infarction
failure
generalized peritonitis
Supervision of other high-risk Urinary tract infection, site
9 pregnancies
Asthma, unspecified
not specified
Dengue haemorrhagic fever
Antenatal screening, Essential (primary) Cerebral infarction,
10 Myopia
unspecified hypertension unspecified
RS Muhammadiyah Tongan
Peringk
at RJTL RITL
Diarrhoea and Diarrhoea and
Surgical follow-up care, Surgical follow-up care,
gastroenteritis of presumed gastroenteritis of presumed
1 unspecified unspecified
infectious origin infectious origin
Follow-up exam after other Maternal care due to uterine Maternal care due to uterine
treatment for other
2 treatment for other conditions scar from previous surgery scar from previous surgery
conditions
Supervision of high-risk Supervision of high-risk Delivery by emergency Delivery by emergency
3 pregnancy, unspecified pregnancy, unspecified caesarean section caesarean section
Supervision of normal Supervision of normal Maternal care for Maternal care for
4 disproportion, unspecified
pregnancy, unspecified pregnancy, unspecified disproportion, unspecified
Other specified abnormal
Other specified abnormal Blighted ovum and Blighted ovum and
uterine and vaginal
5 uterine and vaginal bleeding nonhydatidiform mole nonhydatidiform mole
bleeding
Antenatal screening, Antenatal screening, Leiomyoma of uterus, Leiomyoma of uterus,
6 unspecified unspecified unspecified unspecified
Acute upper respiratory Acute upper respiratory Bronchopneumonia, Bronchopneumonia,
7 infection, unspecified infection, unspecified unspecified unspecified
Maternal care due to uterine Dengue fever [classical Dengue fever [classical
uterine scar from previous
8 scar from previous surgery dengue] dengue]
surgery
9 Other antenatal screening Other antenatal screening Missed abortion Missed abortion
10 Asthma, unspecified Asthma, unspecified Oligohydramnios Oligohydramnios

RS Hasta Brata
Peringk
at RJTL RITL
treatment for other Typhoid fever Typhoid fever
conditions
Other specified orthopaedic Other specified
2 Congestive heart failure Congestive heart failure
follow-up care orthopaedic follow-up care
Maternal care for
3 Chronic apical periodontitis Congestive heart failure Pneumonia, unspecified
disproportion, unspecified
Chronic apical Bronchopneumonia, Maternal care for
4 Congestive heart failure
unspecified
periodontitis disproportion, unspecified
Non-insulin-depend
Bronchopneumonia,
Fever, unspecified diabetes mellitus with otherDengue haemorrhagic fever
5 unspecified
spec comp
Non-insulin-depend diabetes Acute upper respiratory Maternal care for breech
6 Fever, unspecified
infection, unspecified
mellitus with other spec comp presentation
Benign neoplasm, brain, Fracture of lower leg, part
7 supratentorial
Heart failure, unspecified Pneumonia, unspecified
unspecified , open
Malignant neoplasm, breast, Open wound of unspecifiedMaternal care for breech
8 Hypermetropia
unspecified body region presentation
Loss of teeth accident
Follow-up examination after Acute appendicitis,
extraction or local Hypermetropia
9 chemotherapy for oth conditions unspecified
periodontal dis
Follow-up exam after unspec
Periapical abscess without Acute pharyngitis, Generalized and unspecified
treatment for malignant
10 neoplasm
sinus unspecified atherosclerosis
RS Abd Saleh
Peringk
at RJTL RITL
Other allergic rhinitis Other allergic rhinitis gastroenteritis of presumed gastroenteritis of presumed
1 infectious origin infectious origin
Necrosis of pulp Necrosis of pulp Typhoid fever Typhoid fever

2
Non-insulin-dependent diabetes
diabetes mellitus with Spontaneous vertex delivery Spontaneous vertex delivery
3 mellitus with unspec comps
unspec comps
Acute pharyngitis, Dengue fever [classical
4 Pulpitis Pulpitis
unspecified dengue]
5 Injury, unspecified Injury, unspecified Dengue haemorrhagic fever Dengue haemorrhagic fever
Dengue fever [classical Acute pharyngitis,
6 Asthma, unspecified Asthma, unspecified
dengue] unspecified
Essential (primary)
7 Mild hyperemesis gravidarum
hypertension
Other allergic rhinitis Other appendicitis
Essential (primary) Mild hyperemesis Bronchopneumonia,

Other appendicitis
8 hypertension gravidarum unspecified
Cerebral infarction due to
Chronic apical
Chronic apical periodontitis Dizziness and giddiness thrombosis of cerebral
9 periodontitis
arteries
Primary generalized Primary generalized
10 (osteo)arthrosis (osteo)arthrosis
Fever, unspecified Haematemesis
RS Permata Bunda
Peringk
at RJTL RITL
Prolonged pregnancy Prolonged pregnancy
1 pregnancy normal pregnancy
Routine postpartum Maternal care due to uterine Maternal care due to uterine
Routine postpartum follow-up
2 follow-up scar from previous surgery scar from previous surgery
Other specified surgical Dengue fever [classical Delivery by emergency

Necrosis of pulp
3 follow-up care dengue] caesarean section
Other specified surgical follow- Other and unspecified Delivery by emergency Maternal care for breech
4 caesarean section
up care ovarian cysts presentation
Maternal care for breech Dengue fever [classical
5 Secondary amenorrhoea Necrosis of pulp
presentation dengue]
Other and unspecified ovarian Maternal care for
6 cysts
Secondary amenorrhoea Dengue haemorrhagic fever
disproportion, unspecified
Leiomyoma of uterus, Fetus and newborn affected
7 Pulpitis
unspecified by caesarean delivery
Typhoid fever
Leiomyoma of uterus, Need for continuous Maternal care for

8 unspecified supervision disproportion, unspecified
Acute nasopharyngitis Leiomyoma of uterus,
9 Need for continuous supervision
[common cold]
unspecified
Acute nasopharyngitis Delivery by elective
10 [common cold]
Pulpitis Typhoid fever
caesarean section
Peringk
RJTL RITL
at
Follow-up exam after other Essential (primary)
treatment for other Pneumonia, unspecified
1 treatment for other conditions hypertension
conditions
Special screening
Special screening examination Delivery by elective Essential (primary)
examination for diabetes
2 for diabetes mellitus caesarean section hypertension
mellitus
Follow-up examination after Supervision of normal Delivery by elective
3 Dengue haemorrhagic fever
surgery for other conditions pregnancy, unspecified caesarean section
Follow-up examination Cerebral infarct due to
Dental examination after surgery for other Typhoid fever thrombosis of precerebral
4
conditions arteries
Cerebral infarct due to
Supervision of normal
Dental examination thrombosis of precerebral Typhoid fever
5 pregnancy, unspecified
arteries
Special screening Chronic obstructive Unilateral or unspecified
Special screening examination
examination for respiratory pulmonary disease, inguinal hernia, without
6 for respiratory tuberculosis
unspecified
tuberculosis obstruction or gangrene
Observation for other Other acute upper
Observation for other suspected Tb lung without mention of
suspected diseases and respiratory infections of
7 diseases and conditions
multiple sites
bact or histological confirm
conditions
8 Presence of intraocular lens Presence of intraocular lensPneumonia, unspecified Congestive heart failure
Special screening Unilateral or unspecified Chronic obstructive
Special screening examination
examination for inguinal hernia, without pulmonary disease,
9 for cardiovascular disorders
cardiovascular disorders obstruction or gangrene unspecified
Special screening exam for Diarrhoea and
Special screening exam for oth
oth spec diseases and gastroenteritis of presumed Cataract, unspecified
10 spec diseases and disorders
disorders infectious origin
RS Mitra Delima
Peringk
RJTL RITL
at
Follow-up exam after
Follow-up exam after unspec Delivery by caesarean Delivery by caesarean
unspec treatment for other
1 treatment for other conditions section, unspecified section, unspecified
conditions
Follow-up examination after
after surgery for other Dyspepsia Dyspepsia
2 surgery for other conditions
conditions
Essential (primary) Single spontaneous delivery,
3 Congestive heart failure
unspecified
hypertension
Hypertensive heart disease with Essential (primary)
4 Pneumonia, unspecified Heart failure, unspecified
(congestive) heart failure hypertension
Single spontaneous delivery,
Congestive heart failure uterine scar from previous Dengue haemorrhagic fever
5 unspecified
surgery
Hypertensive heart disease
Essential (primary)
Dyspepsia with (congestive) heart Heart failure, unspecified
6 hypertension
failure
Maternal care due to uterine Essential (primary)
7 scar from previous surgery
hypertension
Congestive heart failure
Diarrhoea and
Acute upper respiratory
Dyspepsia gastroenteritis of presumed Dengue haemorrhagic fever
8 infection, unspecified
infectious origin
Diarrhoea and
Heart failure, unspecified Congestive heart failure gastroenteritis of presumed
infectious origin
Maternal care for breech Maternal care for breech Other abortion, incomplete, Leiomyoma of uterus,
10 presentation presentation without complication unspecified
RSI Gondanglegi
Peringk
RJTL RITL
at
treatment for other Typhoid fever Pneumonia, unspecified
conditions
2 Pulpitis Pulpitis Dyspepsia Dyspepsia
Follow-up examination after Essential (primary)
after surgery for other Typhoid fever
3 surgery for other conditions hypertension
conditions
Essential (primary) Essential (primary) Essential (primary)
4 Pneumonia, unspecified
hypertension hypertension hypertension
Tb lung without mention of Tb lung without mention of
5 Dyspepsia Dyspepsia
bact or histological confirm bact or histological confirm
Hypertensive heart disease Hypertensive heart disease
Other specified orthopaedic Other specified
with (congestive) heart with (congestive) heart
6 follow-up care orthopaedic follow-up care
failure failure
Observation for other
Other and unspec diseases of Bacterial intestinal infection,Bacterial intestinal infection,
suspected diseases and
7 pulp and periapical tissues unspecified unspecified
conditions
Other and unspec diseases Insulin-dependent diabetes Insulin-dependent diabetes
Observation for other suspected
of pulp and periapical mellitus with periph circ mellitus with periph circ
8 diseases and conditions
comps
tissues comps
Non-insulin-depend
Non-insulin-depend diabetes
diabetes mellitus with Congestive heart failure Congestive heart failure
9 mellitus with periph circ comp
periph circ comp
Pneumonia, unspecified Dengue haemorrhagic fever Heart failure, unspecified
RS Prima Husada
Peringk
RJTL RITL
at
Other specified medical
1 Other specified medical care
care
Typhoid fever Typhoid fever
Other specified surgical follow- Other specified surgical Essential (primary) Essential (primary)
2 up care follow-up care hypertension hypertension
Supervision of normal Bronchopneumonia,
Asthma, unspecified Fever, unspecified
unspecified
Supervision of normal
Asthma, unspecified gastroenteritis of presumed gastroenteritis of presumed
Bronchopneumonia,
5 Typhoid fever Heart failure, unspecified
unspecified
Non-insulin-dependent diabetes Single spontaneous delivery, Tb lung without mention of
diabetes mellitus with
6 mellitus with unspec comps unspecified bact or histological confirm
unspec comps
Essential (primary) Delivery by emergency
7 hypertension
Typhoid fever Other acute gastritis
caesarean section
Essential (primary)
8 Heart failure, unspecified
hypertension
Dengue haemorrhagic fever Fever, unspecified
Non-insulin-dependent Non-insulin-dependent
diabetes mellitus with diabetes mellitus with
9 pregnancy normal pregnancy
unspec comps unspec comps
Tb lung without mention of
10 Pneumonia, unspecified Pneumonia, unspecified
bact or histological confirm
Congestive heart failure
RS Ben Mari
Peringkat RJTL RITL
Follow-up examination after Delivery by emergency Delivery by emergency
after surgery for other
1 surgery for other conditions caesarean section caesarean section
conditions
Other specified
Other specified pregnancy- Delivery by elective Delivery by elective
pregnancy-related
2 related conditions caesarean section caesarean section
conditions
Abnormal uterine and Abnormal uterine and
vaginal bleeding, vaginal bleeding, Fever, unspecified Polyp of corpus uteri
3
Pregnancy-related Pregnancy-related
4 Dyspepsia Dyspepsia
condition, unspecified condition, unspecified
Abnormal uterine and
Dysmenorrhoea, Dysmenorrhoea,
Polyp of corpus uteri vaginal bleeding,
5 unspecified unspecified
unspecified
Open wound of other and Open wound of other and Open wound of other and
Essential (primary)
unspecified parts of unspecified parts of unspecified parts of
6 hypertension
abdomen abdomen abdomen
Open wound of other and
Essential (primary)
Dyspepsia Polyp of corpus uteri unspecified parts of
7 abdomen
hypertension
Diarrhoea and
Polyp of corpus uteri Secondary amenorrhoea gastroenteritis of presumed Fever, unspecified
8 infectious origin
Abnormal uterine and
Thrombocytopenia,
Secondary amenorrhoea Dyspepsia vaginal bleeding,
9 unspecified
unspecified
Other specified abnormal
Acute upper respiratory Thrombocytopenia,
uterine and vaginal Typhoid fever
10 infection, unspecified unspecified
Rumkitban Lawang
Peringkat RJTL RITL
Supervision of pregnancy Supervision of pregnancy
with hist insuffic antenatal with hist insuffic antenatal Typhoid fever Typhoid fever
1 care care
Acute upper respiratory Acute upper respiratory
2 Prolonged pregnancy Prolonged pregnancy
infection, unspecified infection, unspecified
Other specified surgical Other specified surgical Delivery by elective Delivery by elective
3 follow-up care follow-up care caesarean section caesarean section
Care and examination of Care and examination of Premature rupture of Premature rupture of
4 membranes, unspecified
lactating mother lactating mother membranes, unspecified
gastroenteritis of presumedgastroenteritis of presumed Follicular cyst of ovary Follicular cyst of ovary
5
Other and unspecified Other and unspecified
6 Asthma, unspecified Asthma, unspecified
ovarian cysts ovarian cysts
Follow-up exam after other Follow-up exam after other
treatment for other treatment for other Dyspepsia Dyspepsia
7 conditions conditions
Bronchopneumonia, Bronchopneumonia,
8 Myopia Myopia
Predominantly allergic Predominantly allergic Leiomyoma of uterus, Leiomyoma of uterus,
9 asthma unspecified
asthma unspecified
Gastroenteritis and colitis Gastroenteritis and colitis
10 Presbyopia Presbyopia
due to radiation due to radiation
RS Prasetya Husada
Peringkat RJTL RITL
Personal history of other Personal history of other
1 Typhoid fever Typhoid fever
specified conditions specified conditions
Attention to surgical Attention to surgical
gastroenteritis of presumed gastroenteritis of presumed
2 dressings and sutures dressings and sutures
Other single delivery by Other single delivery by
3 Heart failure, unspecified Heart failure, unspecified
caesarean section caesarean section
Pregnancy-related condition, Pregnancy-related Essential (primary) Essential (primary)
4 hypertension
unspecified condition, unspecified hypertension
Acute upper respiratory Acute upper respiratory Other specified assisted
5 Pneumonia, unspecified
infection, unspecified infection, unspecified single delivery
Bronchopneumonia,
6 Lain-lain Lain-lain Pneumonia, unspecified
unspecified
Essential (primary)
7 Asthma, unspecified Other acute gastritis Dyspepsia
hypertension
Essential (primary) Delivery by emergency
8 Pulpitis Dyspepsia
hypertension caesarean section
Unspecified abortion,
Other specified assisted
Dyspepsia Pulpitis incomplete, without
9 complication
single delivery
Bronchopneumonia,
10 Tidak Terrdefinisi Dyspepsia
unspecified
Peringkat Grouping INA-CBGs Terbanyak
RSIA Muhammadiyah
Pering
kat RJTL RITL
INA CBG : Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
1
INACBG: Z-3-24-0 -PROSEDUR INACBG: W-1-11-i -PROSEDUR INACBG: W-1-11-i -PROSEDUR
INACBG: Z-3-24-0 -PROSEDUR
ULTRASOUND PEMBULUH DILATASI, KURET, INTRAUTERIN & DILATASI, KURET, INTRAUTERIN &
ULTRASOUND PEMBULUH DARAH
2 DARAH SERVIK RINGAN SERVIK RINGAN
INACBG: U-3-15-0 -PROSEDUR
INACBG: U-3-15-0 -PROSEDUR LAIN-
LAIN-LAIN PADA TELINGA, INACBG: O-6-13-ii -PERSALINAN INACBG: O-6-13-ii -PERSALINAN
LAIN PADA TELINGA, HIDUNG, MULUT
HIDUNG, MULUT DAN VAGINAL SEDANG VAGINAL SEDANG
DAN TENGGOROKAN
3 TENGGOROKAN
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: O-6-13-i -PERSALINAN INACBG: O-6-13-i -PERSALINAN
4 KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN VAGINAL RINGAN VAGINAL RINGAN
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-42-0 -PENYAKIT INACBG: O-6-10-ii -OPERASI INACBG: O-6-10-ii -OPERASI
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN PEMBEDAHAN CAESAR SEDANG PEMBEDAHAN CAESAR SEDANG
5
INACBG: J-3-13-0 -PROSEDUR TERAPI INACBG: J-3-13-0 -PROSEDUR INACBG: O-6-10-i -OPERASI INACBG: O-6-10-i -OPERASI
SALURAN PERNAFASAN TERAPI SALURAN PERNAFASAN PEMBEDAHAN CAESAR RINGAN PEMBEDAHAN CAESAR RINGAN
6
INACBG: N-4-12-iii-INFEKSI GINJAL INACBG: N-4-12-iii-INFEKSI GINJAL
DAN SALURAN URIN BERAT DAN SALURAN URIN BERAT
7
INACBG: N-4-12-i -INFEKSI GINJAL INACBG: N-4-12-i -INFEKSI GINJAL
DAN SALURAN URIN RINGAN DAN SALURAN URIN RINGAN
8
INACBG: A-4-14-iii-PENYAKIT INACBG: A-4-14-iii-PENYAKIT
INFEKSI BAKTERI DAN PARASIT INFEKSI BAKTERI DAN PARASIT
9 LAIN-LAIN BERAT LAIN-LAIN BERAT
INACBG: A-4-14-i -PENYAKIT INACBG: A-4-14-i -PENYAKIT
INFEKSI BAKTERI DAN PARASIT INFEKSI BAKTERI DAN PARASIT
10 LAIN-LAIN RINGAN LAIN-LAIN RINGAN
RS Hasta Brata
Pering
kat RJTL RITL
INA CBG: Z-3-27-0 -PERAWATAN LUKA INA CBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
LUKA ANTEPARTUM SEDANG ANTEPARTUM SEDANG
1
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR INACBG: W-4-12-ii -GANGGUAN INACBG: W-4-12-ii -GANGGUAN
GIGI PADA GIGI MENSTRUASI & SISTEM MENSTRUASI & SISTEM
REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
2 (SEDANG) (SEDANG)
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: V-1-13-iii-PROSEDUR PADA INACBG: V-1-13-iii-PROSEDUR PADA
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN SKROTUM DAN PROSTAT NON SKROTUM DAN PROSTAT NON
KOMPLEK (BERAT) KOMPLEK (BERAT)
3
INACBG: Q-5-29-0 -GAGAL JANTUNG INACBG: Q-5-29-0 -GAGAL INACBG: U-4-13-iii-PERADANGAN INACBG: U-4-13-iii-PERADANGAN
KONGESTIF DAN KONDISI JANTUNG JANTUNG KONGESTIF DAN EPIGLOTIS, TELINGA TENGAH, ISPA EPIGLOTIS, TELINGA TENGAH, ISPA
4 LAIN-LAIN KONDISI JANTUNG LAIN-LAIN DAN LARINGOTRAKEITIS BERAT DAN LARINGOTRAKEITIS BERAT
INACBG: U-4-13-ii -PERADANGAN INACBG: U-4-13-ii -PERADANGAN
EPIGLOTIS, TELINGA TENGAH, ISPA EPIGLOTIS, TELINGA TENGAH, ISPA
5 DAN LARINGOTRAKEITIS SEDANG DAN LARINGOTRAKEITIS SEDANG
INACBG: U-4-13-i -PERADANGAN INACBG: U-4-13-i -PERADANGAN
6 DAN LARINGOTRAKEITIS RINGAN DAN LARINGOTRAKEITIS RINGAN
INACBG: U-4-11-ii - INACBG: U-4-11-ii -

7 DYSEQUILIBRIUM SEDANG DYSEQUILIBRIUM SEDANG
INACBG: O-6-13-ii -PERSALINAN INACBG: O-6-13-ii -PERSALINAN

8 VAGINAL SEDANG VAGINAL SEDANG
INACBG: O-6-13-i -PERSALINAN INACBG: O-6-13-i -PERSALINAN

9 VAGINAL RINGAN VAGINAL RINGAN
INACBG: O-6-10-i -OPERASI INACBG: O-6-10-i -OPERASI

10 PEMBEDAHAN CAESAR RINGAN PEMBEDAHAN CAESAR RINGAN
RS Panti Nirmala
Peringk
at RJTL RITL
INA CBG: Z-4-12-ii -FAKTOR-
INACBG: Z-4-12-ii -FAKTOR-FAKTOR
INACBG: Z-3-27-0 -PERAWATAN FAKTOR YANG MEMPENGARUHI
INACBG: Z-3-27-0 -PERAWATAN LUKA YANG MEMPENGARUHI STATUS
LUKA STATUS KESEHATAN LAIN-LAIN
KESEHATAN LAIN-LAIN (SEDANG)
1 (SEDANG)
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR INACBG: W-4-16-iii-GANGGUAN INACBG: W-4-16-iii-GANGGUAN
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK ANTEPARTUM BERAT ANTEPARTUM BERAT
2
INACBG: Z-3-24-0 -PROSEDUR INACBG: Z-3-24-0 -PROSEDUR INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
ULTRASOUND PEMBULUH DARAH ULTRASOUND PEMBULUH DARAH ANTEPARTUM SEDANG ANTEPARTUM SEDANG
3
INACBG: Z-3-23-0 -PROSEDUR INACBG: Z-3-23-0 -PROSEDUR INACBG: W-4-10-iii-TUMOR SISTEM INACBG: W-4-10-iii-TUMOR SISTEM
4 ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN REPRODUKSI WANITA BERAT REPRODUKSI WANITA BERAT
INACBG: Z-3-19-0 -CT SCAN LAIN- INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
INACBG: Z-3-19-0 -CT SCAN LAIN-LAIN
LAIN PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
5
INACBG: W-1-11-ii -PROSEDUR INACBG: W-1-11-ii -PROSEDUR
INACBG: Z-3-18-0 -CT-SCAN
INACBG: Z-3-18-0 -CT-SCAN KEPALA DILATASI, KURET, INTRAUTERIN & DILATASI, KURET, INTRAUTERIN &
KEPALA
6 SERVIK SEDANG SERVIK SEDANG
INACBG: V-1-14-ii - INACBG: V-1-14-ii -
INACBG: W-2-34-0 -PROSEDUR INACBG: W-2-34-0 -PROSEDUR
PENGANGKATAN PROSTAT PENGANGKATAN PROSTAT
GINEKOLOGI LAIN-LAIN GINEKOLOGI LAIN-LAIN
7 MELALUI URETRA SEDANG MELALUI URETRA SEDANG
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR INACBG: V-1-14-i -PENGANGKATAN INACBG: V-1-14-i -PENGANGKATAN
GIGI PADA GIGI PROSTAT MELALUI URETRA RINGAN PROSTAT MELALUI URETRA RINGAN
8
INACBG: U-3-15-0 -PROSEDUR LAIN- INACBG: U-4-13-i -PERADANGAN INACBG: U-4-13-i -PERADANGAN
LAIN-LAIN PADA TELINGA,
LAIN PADA TELINGA, HIDUNG, MULUT EPIGLOTIS, TELINGA TENGAH, ISPA EPIGLOTIS, TELINGA TENGAH, ISPA
HIDUNG, MULUT DAN
DAN TENGGOROKAN DAN LARINGOTRAKEITIS RINGAN DAN LARINGOTRAKEITIS RINGAN
9 TENGGOROKAN
DIAGNOSTIK LAIN-LAIN PADA INACBG: U-4-11-ii - INACBG: U-4-11-ii -
DIAGNOSTIK LAIN-LAIN PADA TELINGA,
TELINGA, HIDUNG, MULUT DAN DYSEQUILIBRIUM SEDANG DYSEQUILIBRIUM SEDANG
HIDUNG, MULUT DAN TENGGOROKAN
10 TENGGOROKAN
RS Melati Husada
Peringka
t RJTL RITL
CBG: W-4-12-ii -GANGGUAN INACBG: W-4-12-ii -GANGGUAN
INACBG: Z-3-27-0 -PERAWATAN INACBG: Z-3-27-0 -PERAWATAN MENSTRUASI & SISTEM MENSTRUASI & SISTEM
LUKA LUKA REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
1 (SEDANG) (SEDANG)
INACBG: W-4-10-ii -TUMOR INACBG: W-4-10-ii -TUMOR
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR
SISTEM REPRODUKSI WANITA SISTEM REPRODUKSI WANITA
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK
2 SEDANG SEDANG
INACBG: W-1-30-i -PROSEDUR INACBG: W-1-30-i -PROSEDUR

PADA VAGINA, SERVIK & VULVA PADA VAGINA, SERVIK & VULVA
ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN
RINGAN RINGAN
3
PADA RAHIM & ADNEKSA PADA RAHIM & ADNEKSA
KECIL GINEKOLOGI KECIL GINEKOLOGI
4 SEDANG SEDANG
SEDANG GINEKOLOGI SEDANG GINEKOLOGI
5 RINGAN RINGAN
INACBG: Q-5-44-0 -PENYAKIT INACBG: Q-5-44-0 -PENYAKIT
DILATASI, KURET, INTRAUTERIN & DILATASI, KURET, INTRAUTERIN &
KRONIS KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN
INACBG: W-1-01-i -OPERASI INACBG: W-1-01-i -OPERASI
INACBG: Q-5-43-0 -PENYAKIT INACBG: Q-5-43-0 -PENYAKIT PENGANGKATAN RAHIM DAN PENGANGKATAN RAHIM DAN
KRONIS BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN VULVA RADIKAL & EVISCERASI VULVA RADIKAL & EVISCERASI
7 RINGAN RINGAN
INACBG: U-4-15-i -DIAGNOSIS INACBG: U-4-15-i -DIAGNOSIS
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT
TENGGOROKAN, MULUT, HIDUNG TENGGOROKAN, MULUT, HIDUNG
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN
8 & TELINGA LAIN-LAIN (RINGAN) & TELINGA LAIN-LAIN (RINGAN)
INACBG: Q-5-29-0 -GAGAL INACBG: Q-5-29-0 -GAGAL INACBG: P-8-17-ii -NEONATAL, INACBG: P-8-17-ii -NEONATAL,
JANTUNG KONGESTIF DAN JANTUNG KONGESTIF DAN BBL GROUP-5 TANPA PROSEDUR BBL GROUP-5 TANPA PROSEDUR
9 KONDISI JANTUNG LAIN-LAIN KONDISI JANTUNG LAIN-LAIN MAYOR SEDANG MAYOR SEDANG
INACBG: P-8-13-ii -NEONATAL, INACBG: P-8-13-ii -NEONATAL,
INACBG: J-3-13-0 -PROSEDUR INACBG: J-3-13-0 -PROSEDUR
BBL GROUP-4 TANPA PROSEDUR BBL GROUP-4 TANPA PROSEDUR
TERAPI SALURAN PERNAFASAN TERAPI SALURAN PERNAFASAN
10 MAYOR SEDANG MAYOR SEDANG
RS. Abd Saleh
Pering
kat RJTL RITL
INACBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-i -GANGGUAN INACBG: W-4-16-i -GANGGUAN
INACBG: Z-3-27-0 -PERAWATAN LUKA
LUKA ANTEPARTUM RINGAN ANTEPARTUM RINGAN
1
INACBG: W-4-12-ii -GANGGUAN INACBG: W-4-12-ii -GANGGUAN
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT MENSTRUASI & SISTEM MENSTRUASI & SISTEM
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
2 (SEDANG) (SEDANG)

INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-43-0 -PENYAKIT
BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN
DAN LARINGOTRAKEITIS SEDANG DAN LARINGOTRAKEITIS SEDANG
3
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: U-4-11-i - INACBG: U-4-11-i -
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN DYSEQUILIBRIUM RINGAN DYSEQUILIBRIUM RINGAN
5
INACBG: Q-5-27-0 -SISTEM INACBG: Q-5-27-0 -SISTEM INACBG: O-6-13-i -PERSALINAN INACBG: O-6-13-i -PERSALINAN
PERSARAFAN PUSAT AKUT PERSARAFAN PUSAT AKUT VAGINAL RINGAN VAGINAL RINGAN
6
INACBG: J-3-13-0 -PROSEDUR TERAPI INACBG: J-3-13-0 -PROSEDUR INACBG: N-4-12-i -INFEKSI GINJAL INACBG: N-4-12-i -INFEKSI GINJAL
SALURAN PERNAFASAN TERAPI SALURAN PERNAFASAN DAN SALURAN URIN RINGAN DAN SALURAN URIN RINGAN
7
INACBG: N-4-10-i -TUMOR GINJAL INACBG: N-4-10-i -TUMOR GINJAL
& SALURAN URIN & GAGAL & SALURAN URIN & GAGAL
8 GINJAL RINGAN GINJAL RINGAN
INACBG: K-4-18-i -DIAGNOSIS INACBG: K-4-18-i -DIAGNOSIS
SISTEM PENCERNAAN LAIN-LAIN SISTEM PENCERNAAN LAIN-LAIN
9 (RINGAN) (RINGAN)
INACBG: K-4-17-ii -NYERI INACBG: K-4-17-ii -NYERI
ABDOMEN & GASTROENTERITIS ABDOMEN & GASTROENTERITIS
10 LAIN-LAIN (SEDANG) LAIN-LAIN (SEDANG)
RS Prasetya Husada
Pering
kat RJTL RITL
INACBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
1
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR INACBG: W-4-16-i -GANGGUAN INACBG: W-4-16-i -GANGGUAN
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK ANTEPARTUM RINGAN ANTEPARTUM RINGAN
2
INACBG: W-4-12-iii-GANGGUAN INACBG: W-4-12-iii-GANGGUAN
INACBG: Z-3-23-0 -PROSEDUR INACBG: Z-3-23-0 -PROSEDUR MENSTRUASI & SISTEM MENSTRUASI & SISTEM
ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
3 (BERAT) (BERAT)
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR MENSTRUASI & SISTEM MENSTRUASI & SISTEM
GIGI PADA GIGI REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
4 (SEDANG) (SEDANG)
INACBG: W-4-12-i -GANGGUAN INACBG: W-4-12-i -GANGGUAN
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT MENSTRUASI & SISTEM MENSTRUASI & SISTEM
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
5 (RINGAN) (RINGAN)
INACBG: W-4-10-iii-TUMOR INACBG: W-4-10-iii-TUMOR
6 BERAT BERAT
INACBG: W-4-10-ii -TUMOR INACBG: W-4-10-ii -TUMOR
7 SEDANG SEDANG
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: W-4-10-i -TUMOR SISTEM INACBG: W-4-10-i -TUMOR SISTEM
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN REPRODUKSI WANITA RINGAN REPRODUKSI WANITA RINGAN
8
INACBG: Q-5-40-0 -INFEKSI SALURAN INACBG: Q-5-40-0 -INFEKSI
KEMIH AKUT SALURAN KEMIH AKUT
INACBG: Q-5-39-0 -KECEDERAAN INACBG: Q-5-39-0 -KECEDERAAN
BESAR PADA JARINGAN LU BESAR PADA JARINGAN LUNAK
10 SERVIK RINGAN SERVIK RINGAN
Pering
RJTL RITL
kat
INACBG: Z-4-12-iii-FAKTOR-
INACBG: Z-3-28-0 -IMAGING INACBG: Z-3-28-0 -IMAGING INACBG: W-4-16-ii -GANGGUAN FAKTOR YANG MEMPENGARUHI
PAYUDARA PAYUDARA ANTEPARTUM SEDANG STATUS KESEHATAN LAIN-LAIN
1 (BERAT)
INACBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-i -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
2 LUKA ANTEPARTUM RINGAN ANTEPARTUM SEDANG
INACBG: W-4-12-iii-GANGGUAN
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR MENSTRUASI & SISTEM INACBG: W-4-16-i -GANGGUAN
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK REPRODUKSI WANITA LAIN-LAIN ANTEPARTUM RINGAN
3 (BERAT)
INACBG: W-4-12-ii -GANGGUAN INACBG: W-4-12-iii-GANGGUAN
4 (SEDANG) (BERAT)
INACBG: W-4-12-i -GANGGUAN INACBG: W-4-12-ii -GANGGUAN
INACBG: Z-3-22-0 -IMAGING KONTRAS INACBG: Z-3-22-0 -IMAGING MENSTRUASI & SISTEM MENSTRUASI & SISTEM
LAIN-LAIN KONTRAS LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
5 (RINGAN) (SEDANG)
INACBG: W-4-12-i -GANGGUAN
INACBG: Z-3-19-0 -CT SCAN INACBG: W-4-11-i -INFEKSI SISTEM MENSTRUASI & SISTEM
INACBG: Z-3-19-0 -CT SCAN LAIN-LAIN
LAIN-LAIN REPRODUKSI WANITA RINGAN REPRODUKSI WANITA LAIN-LAIN
6 (RINGAN)
INACBG: W-4-10-ii -TUMOR
INACBG: W-3-12-0 -PROSEDUR KECIL INACBG: W-3-12-0 -PROSEDUR INACBG: W-4-11-i -INFEKSI SISTEM
SISTEM REPRODUKSI WANITA
GINEKOLOGI KECIL GINEKOLOGI REPRODUKSI WANITA RINGAN
7 SEDANG
INACBG: W-4-10-ii -TUMOR
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR INACBG: W-4-10-i -TUMOR SISTEM
SISTEM REPRODUKSI WANITA
GIGI PADA GIGI REPRODUKSI WANITA RINGAN
8 SEDANG
INACBG: W-1-20-ii -PROSEDUR
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: W-4-10-i -TUMOR SISTEM
PADA RAHIM & ADNEKSA
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN REPRODUKSI WANITA RINGAN
9 SEDANG
INACBG: Z-4-12-iii-FAKTOR-
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-42-0 -PENYAKIT FAKTOR YANG MEMPENGARUHI
PADA RAHIM & ADNEKSA
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN STATUS KESEHATAN LAIN-LAIN
SEDANG
10 (BERAT)
RS Mitra Delima
Pering
kat RJTL RITL
INACBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
1
2
3 (SEDANG) (SEDANG)
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR MENSTRUASI & SISTEM MENSTRUASI & SISTEM
GIGI PADA GIGI REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
4 (RINGAN) (RINGAN)
INACBG: U-3-15-0 -PROSEDUR LAIN- INACBG: W-1-30-ii -PROSEDUR INACBG: W-1-30-ii -PROSEDUR
LAIN-LAIN PADA TELINGA,
LAIN PADA TELINGA, HIDUNG, MULUT PADA VAGINA, SERVIK & VULVA PADA VAGINA, SERVIK & VULVA
HIDUNG, MULUT DAN
DAN TENGGOROKAN SEDANG SEDANG
5 TENGGOROKAN
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN
6 SEDANG SEDANG
INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-43-0 -PENYAKIT INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
7
INACBG: W-1-11-iii-PROSEDUR INACBG: W-1-11-iii-PROSEDUR
8 SERVIK BERAT SERVIK BERAT
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN
INACBG: U-4-13-iii-PERADANGAN INACBG: U-4-13-iii-PERADANGAN
INACBG: Q-5-40-0 -INFEKSI SALURAN INACBG: Q-5-40-0 -INFEKSI
KEMIH AKUT SALURAN KEMIH AKUT
10 DAN LARINGOTRAKEITIS BERAT DAN LARINGOTRAKEITIS BERAT
RSI Gondanglegi
Pering
kat RJTL RITL
INA CBG: Z-3-27-0 -PERAWATAN INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
1
2
3 (SEDANG) (SEDANG)
INACBG: Z-3-22-0 -IMAGING KONTRAS INACBG: Z-3-22-0 -IMAGING INACBG: W-1-20-ii -PROSEDUR INACBG: W-1-20-ii -PROSEDUR
4 LAIN-LAIN KONTRAS LAIN-LAIN PADA RAHIM & ADNEKSA SEDANG PADA RAHIM & ADNEKSA SEDANG
INACBG: V-4-11-i -DIAGNOSIS INACBG: V-4-11-i -DIAGNOSIS
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: U-3-16-0 -PROSEDUR
SISTEM REPRODUKSI LAKI-LAKI SISTEM REPRODUKSI LAKI-LAKI
GIGI PADA GIGI
5 SELAIN TUMOR (RINGAN) SELAIN TUMOR (RINGAN)
INACBG: V-1-13-i -PROSEDUR INACBG: V-1-13-i -PROSEDUR
PADA SKROTUM DAN PROSTAT PADA SKROTUM DAN PROSTAT
SINUS & MASTOID PADA SINUS & MASTOID
6 NON KOMPLEK (RINGAN) NON KOMPLEK (RINGAN)
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: U-4-14-ii -PENYAKIT INACBG: U-4-14-ii -PENYAKIT
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN MULUT DAN GIGI SEDANG MULUT DAN GIGI SEDANG
7
INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-43-0 -PENYAKIT INACBG: U-4-11-ii - INACBG: U-4-11-ii -
BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN DYSEQUILIBRIUM SEDANG DYSEQUILIBRIUM SEDANG
8
INACBG: U-4-10-ii -TUMOR INACBG: U-4-10-ii -TUMOR
KERONGKONGAN, MULUT, KERONGKONGAN, MULUT,
9 HIDUNG DAN TELINGA SEDANG HIDUNG DAN TELINGA SEDANG
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: U-1-30-ii -PROSEDUR INACBG: U-1-30-ii -PROSEDUR
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN MULUT SEDANG MULUT SEDANG
10
RS Prima Husada
Pering
kat RJTL RITL
1
INACBG: Z-3-26-0 -PROSEDUR BESAR INACBG: Z-3-26-0 -PROSEDUR MENSTRUASI & SISTEM MENSTRUASI & SISTEM
RADIOGRAFI BESAR RADIOGRAFI REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
2 (SEDANG) (SEDANG)
INACBG: Z-3-23-0 -PROSEDUR INACBG: Z-3-23-0 -PROSEDUR INACBG: W-4-10-ii -TUMOR SISTEM INACBG: W-4-10-ii -TUMOR SISTEM
ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN REPRODUKSI WANITA SEDANG REPRODUKSI WANITA SEDANG
3
REHABILITASI REHABILITASI
5 SERVIK RINGAN SERVIK RINGAN
INACBG: V-4-11-iii-DIAGNOSIS INACBG: V-4-11-iii-DIAGNOSIS
6 SELAIN TUMOR (BERAT) SELAIN TUMOR (BERAT)
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-42-0 -PENYAKIT INACBG: V-1-15-i -SIRKUMSISI INACBG: V-1-15-i -SIRKUMSISI
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN RINGAN RINGAN
7
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: U-4-14-i -PENYAKIT INACBG: U-4-14-i -PENYAKIT
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN MULUT DAN GIGI RINGAN MULUT DAN GIGI RINGAN
8
INACBG: U-4-11-iii- INACBG: U-4-11-iii-
INACBG: Q-5-38-0 -PARU AKUT INACBG: Q-5-38-0 -PARU AKUT
DYSEQUILIBRIUM BERAT DYSEQUILIBRIUM BERAT
9
INACBG: Q-5-32-0 -SALURAN KEMIH INACBG: Q-5-32-0 -SALURAN INACBG: U-4-11-ii - INACBG: U-4-11-ii -
AKUT KEMIH AKUT DYSEQUILIBRIUM SEDANG DYSEQUILIBRIUM SEDANG
10
RS Ben Mari
Pering
kat RJTL RITL
INACBG: Z-4-12-ii -FAKTOR- INACBG: Z-4-12-iii-FAKTOR-
INACBG: Z-3-27-0 -PERAWATAN FAKTOR YANG MEMPENGARUHI FAKTOR YANG MEMPENGARUHI
LUKA STATUS KESEHATAN LAIN-LAIN STATUS KESEHATAN LAIN-LAIN
1 (SEDANG) (BERAT)
INACBG: Z-4-12-ii -FAKTOR-
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR INACBG: W-4-16-iii-GANGGUAN FAKTOR YANG MEMPENGARUHI
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK ANTEPARTUM BERAT STATUS KESEHATAN LAIN-LAIN
2 (SEDANG)
INACBG: W-3-11-0 -PROSEDUR INACBG: W-3-11-0 -PROSEDUR INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-iii-GANGGUAN
SEDANG GINEKOLOGI SEDANG GINEKOLOGI ANTEPARTUM SEDANG ANTEPARTUM BERAT
3
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: W-4-16-i -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
4 KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN ANTEPARTUM RINGAN ANTEPARTUM SEDANG
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-42-0 -PENYAKIT MENSTRUASI & SISTEM INACBG: W-4-16-i -GANGGUAN
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN ANTEPARTUM RINGAN
5 (RINGAN)
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: W-1-20-iii-PROSEDUR MENSTRUASI & SISTEM
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN PADA RAHIM & ADNEKSA BERAT REPRODUKSI WANITA LAIN-LAIN
6 (RINGAN)
INACBG: Q-5-29-0 -GAGAL JANTUNG INACBG: Q-5-29-0 -GAGAL
INACBG: W-1-20-ii -PROSEDUR INACBG: W-1-20-iii-PROSEDUR
KONGESTIF DAN KONDISI JANTUNG JANTUNG KONGESTIF DAN
PADA RAHIM & ADNEKSA SEDANG PADA RAHIM & ADNEKSA BERAT
7 LAIN-LAIN KONDISI JANTUNG LAIN-LAIN
INACBG: Q-5-26-0 -BRONKIAL INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-ii -PROSEDUR
INACBG: Q-5-26-0 -BRONKIAL AKUT
8 AKUT PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA SEDANG
INACBG: W-1-20-i -PROSEDUR
DILATASI, KURET, INTRAUTERIN &
PADA RAHIM & ADNEKSA RINGAN
9 SERVIK SEDANG
10
Rumkitban Lawang
Pering
kat RJTL RITL
Z-3-25-0 -PROSEDUR ULTRASOUND Z-3-25-0 -PROSEDUR W-4-16-ii -GANGGUAN W-4-16-ii -GANGGUAN
GINEKOLOGIK ULTRASOUND GINEKOLOGIK ANTEPARTUM SEDANG ANTEPARTUM SEDANG
1
Q-5-44-0 -PENYAKIT KRONIS KECIL Q-5-44-0 -PENYAKIT KRONIS W-4-16-i -GANGGUAN W-4-16-i -GANGGUAN
LAIN-LAIN KECIL LAIN-LAIN ANTEPARTUM RINGAN ANTEPARTUM RINGAN
2
Q-5-42-0 -PENYAKIT AKUT KECIL LAIN- INACBG: Q-5-42-0 -PENYAKIT

U-4-11-iii-DYSEQUILIBRIUM BERAT U-4-11-iii-DYSEQUILIBRIUM BERAT
LAIN AKUT KECIL LAIN-LAIN
3
Q-5-41-0 -PENYAKIT AKUT BESAR Q-5-41-0 -PENYAKIT AKUT BESAR U-4-11-ii -DYSEQUILIBRIUM U-4-11-ii -DYSEQUILIBRIUM
4 LAIN-LAIN LAIN-LAIN SEDANG SEDANG
: Q-5-38-0 -PARU AKUT Q-5-38-0 -PARU AKUT S-4-16-i -LUKA BAKAR RINGAN S-4-16-i -LUKA BAKAR RINGAN
5
J-3-13-0 -PROSEDUR TERAPI SALURAN J-3-13-0 -PROSEDUR TERAPI O-6-13-ii -PERSALINAN VAGINAL O-6-13-ii -PERSALINAN VAGINAL
PERNAFASAN SALURAN PERNAFASAN SEDANG SEDANG
6
O-6-13-i -PERSALINAN VAGINAL O-6-13-i -PERSALINAN VAGINAL
RINGAN RINGAN
7
O-6-10-i -OPERASI PEMBEDAHAN O-6-10-i -OPERASI PEMBEDAHAN
CAESAR RINGAN CAESAR RINGAN
8
N-4-11-ii -PERADANGAN GINJAL N-4-11-ii -PERADANGAN GINJAL
SEDANG SEDANG
9
N-1-11-i -PROSEDUR KANDUNG N-1-11-i -PROSEDUR KANDUNG
KEMIH KOMPLEK RINGAN KEMIH KOMPLEK RINGAN
10
RS Unisma
Pering
kat RJTL RITL
INACBG: Z-3-27-0 -PERAWATAN LUKA INACBG: Q-5-38-0 -PARU AKUT
ANTEPARTUM RINGAN ANTEPARTUM RINGAN
1
INACBG: Z-3-25-0 -PROSEDUR INACBG: Q-5-34-0 -INFEKSI VIRUS INACBG: W-4-14-i -ABORTUS INACBG: W-4-14-i -ABORTUS
ULTRASOUND GINEKOLOGIK HIV MENGANCAM RINGAN MENGANCAM RINGAN
2
INACBG: Z-3-12-0 -PROSEDUR INACBG: Q-5-33-0 -HEMATOLOGI MENSTRUASI & SISTEM MENSTRUASI & SISTEM
REHABILITASI AKUT REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
3 (SEDANG) (SEDANG)
INACBG: Q-5-29-0 -GAGAL
INACBG: W-3-11-0 -PROSEDUR INACBG: W-1-20-ii -PROSEDUR INACBG: W-1-20-ii -PROSEDUR
JANTUNG KONGESTIF DAN
SEDANG GINEKOLOGI PADA RAHIM & ADNEKSA SEDANG PADA RAHIM & ADNEKSA SEDANG
4 KONDISI JANTUNG LAIN-LAIN
INACBG: U-3-16-0 -PROSEDUR PADA INACBG: Q-5-28-0 -KECEDERAAN INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
GIGI SISTEM PERSARAFAN PUSAT PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
5
INACBG: V-4-11-i -DIAGNOSIS INACBG: V-4-11-i -DIAGNOSIS
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-27-0 -SISTEM
KECIL LAIN-LAIN PERSARAFAN PUSAT AKUT
6 SELAIN TUMOR (RINGAN) SELAIN TUMOR (RINGAN)
INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-26-0 -BRONKIAL INACBG: U-4-14-iii-PENYAKIT INACBG: U-4-14-iii-PENYAKIT
BESAR LAIN-LAIN AKUT MULUT DAN GIGI BERAT MULUT DAN GIGI BERAT
7
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-25-0 - INACBG: U-4-14-ii -PENYAKIT INACBG: U-4-14-ii -PENYAKIT
KECIL LAIN-LAIN GASTROINTESTINAL AKUT MULUT DAN GIGI SEDANG MULUT DAN GIGI SEDANG
8
INACBG: Q-5-19-0 -KONTAK
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: U-4-14-i -PENYAKIT INACBG: U-4-14-i -PENYAKIT
PELAYANAN KESEHATAN LAIN-
BESAR LAIN-LAIN MULUT DAN GIGI RINGAN MULUT DAN GIGI RINGAN
9 LAIN
INACBG: Q-5-40-0 -INFEKSI SALURAN
INACBG: Q-5-12-0 -GIGI EPIGLOTIS, TELINGA TENGAH, ISPA EPIGLOTIS, TELINGA TENGAH, ISPA
KEMIH AKUT
10 DAN LARINGOTRAKEITIS SEDANG DAN LARINGOTRAKEITIS SEDANG
RS Puri Bunda
Pering
kat RJTL RITL
INA CBG: W-1-11-i -PROSEDUR
INACBG: Z-3-25-0 -PROSEDUR INA CBG: Z-3-25-0 -PROSEDUR INACBG: Z-4-11-iii-GEJALA-GEJALA
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK DAN TANDA-TANDA BERAT
1 SERVIK RINGAN
INACBG: U-4-13-iii-PERADANGAN
INACBG: Z-3-23-0 -PROSEDUR INACBG: Z-3-23-0 -PROSEDUR INACBG: W-4-16-iii-GANGGUAN
EPIGLOTIS, TELINGA TENGAH, ISPA
ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN ANTEPARTUM BERAT
2 DAN LARINGOTRAKEITIS BERAT
INACBG: U-4-13-ii -PERADANGAN

INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: W-4-16-ii -GANGGUAN
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN ANTEPARTUM SEDANG
DAN LARINGOTRAKEITIS SEDANG
3
INACBG: U-4-13-i -PERADANGAN
INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-43-0 -PENYAKIT INACBG: W-4-16-i -GANGGUAN
BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN ANTEPARTUM RINGAN
4 DAN LARINGOTRAKEITIS RINGAN
INACBG: Q-5-42-0 -PENYAKIT AKUT INACBG: Q-5-42-0 -PENYAKIT INACBG: W-4-14-iii-ABORTUS INACBG: O-6-13-ii -PERSALINAN
KECIL LAIN-LAIN AKUT KECIL LAIN-LAIN MENGANCAM BERAT VAGINAL SEDANG
5
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: W-4-14-ii -ABORTUS INACBG: O-6-13-i -PERSALINAN
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN MENGANCAM SEDANG VAGINAL RINGAN
6
INACBG: W-4-12-ii -GANGGUAN
MENSTRUASI & SISTEM INACBG: O-6-10-iii-OPERASI
INACBG: Q-5-38-0 -PARU AKUT INACBG: Q-5-38-0 -PARU AKUT
REPRODUKSI WANITA LAIN-LAIN PEMBEDAHAN CAESAR BERAT
7 (SEDANG)
INACBG: Q-5-26-0 -BRONKIAL INACBG: W-1-20-ii -PROSEDUR INACBG: O-6-10-ii -OPERASI

INACBG: Q-5-26-0 -BRONKIAL AKUT
AKUT PADA RAHIM & ADNEKSA SEDANG PEMBEDAHAN CAESAR SEDANG
8
INACBG: J-3-13-0 -PROSEDUR TERAPI INACBG: J-3-13-0 -PROSEDUR INACBG: W-1-20-i -PROSEDUR INACBG: O-6-10-i -OPERASI
SALURAN PERNAFASAN TERAPI SALURAN PERNAFASAN PADA RAHIM & ADNEKSA RINGAN PEMBEDAHAN CAESAR RINGAN
9
INACBG: N-4-12-ii -INFEKSI GINJAL
DAN SALURAN URIN SEDANG
10 SERVIK SEDANG
RS Permata Bunda
Pering
kat RJTL RITL
INA CBG: W-4-12-ii -GANGGUAN
MENSTRUASI & SISTEM
INACBG: Z-3-27-0 -PERAWATAN MENSTRUASI & SISTEM
INA CBG: Z-3-27-0 -PERAWATAN LUKA REPRODUKSI WANITA LAIN-LAIN
LUKA REPRODUKSI WANITA LAIN-LAIN
(SEDANG)
1 (SEDANG)
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK REPRODUKSI WANITA LAIN-LAIN REPRODUKSI WANITA LAIN-LAIN
2 (RINGAN) (RINGAN)
INACBG: Q-5-44-0 -PENYAKIT KRONIS INACBG: Q-5-44-0 -PENYAKIT INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
KECIL LAIN-LAIN KRONIS KECIL LAIN-LAIN PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
3
INACBG: Q-5-38-0 -PARU AKUT INACBG: Q-5-38-0 -PARU AKUT DILATASI, KURET, INTRAUTERIN & DILATASI, KURET, INTRAUTERIN &
INACBG: P-8-17-i -NEONATAL, BBL INACBG: P-8-17-i -NEONATAL, BBL
INACBG: Q-5-25-0 -GASTROINTESTINAL INACBG: Q-5-25-0 -
GROUP-5 TANPA PROSEDUR GROUP-5 TANPA PROSEDUR
AKUT GASTROINTESTINAL AKUT
5 MAYOR RINGAN MAYOR RINGAN
INACBG: Q-5-19-0 -KONTAK
INACBG: Q-5-19-0 -KONTAK INACBG: O-6-13-i -PERSALINAN INACBG: O-6-13-i -PERSALINAN
PELAYANAN KESEHATAN LAIN-
PELAYANAN KESEHATAN LAIN-LAIN VAGINAL RINGAN VAGINAL RINGAN
6 LAIN
INACBG: O-6-10-ii -OPERASI INACBG: O-6-10-ii -OPERASI

PEMBEDAHAN CAESAR SEDANG PEMBEDAHAN CAESAR SEDANG
7
INACBG: O-6-10-i -OPERASI INACBG: O-6-10-i -OPERASI
PEMBEDAHAN CAESAR RINGAN PEMBEDAHAN CAESAR RINGAN
8
INACBG: K-4-17-iii-NYERI INACBG: K-4-17-iii-NYERI
ABDOMEN & GASTROENTERITIS ABDOMEN & GASTROENTERITIS
9 LAIN-LAIN (BERAT) LAIN-LAIN (BERAT)
INACBG: K-1-13-ii -PROSEDUR INACBG: K-1-13-ii -PROSEDUR

APPENDIK SEDANG APPENDIK SEDANG
RS UMM
Pering
kat RJTL RITL
asus Terbesar Biaya Terbesar Kasus Terbesar Biaya Terbesar
INA CBG: Z-3-27-0 PERAWATAN INACBG: W-4-16-ii -GANGGUAN INACBG: W-4-16-ii -GANGGUAN
INA CBG: Z-3-27-0 PERAWATAN LUKA
1
INACBG: Z-3-25-0 -PROSEDUR INACBG: Z-3-25-0 -PROSEDUR INACBG: W-4-14-ii -ABORTUS INACBG: W-4-14-ii -ABORTUS
ULTRASOUND GINEKOLOGIK ULTRASOUND GINEKOLOGIK MENGANCAM SEDANG MENGANCAM SEDANG
2
INACBG: Z-3-23-0 -PROSEDUR INACBG: Z-3-23-0 -PROSEDUR INACBG: W-4-14-i -ABORTUS INACBG: W-4-14-i -ABORTUS
ULTRASOUND LAIN-LAIN ULTRASOUND LAIN-LAIN MENGANCAM RINGAN MENGANCAM RINGAN
3
INACBG: Z-3-19-0 -CT SCAN
INACBG: Z-3-19-0 -CT SCAN LAIN-LAIN PADA VAGINA, SERVIK & VULVA PADA VAGINA, SERVIK & VULVA
LAIN-LAIN
4 SEDANG SEDANG
INACBG: U-3-15-0 -PROSEDUR LAIN-
LAIN-LAIN PADA TELINGA, INACBG: W-1-20-i -PROSEDUR INACBG: W-1-20-i -PROSEDUR
LAIN PADA TELINGA, HIDUNG, MULUT
HIDUNG, MULUT DAN PADA RAHIM & ADNEKSA RINGAN PADA RAHIM & ADNEKSA RINGAN
DAN TENGGOROKAN
5 TENGGOROKAN
INACBG: U-4-13-iii-PERADANGAN INACBG: U-4-13-iii-PERADANGAN
SINUS & MASTOID PADA SINUS & MASTOID
6 DAN LARINGOTRAKEITIS BERAT DAN LARINGOTRAKEITIS BERAT
INACBG: Q-5-43-0 -PENYAKIT KRONIS INACBG: Q-5-43-0 -PENYAKIT INACBG: U-4-11-i - INACBG: U-4-11-i -
BESAR LAIN-LAIN KRONIS BESAR LAIN-LAIN DYSEQUILIBRIUM RINGAN DYSEQUILIBRIUM RINGAN
8
INACBG: U-1-20-i -PROSEDUR INACBG: U-1-20-i -PROSEDUR
TENGGOROKAN, MULUT, HIDUNG TENGGOROKAN, MULUT, HIDUNG
9 DAN TELINGA LAIN-LAIN (RINGAN) DAN TELINGA LAIN-LAIN (RINGAN)
INACBG: Q-5-41-0 -PENYAKIT AKUT INACBG: Q-5-41-0 -PENYAKIT INACBG: U-1-15-ii -PROSEDUR INACBG: U-1-15-ii -PROSEDUR
BESAR LAIN-LAIN AKUT BESAR LAIN-LAIN TONSIL & ADENOID SEDANG TONSIL & ADENOID SEDANG
10
Okt'14 (S.L I) Okt'14 (S.L II) Okt'14 (S.L III)
Jumlah Jumlah Jumlah

NAMA RS Kasus Jml. Biaya U.C Kasus Jml. Biaya U.C Kasus Jml. Biaya U.C
RSI UNISMA 105 362.797.200 3.455.211 75 473.669.900 6.315.599 42 431.371.800 10.270.757
RSUI MADINAH KASEMBON 104 258.876.500 2.489.197 138 471.460.000 3.416.377 23 95.958.300 4.172.100
RS PRASETYA HUSADA 146 427.999.900 2.931.506 72 268.045.100 3.722.849 11 63.388.100 5.762.555
RS PRIMA HUSADA 105 319.635.341 3.044.146 48 173.627.074 3.617.231 30 143.826.398 4.794.213
RSI GONDANGLEGI 48 127.419.400 2.654.571 44 172.574.400 3.922.145 15 91.257.200 6.083.813
RS Bala Keselamatan Bokor 75 187.976.300 2.506.351 19 68.796.000 3.620.842 9 32.234.100 3.581.567
BEN MARI 64 220.533.600 3.445.838 18 84.211.400 4.678.411 9 45.239.800 5.026.644
PERMATA BUNDA 61 210.771.000 3.455.262 7 30.236.400 4.319.486 0 0 0
RUMAH SAKIT LAVALETTE 180 690.353.800 3.835.299 184 956.946.300 5.200.795 78 628.535.000 8.058.141
RS BHAYANGKARA HASTA
25 72.219.800 2.888.792 14 59.902.900 4.278.779 14 97.237.000 6.945.500
BRATA
RUMKITBAN 05.08.04 LAWANG 39 124.680.700 3.196.941 3 9.289.000 3.096.333 6 28.812.400 4.802.067
RS. ABD. SALEH 33 75.827.700 2.297.809 4 11.444.300 2.861.075 0 0 0
RUMKITBAN 05.08.02 MALANG 21 62.448.900 2.973.757 0 0 0 0 0 0

Nov'14 (S.L I) Nov'14 (S.L II) Nov'14 (S.L III)

RS MELATI HUSADA 227 938.663.500 4.135.081 29 185.064.900 6.381.548 1 12.967.400 12.967.400
PRIMA HUSADA (JST) 73 219.146.600 3.002.008 63 261.116.100 4.144.700 33 220.271.600 6.674.897
RS Mitra Delima 85 278.084.300 3.271.580 35 154.263.500 4.407.529 13 64.579.500 4.967.654
RSI GONDANGLEGI 39 121.326.800 3.110.944 33 129.634.900 3.928.330 22 137.993.300 6.272.423
BEN MARI (JST) 60 230.977.100 3.849.618 13 76.891.500 5.914.731 7 34.000.900 4.857.271
PERMATA BUNDA (JST) 56 185.976.600 3.321.011 2 6.172.800 3.086.400 0 0 0

RUMKITBAN 05.08.04
28 81.688.400 2.917.443 4 10.639.100 2.659.775 8 36.428.100 4.553.513
LAWANG
14 34.951.500 2.496.536 12 50.328.800 4.194.067 14 115.478.900 8.248.493
BRATA
RS. ABD. SALEH 30 66.836.900 2.227.897 4 14.872.800 3.718.200 0 0 0
RUMKITBAN 05.08.02
12 36.634.400 3.052.867 0 0 0 0 0 0
MALANG
RSIA MUHAMMADIYAH
2 7.962.600 3.981.300 1 8.933.600 8.933.600 0 0 0
MALANG
Des'14 (S.L I) Des'14 (S.L II) Des'14 (S.L III)

NAMA RS0 Kasus Jml. Biaya U.C Kasus Jml. Biaya U.C Kasus Jml. Biaya U.C
RS MELATI HUSADA 250 1.056.487.300 4.225.949 31 231.493.800 7.467.542 2 16.868.800 8.434.400
PURI BUNDA (JST) 47 143.992.500 3.063.670 154 651.975.500 4.233.607 7 34.795.500 4.970.786
ISLAM UNISMA (JST) 120 494.359.900 4.119.666 64 354.280.000 5.535.625 23 197.910.800 8.604.817
PRIMA HUSADA (JST) 94 277.765.100 2.954.948 64 245.416.900 3.834.639 28 135.787.200 4.849.543
RS Mitra Delima 97 309.484.900 3.190.566 37 134.825.300 3.643.927 20 117.083.200 5.854.160
BEN MARI (JST) 48 188.055.700 3.917.827 11 49.676.500 4.516.045 2 7.896.600 3.948.300
PERMATA BUNDA (JST) 56 188.705.700 3.369.745 3 10.934.500 3.644.833 0 0 0
LAWANG MEDIKA (JST) 10 28.161.800 2.816.180 26 101.296.600 3.896.023 20 106.831.200 5.341.560

RUMKITBAN 05.08.04
29 90.482.100 3.120.072 4 17.178.500 4.294.625 15 66.462.800 4.430.853
LAWANG
22 68.798.900 3.127.223 18 67.344.500 3.741.361 8 39.602.500 4.950.313
BRATA
RS. ABD. SALEH 16 37.155.200 2.322.200 2 7.441.100 3.720.550 0 0 0
Jan’15 (S.L I) Jan’15 (S.L II) Jan’15 (S.L III)

RS MELATI HUSADA 277 1.152.534.100 4.160.773 33 200.063.200 6.062.521 0 0 0
ISLAM UNISMA (JST) 139 483.139.300 3.475.822 80 475.597.900 5.944.974 30 326.441.700 10.881.390
RSU. UNIVERSITAS
21 121.840.300 5.801.919 8 100.328.900 12.541.113
MUHAMMADIYAH
PRIMA HUSADA (JST) 140 403.894.000 2.884.957 91 370.580.400 4.072.312 29 128.786.000 4.440.897
RSI GONDANGLEGI 66 187.035.200 2.833.867 36 144.409.300 4.011.369 25 144.980.600 5.799.224
RS Mitra Delima 75 234.047.900 3.120.639 33 118.679.100 3.596.336 15 64.091.500 4.272.767
BEN MARI (JST) 50 168.529.100 3.370.582 11 35.341.300 3.212.845 9 37.064.900 4.118.322

31 91.390.200 2.948.071 18 67.316.300 3.739.794 12 71.324.800 5.943.733
BRATA
RUMKITBAN 05.08.04 LAWANG 33 120.690.200 3.657.279 4 14.414.100 3.603.525 16 72.113.000 4.507.063
RS. ABD. SALEH 44 88.688.800 2.015.655 3 7.321.400 2.440.467 0 0 0
RUMKITBAN 05.08.02 MALANG 11 34.654.200 3.150.382 0 0 0 0 0 0
RS PANTI NIRMALA 38 120.790.100 3.178.687 52 322.954.500 6.210.663 17 147.834.800 8.696.165

RSIA MUHAMMADIYAH
29 108.755.100 3.750.176 9 48.224.000 5.358.222 0 0 0
MALANG
Feb'15 (S.L I) Feb’15(S.L II) Feb’15 (S.L III)
RS MELATI HUSADA 274 1.146.587.100 4.184.624 40 255.965.900 6.399.148 0 0 0
PURI BUNDA (JST) 141 531.581.800 3.770.084 84 383.135.000 4.561.131 12 51.269.600 4.272.467
ISLAM UNISMA (JST) 122 418.332.700 3.428.957 59 315.291.100 5.343.917 24 253.220.50010.550.854
PRIMA HUSADA (JST) 191 510.982.300 2.675.300 101 400.283.000 3.963.198 14 70.624.000 5.044.571
RS Mitra Delima 99 313.020.100 3.161.819 23 75.964.800 3.302.817 12 47.226.900 3.935.575
RSI GONDANGLEGI 59 172.158.600 2.917.942 41 165.859.300 4.045.349 20 108.403.300 5.420.165
BEN MARI (JST) 39 136.452.600 3.498.785 17 73.611.500 4.330.088 13 55.354.000 4.258.000
PERMATA BUNDA (JST) 55 173.870.800 3.161.287 3 13.947.300 4.649.100 1 3.532.900 3.532.900
RS PANTI NIRMALA 77 278.474.800 3.616.556 86 525.024.400 6.104.935 50 494.406.500 9.888.130

34 95.054.600 2.795.724 39 144.624.600 3.708.323 17 105.550.900 6.208.876
BRATA
RS. ABD. SALEH 54 101.894.400 1.886.933 11 30.308.100 2.755.282 0 0 0
RUMKITBAN 05.08.02
16 57.273.300 3.579.581 0 0 0 0 0 0
MALANG
RSIA MUHAMMADIYAH
28 85.776.300 3.063.439 7 29.992.500 4.284.643 2 8.499.500 4.249.750
MALANG
Mar'15 (S.L I) Mar’15 (S.L II) Mar’15 (S.L III)

RS MELATI HUSADA 275 1.212.401.000 4.408.731 68 443.954.600 6.528.744 0 0 0
RSU. UNIVERSITAS
101 373.064.000 3.693.703 66 441.309.900 6.686.514 31 234.923.900 7.578.190
MUHAMMADIYAH
PRIMA HUSADA (JST) 173 525.906.600 3.039.923 97 372.524.100 3.840.455 43 194.647.900 4.526.695
RS Mitra Delima 108 318.131.900 2.945.666 29 98.189.400 3.385.841 15 53.790.400 3.586.027
RSI GONDANGLEGI 55 160.670.400 2.921.280 38 145.580.100 3.831.055 30 182.965.100 6.098.837
PERMATA BUNDA (JST) 87 288.588.700 3.317.111 9 31.346.700 3.482.967 2 7.847.600 3.923.800
BEN MARI (JST) 62 236.352.000 3.812.129 12 59.303.100 4.941.925 8 51.232.800 6.404.100

43 126.846.000 2.949.907 34 126.572.600 3.722.724 9 60.516.900 6.724.100
BRATA
RUMKITBAN 05.08.04
50 179.299.100 3.585.982 6 18.108.000 3.018.000 23 103.986.500 4.521.152
LAWANG
RS. ABD. SALEH 65 145.574.800 2.239.612 6 13.357.700 2.226.283 0 0 0
RUMKITBAN 05.08.02
17 62.661.500 3.685.971 0 0 0 0 0 0
MALANG
Apr’15 (S.L I) Apr’15(S.L II) Apr’15 (S.L III)

RS Mitra Delima 95 296.610.500 3.122.216 28 110.917.400 3.961.336 10 49.540.600 4.954.060
RUMKITBAN 05.08.04
52 162.113.500 3.117.567 5 18.724.700 3.744.940 29 134.191.800 4.627.303
LAWANG
RSIA MUHAMMADIYAH
44 126.323.900 2.870.998 4 14.909.400 3.727.350 0 0 0
MALANG
Okt-14 Nov-14 Des-14
Nama RS Kasus LOS ALOS Nama RS Kasus LOS ALOS Nama RS Kasus LOS ALOS
RSUI MADINAH RSUI MADINAH
265 1.097 4,14 239 934 3,91 RSUI MADINAH KASEMBON 269 1.078 4,01
KASEMBON KASEMBON
RS PRASETYA
229 863 3,77 PRIMA HUSADA (JST) 169 613 3,63 RS PRASETYA HUSADA 229 759 3,31
HUSADA
PRIMA HUSADA
183 673 3,68 RS Mitra Delima 133 545 4,10 PRIMA HUSADA (JST) 186 651 3,50
(JST)
RSI GONDANGLEGI 107 467 4,36 RSI GONDANGLEGI 94 455 4,84 RS Mitra Delima 154 607 3,94
RS Bala RS Bala Keselamatan

103 379 3,68 80 297 3,71 RS Bala Keselamatan Bokor 93 326 3,51
Keselamatan Bokor Bokor
BEN MARI (JST) 91 316 3,47 BEN MARI (JST) 80 269 3,36 BEN MARI (JST) 61 209 3,43
PERMATA BUNDA
68 284 4,18 PERMATA BUNDA (JST) 58 214 3,69 PERMATA BUNDA (JST) 59 216 3,66
(JST)
RS BHAYANGKARA RUMKITBAN 05.08.04

53 203 3,83 40 138 3,45 LAWANG MEDIKA (JST) 56 211 3,77
HASTA BRATA LAWANG
RUMKITBAN RS BHAYANGKARA
48 199 4,15 40 165 4,13 RUMKITBAN 05.08.04 LAWANG 48 179 3,73
05.08.04 LAWANG HASTA BRATA
RS. ABD. SALEH 37 124 3,35 RS. ABD. SALEH 34 108 3,18 48 174 3,63
BRATA
RUMKITBAN RUMKITBAN 05.08.02

21 71 3,38 12 39 3,25 RS. ABD. SALEH 18 57 3,17
05.08.02 MALANG MALANG
Jan’15 Feb’15 Mar’15
Nama RS Kasus LOS ALOS Nama RS Kasus LOS ALOS Nama RS Kasus LOS ALOS
RS MELATI HUSADA 310 1.079 3,48 RS MELATI HUSADA 314 1.091 3,47 RS MELATI HUSADA 343 1.194 3,48
RSU. UNIVERSITAS
ISLAM UNISMA (JST) 249 1.164 4,67 PURI BUNDA 237 758 3,20 198 957 4,83
MUHAMMADIYAH
RSU. UNIVERSITAS
29 137 4,72 ISLAM UNISMA 205 936 4,57 RS PRASETYA HUSADA 341 1.253 3,67
MUHAMMADIYAH
RS PRASETYA
301 1.117 3,71 RS PRASETYA HUSADA 310 1.191 3,84 PRIMA HUSADA 313 1.242 3,97
HUSADA
RSUI MADINAH
275 1.137 4,13 PRIMA HUSADA 306 1.159 3,79 RS Mitra Delima 152 588 3,87
KASEMBON
PRIMA HUSADA (JST) 260 949 3,65 RSUI MADINAH KASEMBON 265 1.093 4,12 RS Bala Keselamatan Bokor 129 490 3,80
RSI GONDANGLEGI 127 549 4,32 RS Mitra Delima 134 500 3,73 RSI GONDANGLEGI 123 534 4,34
RS Mitra Delima 123 471 3,83 RS Bala Keselamatan Bokor 121 487 4,02 PERMATA BUNDA 98 397 4,05
RS Bala Keselamatan
109 391 3,59 RSI GONDANGLEGI 120 574 4,78 BEN MARI 82 285 3,48
Bokor
BEN MARI (JST) 70 244 3,49 LAWANG MEDIKA 76 277 3,64 86 377 4,38
BRATA
LAWANG MEDIKA RUMKITBAN 05.08.04
69 279 4,04 BEN MARI (JST) 69 241 3,49 79 311 3,94
(JST) LAWANG
RS BHAYANGKARA
61 242 3,97 PERMATA BUNDA 59 222 3,76 RS. ABD. SALEH 71 221 3,11
HASTA BRATA
RUMKITBAN 05.08.04 RUMKITBAN 05.08.02
53 219 4,13 RS PANTI NIRMALA 213 1.124 5,28 17 66 3,88
LAWANG MALANG
RS. ABD. SALEH 47 140 2,98 90 374 4,16
BRATA
RUMKITBAN 05.08.02
11 39 3,55 RS. ABD. SALEH 65 261 4,02
MALANG
RUMKITBAN 05.08.02
RS PANTI NIRMALA 107 501 4,68 16 52 3,25
MALANG
RSIA
RSIA MUHAMMADIYAH
MUHAMMADIYAH 38 140 3,68 37 144 3,89
MALANG
MALANG
Apr-15
Nama RS Kasus LOS ALOS

RS Mitra Delima 133 499 3,75
RUMKITBAN 05.08.04 LAWANG 86 337 3,92

RSIA MUHAMMADIYAH
48 177 3,69
MALANG
BULAN JENIS
NAMA RS BIAYA CBG BIAYA RIIL BEBAN JUMLAH KASUS PELAYANAN
RS BEN MARI 15.461.300 7.624.900 Oktober 2014 80 RJTL
RS BEN MARI 21.165.900 11.143.500 November 2014 96 RJTL
RS BEN MARI 20.834.000 11.079.500 Desember 2014 93 RJTL
RS BEN MARI 18.194.400 10.293.000 Januari 2015 83 RJTL
RS BEN MARI 18.449.400 10.508.000 Februari 2015 81 RJTL
RS BEN MARI 24.832.100 13.083.500 Maret 2015 105 RJTL

BULAN JENIS
RS BEN MARI 358.010.200 333.223.792 Oktober 2014 103 RITL
RS BEN MARI 341.869.500 331.149.600 November 2014 83 RITL

RITL
RS BEN MARI 245.628.800 242.888.300 Desember 2014 68
RS BEN MARI 240.935.300 213.226.000 Januari 2015 72 RITL
RS BEN MARI 265.418.100 234.670.450 Februari 2015 69 RITL
RS BEN MARI 346.887.900 330.349.250 Maret 2015 82 RITL

BULAN JENIS
PRIMA HUSADA (JST) 124.945.672 100.322.922 Oktober 2014 746 RJTL
PRIMA HUSADA (JST) 136.812.900 109.851.503 November 2014 831 RJTL
PRIMA HUSADA (JST) 164.782.900 132.309.521 Desember 2014 1.034 RJTL
PRIMA HUSADA (JST) 189.494.500 152.151.264 Januari 2015 1.180 RJTL
PRIMA HUSADA (JST) 209.754.100 167.733.907 Februari 2015 1.299 RJTL
PRIMA HUSADA (JST) 253.279.700 203.016.440 Maret 2015 1.591 RJTL

BULAN JENIS
PRIMA HUSADA (JST) 649.107.613 521.189.501 Oktober 2014 184 RITL
PRIMA HUSADA (JST) 700.534.300 562.481.652 November 2014 169 RITL
PRIMA HUSADA (JST) 658.969.200 529.107.689 Desember 2014 186 RITL
PRIMA HUSADA (JST) 903.260.400 725.256.996 Januari 2015 260 RITL
PRIMA HUSADA (JST) 981.889.300 858.250.450 Februari 2015 314 RITL
PRIMA HUSADA (JST) 1.167.345.800 859.667.411 Maret 2015 342 RITL

BULAN JENIS
PURI BUNDA (JST) 124.252.800 101.624.556 Oktober 2014 425 RJTL
PURI BUNDA (JST) 153.941.700 125.906.675 November 2014 466 RJTL
PURI BUNDA (JST) 144.976.400 118.574.087 Desember 2014 442 RJTL
PURI BUNDA (JST) 152.376.800 124.626.766 Januari 2015 468 RJTL
PURI BUNDA (JST) 58.610.400 33.745.000 Februari 2015 385 RJTL
PURI BUNDA (JST) 6.874.500 3.390.000 Maret 2015 461 RJTL

BULAN JENIS
PURI BUNDA (JST) 949.445.100 776.537.325 Oktober 2014 247 RITL
PURI BUNDA (JST) 852.798.600 697.491.559 November 2014 205 RITL
PURI BUNDA (JST) 826.325.100 675.839.269 Desember 2014 207 RITL
PURI BUNDA (JST) 949.650.300 776.705.155 Januari 2015 225 RITL
PURI BUNDA (JST) 861.080.700 966.145.000 Februari 2015 207 RITL
PURI BUNDA (JST) 566.636.100 612.335.000 Maret 2015 154 RITL

BULAN JENIS
RS Bala Keselamatan Bokor 70.839.300 52.300.174 Oktober 2014 480 RJTL
RS Bala Keselamatan Bokor 87.707.800 60.094.715 November 2014 550 RJTL
RS Bala Keselamatan Bokor 71.872.800 55.170.700 Desember 2014 498 RJTL
RS Bala Keselamatan Bokor 97.602.100 70.542.600 Januari 2015 640 RJTL
RS Bala Keselamatan Bokor 97.749.600 66.548.400 Februari 2015 636 RJTL
RS Bala Keselamatan Bokor 111.036.600 77.036.192 Maret 2015 716 RJTL

BULAN JENIS
RS Bala Keselamatan Bokor 290.518.400 276.910.500 Oktober 2014 104 RITL
RS Bala Keselamatan Bokor 251.623.300 226.124.000 November 2014 80 RITL
RS Bala Keselamatan Bokor 279.479.000 250.431.000 Desember 2014 93 RITL
RS Bala Keselamatan Bokor 329.955.400 303.428.750 Januari 2015 109 RITL
RS Bala Keselamatan Bokor 328.430.100 302.771.700 Februari 2015 121 RITL
RS Bala Keselamatan Bokor 392.229.300 355.475.728 Maret 2015 148 RITL

BULAN JENIS
ISLAM UNISMA (JST) 168.548.100 158.696.415 Oktober 2014 988 RJTL
ISLAM UNISMA (JST) 150.045.700 141.275.486 November 2014 888 RJTL
ISLAM UNISMA (JST) 182.907.300 172.216.316 Desember 2014 1.051 RJTL
ISLAM UNISMA (JST) 211.153.100 182.202.105 Januari 2015 1.231 RJTL
ISLAM UNISMA (JST) 212.709.200 193.397.705 Februari 2015 1.238 RJTL
- - - Maret 2015 - RJTL

BULAN JENIS
ISLAM UNISMA (JST) 1.273.726.200 1.199.276.538 Oktober 2014 223 RITL
ISLAM UNISMA (JST) 1.181.905.900 1.112.823.161 November 2014 187 RITL
ISLAM UNISMA (JST) 1.046.550.700 985.379.511 Desember 2014 207 RITL
ISLAM UNISMA (JST) 1.285.178.900 1.292.152.520 Januari 2015 262 RITL
ISLAM UNISMA (JST) 986.844.300 975.663.288 Februari 2015 245 RITL
- - - Maret 2015 - RITL

BULAN JENIS
BRATA 12.413.500 12.073.623 Oktober 2014 70 RJTL
BRATA 8.818.700 8.577.247 November 2014 54 RJTL
BRATA 12.266.100 11.930.259 Desember 2014 69 RJTL
BRATA 11.659.100 11.339.878 Januari 2015 72 RJTL
BRATA 18.903.100 18.311.400 Februari 2015 159 RJTL
BRATA 19.321.000 17.745.650 Maret 2015 152 RJTL
BULAN JENIS
BRATA 229.359.700 223.079.919 Oktober 2014 53 RITL
BRATA 200.759.200 195.262.490 November 2014 40 RITL
BRATA 179.639.000 174.720.553 Desember 2014 49 RITL
BRATA 230.031.300 223.733.131 Januari 2015 61 RITL
BRATA 345.230.100 309.955.150 Februari 2015 96 RITL
BRATA 313.935.500 347.054.750 Maret 2015 101 RITL
BULAN JENIS
RS MELATI HUSADA 236.709.100 258.461.356 Oktober 2014 1.064 RJTL
RS MELATI HUSADA 241.422.100 263.607.454 November 2014 1.116 RJTL
RS MELATI HUSADA 266.432.300 290.915.953 Desember 2014 1.193 RJTL
RS MELATI HUSADA 286.555.200 312.888.036 Januari 2015 1.263 RJTL
RS MELATI HUSADA 274.104.000 147.942.495 Februari 2015 1.237 RJTL
RS MELATI HUSADA 304.379.700 171.356.487 Maret 2015 1.405 RJTL

BULAN JENIS
RS MELATI HUSADA 1.142.329.100 1.247.302.819 Oktober 2014 259 RITL
RS MELATI HUSADA 1.136.695.800 1.241.151.850 November 2014 257 RITL
RS MELATI HUSADA 1.304.849.900 1.424.758.381 Desember 2014 283 RITL
RS MELATI HUSADA 1.352.597.300 1.476.893.502 Januari 2015 310 RITL
RS MELATI HUSADA 1.402.553.000 2.349.936.120 Februari 2015 315 RITL
RS MELATI HUSADA 1.677.971.100 2.666.978.410 Maret 2015 352 RITL

BULAN JENIS
RS Mitra Delima 77.237.800 70.036.650 Oktober 2014 423 RJTL
RS Mitra Delima 61.809.200 61.527.000 November 2014 339 RJTL
RS Mitra Delima 66.253.700 73.757.100 Desember 2014 387 RJTL
RS Mitra Delima 73.858.000 99.041.500 Januari 2015 421 RJTL
RS Mitra Delima 73.059.300 97.013.503 Februari 2015 437 RJTL
RS Mitra Delima 80.224.400 104.549.002 Maret 2015 459 RJTL

BULAN JENIS
RS Mitra Delima 612.330.400 632.142.000 Oktober 2014 151 RITL
RS Mitra Delima 499.907.100 543.193.500 November 2014 134 RITL
RS Mitra Delima 564.373.200 635.409.000 Desember 2014 156 RITL
RS Mitra Delima 416.818.500 603.477.500 Januari 2015 123 RITL
RS Mitra Delima 436.211.800 688.395.000 Februari 2015 134 RITL
RS Mitra Delima 470.111.700 703.533.000 Maret 2015 153 RITL

BULAN JENIS
- - - Oktober 2014 - RJTL
- - - November 2014 - RJTL
- - - Desember 2014 - RJTL
RS PANTI NIRMALA 178.101.500 168.976.110 Januari 2015 450 RJTL
RS PANTI NIRMALA 316.530.900 315.029.400 Februari 2015 951 RJTL
- - - Maret 2015 - RJTL

BULAN JENIS
- - - Oktober 2014 - RITL
- - - November 2014 - RITL
- - - Desember 2014 - RITL
RS PANTI NIRMALA 591.579.400 867.189.381 Januari 2015 108 RITL
RS PANTI NIRMALA 1.301.156.600 1.808.008.539 Februari 2015 247 RITL
- - - Maret 2015 - RITL

BULAN JENIS
RS. ABD. SALEH 51.854.300 25.399.570 Oktober 2014 289 RJTL
RS. ABD. SALEH 52.506.100 25.718.839 November 2014 301 RJTL
RS. ABD. SALEH 48.208.400 23.613.715 Desember 2014 285 RJTL
RS. ABD. SALEH 72.165.000 35.348.274 Januari 2015 411 RJTL
RS. ABD. SALEH 46.613.000 22.832.247 Februari 2015 270 RJTL
RS. ABD. SALEH 61.103.300 26.320.000 Maret 2015 466 RJTL

BULAN JENIS
RS. ABD. SALEH 87.272.000 42.748.071 Oktober 2014 37 RITL
RS. ABD. SALEH 81.709.700 40.023.514 November 2014 34 RITL
RS. ABD. SALEH 44.596.300 21.844.415 Desember 2014 18 RITL
RS. ABD. SALEH 96.010.200 47.028.266 Januari 2015 47 RITL
RS. ABD. SALEH 132.202.500 64.756.186 Februari 2015 65 RITL
RS. ABD. SALEH 161.616.800 88.712.350 Maret 2015 72 RITL

BULAN JENIS
RS PRASETYA HUSADA 175.634.000 149.750.924 Oktober 2014 996 RJTL
RS PRASETYA HUSADA 177.950.500 151.726.042 November 2014 993 RJTL
RS PRASETYA HUSADA 161.621.500 129.339.379 Desember 2014 1.107 RJTL
RS PRASETYA HUSADA 191.431.900 156.090.643 Januari 2015 1.115 RJTL
RS PRASETYA HUSADA 205.771.900 166.774.983 Februari 2015 1.221 RJTL
RS PRASETYA HUSADA 221.420.100 167.724.920 Maret 2015 1.426 RJTL

BULAN JENIS
RS PRASETYA HUSADA 759.433.100 647.515.903 Oktober 2014 229 RITL
RS PRASETYA HUSADA 598.709.100 510.477.702 November 2014 173 RITL
RS PRASETYA HUSADA 759.579.500 679.286.253 Desember 2014 245 RITL
RS PRASETYA HUSADA 1.067.085.500 983.621.980 Januari 2015 321 RITL
RS PRASETYA HUSADA 980.982.000 936.750.892 Februari 2015 329 RITL
RS PRASETYA HUSADA 1.173.024.800 1.016.344.467 Maret 2015 407 RITL

BULAN JENIS
RSI GONDANGLEGI 60.054.200 47.315.222 Oktober 2014 495 RJTL
RSI GONDANGLEGI 60.690.100 47.133.680 November 2014 467 RJTL
RSI GONDANGLEGI 76.482.500 68.594.000 Desember 2014 583 RJTL
RSI GONDANGLEGI 81.108.200 75.013.999 Januari 2015 630 RJTL
RSI GONDANGLEGI 86.274.400 80.103.394 Februari 2015 648 RJTL
RSI GONDANGLEGI 127.869.500 119.000.690 Maret 2015 919 RJTL

BULAN JENIS
RSI GONDANGLEGI 391.251.000 305.237.500 Oktober 2014 108 RITL
RSI GONDANGLEGI 388.955.000 352.885.500 November 2014 94 RITL
RSI GONDANGLEGI 471.022.400 404.653.000 Desember 2014 122 RITL
RSI GONDANGLEGI 476.425.100 401.280.000 Januari 2015 130 RITL
RSI GONDANGLEGI 446.421.200 447.503.000 Februari 2015 121 RITL
RSI GONDANGLEGI 489.215.600 444.613.500 Maret 2015 138 RITL

BULAN JENIS
- - - November 2014 - RJTL
- - - Desember 2014 - RJTL

RSU. UNIVERSITAS
MUHAMMADIYAH 22.711.000 22.711.000 Januari 2015 127 RJTL
RSU. UNIVERSITAS
MUHAMMADIYAH 54.383.100 44.168.838 Februari 2015 329 RJTL
RSU. UNIVERSITAS
MUHAMMADIYAH 106.717.300 94.343.085 Maret 2015 573 RJTL
BULAN JENIS
- - - November 2014 - RITL
- - - Desember 2014 - RITL

RSU. UNIVERSITAS
MUHAMMADIYAH 363.256.500 388.649.308 Januari 2015 75 RITL
RSU. UNIVERSITAS
MUHAMMADIYAH 763.667.400 866.150.594 Februari 2015 156 RITL
RSU. UNIVERSITAS
MUHAMMADIYAH 1.049.297.800 1.560.819.585 Maret 2015 228 RITL
BULAN JENIS
RSUI MADINAH
KASEMBON 143.133.200 136.527.737 Oktober 2014 863 RJTL
RSUI MADINAH
KASEMBON 163.757.000 156.199.768 November 2014 991 RJTL
RSUI MADINAH
KASEMBON 187.358.400 178.711.985 Desember 2014 1.124 RJTL
RSUI MADINAH
KASEMBON 212.698.900 202.883.045 Januari 2015 1.278 RJTL
RSUI MADINAH
KASEMBON 198.999.000 189.815.382 Februari 2015 1.219 RJTL
- - - Maret 2015 - RJTL

BULAN JENIS
RSUI MADINAH
KASEMBON 826.294.800 788.162.068 Oktober 2014 265 RITL
RSUI MADINAH
KASEMBON 725.069.500 691.608.221 November 2014 239 RITL
RSUI MADINAH
KASEMBON 854.582.400 815.144.222 Desember 2014 269 RITL
RSUI MADINAH
KASEMBON 840.845.300 802.041.076 Januari 2015 275 RITL
RSUI MADINAH
KASEMBON 745.929.000 711.505.074 Februari 2015 265 RITL
- - - Maret 2015 - RITL

BULAN JENIS

RSIA MUHAMMADIYAH
MALANG 643.400 224.329 November 2014 3 RJTL
RSIA MUHAMMADIYAH
MALANG 10.233.100 4.121.464 Desember 2014 37 RJTL
RSIA MUHAMMADIYAH
MALANG 21.183.200 8.138.078 Januari 2015 72 RJTL
RSIA MUHAMMADIYAH
MALANG 25.960.500 10.153.533 Februari 2015 89 RJTL
RSIA MUHAMMADIYAH
MALANG 36.276.400 16.985.309 Maret 2015 133 RJTL
BULAN JENIS

RSIA MUHAMMADIYAH
MALANG 11.265.200 12.666.000 November 2014 3 RITL
RSIA MUHAMMADIYAH
MALANG 99.216.200 110.057.200 Desember 2014 31 RITL
RSIA MUHAMMADIYAH
MALANG 132.730.500 164.807.500 Januari 2015 37 RITL
RSIA MUHAMMADIYAH
MALANG 124.268.300 127.112.000 Februari 2015 46 RITL
RSIA MUHAMMADIYAH
MALANG 187.702.200 185.730.900 Maret 2015 60 RITL
Perpres No. 111 Tahun 2013 Pasal 25 Permenkes No. 28 Tahun 2014
Pelayanan yang tidak dijamin JKN
Hukum yang lebih tinggi tingkatannya didahulukan

keberlakuannya daripada hukum yang lebih rendah
Ketentuan Umum Alur Rujukan dan Prosedur
Pelayanan
1. Rujukan berdasarkan indikasi medis dan di luar 155 kondisi penyakit yang bisa
tuntas di FKTP
2. Rujukan APS tidak ditanggung
3. Rujukan diberikan untuk jangka waktu 1 (satu) bulan.
4. FKTL wajib memberikan jawaban atas surat rujukan FKTP atau rujuk balik
pada kasus kronis yang stabil. Peserta yang telah dirujuk-balik pengobatan
dilanjutkan oleh FKTP minimal 3 (tiga) bulan. Peserta dapat dirujuk kembali
ke FKTL hanya atas indikasi medis.
5. Peserta dengan kasus kronis yang belum stabil harus dibuatkan Surat
Keterangan Dalam Perawatan (SKDP). SKDP berlaku untuk 1 (satu) kali
kunjungan pada bulan berikutnya. SKDP dibuat maksimal 2 (dua) kali pada
pasien dengan kasus yang sama. Selanjutnya peserta harus dirujuk-balik.
6. Apabila ditemukan kondisi lain oleh dokter spesialis di FKTL yang perlu
dikonsultasikan dengan spesialis lain maka FKTL wajib membuat surat
rujukan internal.
7. Peserta dengan rujukan internal tidak perlu memperoleh rujukan dari FKTP.
8. Surat rujukan internal dapat digunakan dalam jangka waktu 1 (satu) bulan.
9. FKTL dapat membuat rujukan antar FKTL apabila diperlukan. Peserta tidak
perlu meminta rujukan dari FKTP untuk ke FKTL kedua.
Ketentuan Umum Alur Rujukan
dan Prosedur Pelayanan
(lanjutan)
10. Kasus IGD tanpa indikasi kegawatan tidak ditanggung.
11. Rujukan peserta / pasien baru dari FKTP wajib mempertimbangkan jenis
spesialisasi di FKTL sesuai kelasnya dan diutamakan ke FKTL terdekat.
12. Pada kasus pasien kontrol atau melanjutkan terapi atau kasus tertentu (HD,
Kemoterapi, hemofilia, thalassemia) di FKTL dapat langsung dirujuk di FKTL
tersebut.
13. Pada pasien kontrol yang sebelumnya tidak menggunakan fasilitas JKN,
maka diberlakukan sebagai peserta / pasien baru (merujuk poin 11).
14. FKTL dari wilayah Malang Raya dapat merujuk pasien ke FKTL diharapkan
tidak langsung ke FKTL Kelas B / A (rujukan horizontal) kecuali atas
pertimbangan jenis spesialisasi atau fasilitas di FKTL tujuan dan kecukupan
ruang perawatan.
15. Pada pasien gagal ginjal kronis baru yang perlu penanganan HD diutamakan
dirujuk ke RS kelas C dengan fasilitas HD yaitu : RS Lavalette, RS Panti
Nirmala, dan RS Wava Husada. Namun tetap mempertimbangkan kecukupan
fasilitas.
16. Pada pasien dengan kecurigaan keganasan diutamakan dirujuk ke RS kelas
C / B yang telah memiliki spesialis konsultan onkologi / bedah onkologi, misal
: RS Lavalette, RS Panti Nirmala, RSI Aisyiyah, RS Melati Husada (onkologi
kandungan)
Ketentuan Umum Alur Rujukan
dan Prosedur Pelayanan
(lanjutan)
17. Pada kasus Rehabilitasi Medis diutamakan di RS kelas C yang telah memiliki
fasilitas Rehabilitasi Medis. Khusus wilayah Batu dapat dirujuk ke RS Baptis.
18. Kasus pemasangan stent Jantung dapat dirujuk ke RS UMM
19. Peserta yang memerlukan pemeriksaan penunjang saja dapat dilakukan
rujukan parsial ke FKTL atau Faskes lain (tanpa perlu meminta rujukan dari
FKTP) misal : pemeriksaan CT Scan, MRI, Endoskopi, Bronkoskopi, atau PA.
20. Pada kasus Jiwa dapat langsung dirujuk ke RSJ Dr. Radjiman Wediodiningrat
21. Pasien dengan kondisi gawat darurat yang memerlukan perawatan di FKTL
tidak perlu membawa surat rujukan dari FKTP.
22. Panduan obat program rujuk balik mengikuti aturan SK Binfar dan Alkes
(surat sudah disampaikan).
Alur Pasien JKN
(sesuai Kesepakatan)
Lanjutan
Dirujuk 1. Harus diisi lengkap
Peserta FKTP 2. Diagnosis
Balik
3. Terapi dan dosis obat
A
1. Harus diisi lengkap
2. Diutamakan pada kasus
kronis
Dirujuk Rujukan 3. Berlaku 1 (satu) bulan sesuai
internal tanggal dalam surat rujukan
FKTP
B 4. Surat rujukan internal dan
surat rujukan FKTP sebagai
FKTL Kelas dasar tagihan
C/D 1. Harus diisi lengkap
2. Pada kasus kronis yang
belum stabil
3. SKDP dibuat dua kali
C 4. SKDP 1 untuk kunjungan
kontrol pada bulan
SKDP berikutnya
5. SKDP 2 untuk kunjungan
pada bulan berikutnya
setelah SKDP 1
6. SKDP dan Surat rujukan FKTP
sebagai dasar tagihan
Alur Pasien JKN
(sesuai Alur Kesepakatan penggunaan SKDP)
Lanjutan
FKTL
Pasien ke
poliklinik
dengan rujukan Dibuatkan SKDP 1 pada kasus kronis non
FKTP stabil
1 2 3 4 5 6 7 8 9 10 Bulan April
Pasien ke Pasien membawa SKDP 1 dan surat rujukan awal.

poliklinik tanpa Dibuatkan SKDP 2 pada kasus kronis non stabil, apabila stabil
memperbarui
rujukan FKTP maka dirujuk balik
1 2 3 4 5 6 7 8 9 10 Bulan Mei
Pasien ke Pasien membawa SKDP 2 dan surat rujukan awal.

poliklinik tanpa
memperbarui Diharapkan pasien telah stabil sehingga dapat dirujuk balikkan.
rujukan FKTP
1 2 3 4 5 6 7 8 9 10 Bulan Juni
SK DIRJEN BINFAR DAN ALKES NOMOR : HK.02.03/III/1346/2014 TENTANG PEDOMAN
PENERAPAN FORMULARIUM NASIONAL
Panduan Obat Rujuk Balik Hal. 17 - 26

UR RS TIPE C Dan D

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UR RS TIPE C Dan D

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UTILIZATION REVIEWS

Dr. Ardi Andriatno

Best Western (OJ) Hotel

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INACBG: U-4-11-ii - INACBG: U-4-11-ii -

INACBG: O-6-13-ii -PERSALINAN INACBG: O-6-13-ii -PERSALINAN

INACBG: O-6-13-i -PERSALINAN INACBG: O-6-13-i -PERSALINAN

INACBG: O-6-10-i -OPERASI INACBG: O-6-10-i -OPERASI

INACBG: W-1-30-i -PROSEDUR INACBG: W-1-30-i -PROSEDUR

INACBG: U-4-13-ii -PERADANGAN INACBG: U-4-13-ii -PERADANGAN

Q-5-42-0 -PENYAKIT AKUT KECIL LAIN- INACBG: Q-5-42-0 -PENYAKIT

INACBG: U-4-13-ii -PERADANGAN

INACBG: Q-5-26-0 -BRONKIAL INACBG: W-1-20-ii -PROSEDUR INACBG: O-6-10-ii -OPERASI

INACBG: O-6-10-ii -OPERASI INACBG: O-6-10-ii -OPERASI

INACBG: K-1-13-ii -PROSEDUR INACBG: K-1-13-ii -PROSEDUR

Jumlah Jumlah Jumlah

RS PRASETYA HUSADA 146 427.999.900 2.931.506 72 268.045.100 3.722.849 11 63.388.100 5.762.555

RS PRIMA HUSADA 105 319.635.341 3.044.146 48 173.627.074 3.617.231 30 143.826.398 4.794.213

RSI GONDANGLEGI 48 127.419.400 2.654.571 44 172.574.400 3.922.145 15 91.257.200 6.083.813

RS Bala Keselamatan Bokor 75 187.976.300 2.506.351 19 68.796.000 3.620.842 9 32.234.100 3.581.567

BEN MARI 64 220.533.600 3.445.838 18 84.211.400 4.678.411 9 45.239.800 5.026.644

PERMATA BUNDA 61 210.771.000 3.455.262 7 30.236.400 4.319.486 0 0 0

RS. ABD. SALEH 33 75.827.700 2.297.809 4 11.444.300 2.861.075 0 0 0

RUMKITBAN 05.08.02 MALANG 21 62.448.900 2.973.757 0 0 0 0 0 0

Jumlah Jumlah Jumlah

PRIMA HUSADA (JST) 73 219.146.600 3.002.008 63 261.116.100 4.144.700 33 220.271.600 6.674.897

RS Mitra Delima 85 278.084.300 3.271.580 35 154.263.500 4.407.529 13 64.579.500 4.967.654

RSI GONDANGLEGI 39 121.326.800 3.110.944 33 129.634.900 3.928.330 22 137.993.300 6.272.423

RS Bala Keselamatan Bokor 52 139.629.500 2.685.183 24 94.268.500 3.927.854 4 17.725.300 4.431.325

BEN MARI (JST) 60 230.977.100 3.849.618 13 76.891.500 5.914.731 7 34.000.900 4.857.271

PERMATA BUNDA (JST) 56 185.976.600 3.321.011 2 6.172.800 3.086.400 0 0 0

Jumlah Jumlah Jumlah

PRIMA HUSADA (JST) 94 277.765.100 2.954.948 64 245.416.900 3.834.639 28 135.787.200 4.849.543

RS Mitra Delima 97 309.484.900 3.190.566 37 134.825.300 3.643.927 20 117.083.200 5.854.160

RS Bala Keselamatan Bokor 69 182.224.500 2.640.935 20 78.852.400 3.942.620 4 18.402.100 4.600.525

BEN MARI (JST) 48 188.055.700 3.917.827 11 49.676.500 4.516.045 2 7.896.600 3.948.300

PERMATA BUNDA (JST) 56 188.705.700 3.369.745 3 10.934.500 3.644.833 0 0 0

LAWANG MEDIKA (JST) 10 28.161.800 2.816.180 26 101.296.600 3.896.023 20 106.831.200 5.341.560

Jumlah Jumlah Jumlah

RSI GONDANGLEGI 66 187.035.200 2.833.867 36 144.409.300 4.011.369 25 144.980.600 5.799.224

RS Mitra Delima 75 234.047.900 3.120.639 33 118.679.100 3.596.336 15 64.091.500 4.272.767

RS Bala Keselamatan Bokor 87 238.001.900 2.735.654 13 53.274.800 4.098.062 9 38.678.700 4.297.633

BEN MARI (JST) 50 168.529.100 3.370.582 11 35.341.300 3.212.845 9 37.064.900 4.118.322

LAWANG MEDIKA (JST) 20 84.813.600 4.240.680 35 161.819.800 4.623.423 14 122.479.000 8.748.500

RS. ABD. SALEH 44 88.688.800 2.015.655 3 7.321.400 2.440.467 0 0 0

RUMKITBAN 05.08.02 MALANG 11 34.654.200 3.150.382 0 0 0 0 0 0

RS PANTI NIRMALA 38 120.790.100 3.178.687 52 322.954.500 6.210.663 17 147.834.800 8.696.165

ISLAM UNISMA (JST) 122 418.332.700 3.428.957 59 315.291.100 5.343.917 24 253.220.50010.550.854

PERMATA BUNDA (JST) 55 173.870.800 3.161.287 3 13.947.300 4.649.100 1 3.532.900 3.532.900

RS PANTI NIRMALA 77 278.474.800 3.616.556 86 525.024.400 6.104.935 50 494.406.500 9.888.130

Jumlah Jumlah Jumlah

RS Mitra Delima 108 318.131.900 2.945.666 29 98.189.400 3.385.841 15 53.790.400 3.586.027

RS Bala Keselamatan Bokor 84 217.308.700 2.587.008 26 94.413.700 3.631.296 19 80.506.900 4.237.205

RSI GONDANGLEGI 55 160.670.400 2.921.280 38 145.580.100 3.831.055 30 182.965.100 6.098.837

PERMATA BUNDA (JST) 87 288.588.700 3.317.111 9 31.346.700 3.482.967 2 7.847.600 3.923.800

BEN MARI (JST) 62 236.352.000 3.812.129 12 59.303.100 4.941.925 8 51.232.800 6.404.100