PENGENALAN KODIFIKASI &

MODIFIKASI PROCEDURE
MELALUI ICD -9 CM
 Overview of
The International Classification
of Diseases, 9th Revision, Clinical
Modification (ICD 9-CM):

Procedure Classification
ICD 9 CM

 INTERNATIONAL CLASSIFICATION OF
DISEASES REVISI 9 – CLINICAL
MODIFICATION
ICD 9 CM

 International Classification of Diseases adalah

sistem klasifikasi untuk medical diagnosis dan
prosedur
 ICD 9 CM diadopsi dari ICD 9 (WHO Geneva)
 Di USA 1978 – (NCHS) menggunakan ICD 9 CM
 Updated ICD 9 CM ( CMS)
 ICD 9 CM – 1985 dikoord. Olhh NCHS dan CMS
 SEJARAH ICD 9-CM

• ICD 9 (1975)
Volume 1 – Tabular List
E’ Code – supplementary classification of
external causes of Injury and Poisoning
‘V’ Code – supplementary classification of
Factors Influencing Health Status and Contact
with Health Services
Volume 2 Alfabetic Index
 SEJARAH ICD 9-CM
 ICPM (9 chapters)
 I. Procedures for medical diagnosis
II. Laboratory procedures
III. Radiology and certain other applications of physics in medicine
IV. Preventive procedures
V. Surgical operations
VI &VII. Drugs, medicaments and biological agents
VIII. Other therapeutic procedures
IX. Ancillary procedures

Volume 1 : chapters I, II, IV, VIII and IX

Volume 2 : chapters III, VI and VII
 SEJARAH ICD 9-CM
 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
Tujuan digunakan ICD 9 CM
 Informasi Klasifikasi morbiditas dan Mortalitas untuk statistik
 Indeks penyakit dan operasi
 Laporan diagnosis oleh dokter
 Penyimpanan dan pengambilan data
 Laporan nasional morbiditas dan mortalitas
 Untuk pengelompok penyakit (DRG)
 Membantu kompilasi dan pelaporan data sebagai evaluasi
pelayanan
 Pola pelayanan kesehatan

Langkah-langkah pengkodeaan:
1. Identifikasi prosedur diagnostik yang akan di
kode
2. Putuskan apakah ada “ lead term “
3. Lihat lead term pada buku indeks alphabet
4. Lihat pada beberapa lokasi “modifiers ”
5. Koreksi kode yang didapat pada buku “Tabular
list”
6. Lihat/koreksi juga pada “Inclusion and
Exclusion terms”
7. Tetapkan Kode
 ISI BUKU ICD – 9CM

Bagian I : (Tabular List)

Daftar Classification of Procedures
 Halaman 1 - 52
Bagian II : Index to Procedures
 Alfabet A - Y
 Halaman 52 - 149
 ICD 9-CM Procedure Classification:

1. Surgical procedures termasuk pada grup 01-86

2. Non-surgical procedures terdapat pada 87-99
3. Srtuktur klasifikasi adalah dasar dalam anatomi
“surgical specialty”
4. Kode angka
5. Angka utama 2 digit dengan 2 digit desimal yang
diperlukan
(ekspansi dari ICD 9 3 digit, ICD 9-CM 4 digit)
Pengertian penggunaan

 Operative procedure

 Non-Operative procedure
 OPERATIVE PROCEDURES
 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 PROCEDURES
 Investigasi lain dan diagnostik
prosedur yang tidak dilakukan
sebagai tindakan operasi seperti
pemeriksaan radiologi, usg,
laboratorium, dan lain-lain
procedure.
PEMBAGIAN ICD 9CM BERDASARKAN BLOCK

No Classification of procedures Block Halaman

1 Operation on the nervous system 01 1-3
2 Operation on the endocrine system 06-07 3-4
3 Operation of the Eye 08-16 4-7
4 Operation on the Ear 18-20 7-8
5 Operation on the Nose, Mouth and Pharynx 21-29 8 - 11
6 Operation on the Respiratory system 30-34 11 - 13
7 Operation on the Cardiovascular system 35-39 13 - 19
PEMBAGIAN ICD 9CM BERDASARKAN BLOCK

No Classification of procedures Block Halaman

8 Operation on the Hemicand Lymphatic system 40-41 19 - 20
9 Operation on the Digestive system 42-54 20 - 28
10 Operation on the Urinary system 55-59 28 - 31
11 Operation on the Male Genital Organs 60-64 31 - 32
12 Operation on the Female Genital Organs 65-71 32 - 35
13 Obstetricals procedures 72-75 35 - 36
14 Operation on the Musculosceletal system 76-84 36 - 41
15 Operation on the integumentary system 85-86 41 - 43
16 Misceleneous Diagnostic and therapeutic 87-99 43 - 52
Procedures
16. Miscelleneous Diagnostic and
Therapeutic Procedures
(87-99)
 87 – Diagnostic Radiology
 88 – other D/ radiology and related technique
 89 – Interview, consultation and evaluation
 90 – 91 : Microscopic examination
 92 – nuclear Medicine
 93 – Physical therapy, respiratory therapy,
rehabilitation & related procedure
 94 – Psychologic evaluation and testing
Miscelleneous Diagnostic and Therapeutic
Procedures, cont’d

 94 - Ophtalmologic & Otologic diagnosis and

treatment
 95 – Non operative procedure related to hearing
 96 – Non operative intubation and Irrigation
 97 – Replacement and removal of therapeutic
appliances
 98 – Non operative removal of foreign body or
calculus
 99 – Other non operative procedure
ISTILAH TINDAKAN YG SERING
DIGUNAKAN
 Extirpasi • Restructur
 Excision • Revision
 Ectomy • Repacking
 Incision • Replacement
 Ion
• Rrhapy
 Plasty
• Scopy
 pexy
 Repair
• Stomy
 Removal • tomy
 Remodel • Graphy
 Relaxasion
 Resuture • Gram
 Relocation
• Metry
Conventions in Procedure Coding:

Omit Code – Operative approach

Laparotomy – Splenectomy or Liver repair
Craniotomy – Evacuation of clots
Pengkodeaan ICD – 9 CM

SEMUA PROSEDUR YANG SIGNIFIKAN :.

 Termasuk terapi dan diagnostiknya
 Signifikan kebutuhan non-surgical or non-operative
procedures misalnya CT Scan, MRI

PROSEDUR YANG DIKODE :

 Semua prosedur yang dilakukan di OK
 Semua prosedur yang dikerjakan diluar OK tetapi yang
menggunakan tenaga ahli dan instrumen yang mahal
Contoh bahasa atau istilah2 yg
sering digunakan oleh dokter
 Long line
 Perlengketan
 Sentral line
 hemokonsentrasi
 Bouginasi
 Cetak gigi
 Extirpasi condyloma
 Pematangan paru
Contoh :
 Angkat IUD 97.71
 Pasang IUD 69.7
 Angkat Spalk 97.88
 Pasang Spalk 93.53
 Pasang kateter 57.94
 Ganti Verban 93.37
 Pasang Tampon (vagina) 96.14
 Pasang Gigi palsu 97.22
 Longline 96.35
 Central line 38.93
788025
M.Hirschsprung
Q43.1
pasca kolostomi
Obstruksi ec perlengketan p.ileum terminal K56.5

Pullthrough recto recta 48.65

Appendectomy 47.09
Laparotomy Exp 54.11
Longline 96.35
Transfusi PRC 99.04
Bebaskan perlengketan 54.59
792881
Appendicitis perforasi K35.0
Perlengketan usus K 66.0
Septicaemia A 41.9
Obstruksi usus ec Adhesi + pocket
abses K 56.5

 Laparotomy Explorasi 54.11

 Appedectomy 47.09
 Perlengketan – 54.59
 Evakualsi Pocket – 54.19
 ( abses dan drainage)
Daftar Pustaka

 International Classification of Diseases

Rev 9 – Clinical Modification, WHO, 1999
 ICD 9 CM ( Classification of Procedures),
Hospital University Kebangsaan Malaysia,
2005
 Laporan Pelaksanaan Case-mix di
beberapa RS di Indonesia, Dep.Kes RI,
2009