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(5) latihan koding (1)

Pengenalan Kaidah Koding INA CBG & Teknis Audit Klaim @ Bintan Lagoon Resort, Lagoi, 4-6 Nov 2015

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(5) latihan koding (1)

  1. 1. LATIHAN KODING (1)
  2. 2. Perhatikan penulisan diagnosis, utk penentuan lead term Dlm Bhs Indonesia/Latin  di depan Dlm Bhs Inggris  di tengah / di belakang Termasuk apa ? Nature of condition/disease  Section 1 External causes  Section 2 Poisoning (intoxication)  Section 3 TIPs N TRICKs
  3. 3. 1. Hernia scrotal incarcerated, bilateral Indeks Alfabetik Section 1  Hernia Hernia, hernial (acquired) (recurrent) K46.9 - with - - gangrene (see also Hernia, by site, with, gangrene) K46.1 - - obstruction (see also Hernia, by site, with, obstruction) K46.0 - abdomen, abdominal K46.9 - - specified site NEC K45.8 Selanjutnya telusuri utk menemukan modifier2 lain  scrotal, incarcerated, bilateral Extracted from ICD-10 Second Edition, 2005, H.
  4. 4. 1. Hernia scrotal incarcerated, bilateral Indeks Alfabetik Section 1  Hernia Selanjutnya telusuri utk menemukan modifier2 lain  scrotal, incarcerated, bilateral
  5. 5. Extracted from ICD-10 Second Edition, 2005, H.
  6. 6. Hernia, hernial (acquired) (recurrent) K46.9 - with - - gangrene (see also Hernia, by site, with, gangrene) K46.1 - - obstruction (see also Hernia, by site, with, obstruction) K46.0 - double (inguinal) — see Hernia, inguinal, bilateral - incarcerated — see also Hernia, by site, with obstruction - - with gangrene — see Hernia, by site, with gangrene - incisional — see Hernia, ventral - indirect (inguinal) — see Hernia, inguinal - inguinal (direct) (external) (funicular) (indirect) (internal) (oblique) (scrotal) (sliding) K40.9 - - with - - - gangrene (and obstruction) K40.4 - - - obstruction K40.3 - - bilateral K40.2 - - - with - - - - gangrene (and obstruction) K40.1 - - - - obstruction K40.0 - scrotum, scrotal — see Hernia, inguinal - sliding (inguinal) — see also Hernia, inguinal - - hiatus — see Hernia, hiatal Extracted from ICD-10 Second Edition, 2005, H.
  7. 7. Setelah itu di- cross check ke Volume 1 Extracted from ICD-10 Second Edition, 2005, Diseases of the digestive system
  8. 8. 2. Type II diabetes mellitus with (related) peripheral angiopathy, left foot Dlm bhs Inggris Lead term ?? Type II diabetes mellitus with (related) peripheral angiopathy, left foot Coba cek ke Indeks Alfabetik
  9. 9. Diabetes, diabetic (mellitus) (controlled) (familial) (severe) E14.- - type I E10.- - type II (nonobese) (obese) E11.- Extracted from ICD-10 Second Edition, 2005, D. Tetapi modifier lain tidak ditemukan dalam indeks Note : tidak semua modifier muncul dlm indeks. Terkadang baru terlihat dalam daftar tabulasi (vol 1)
  10. 10. Coba cek Vol 1 E11 Non-insulin-dependent diabetes mellitus See before E10 for subdivisions Includes: diabetes (mellitus) (nonobese) (obese): -adult-onset -maturity-onset -nonketotic -stable -type II non-insulin-dependent diabetes of the young Excludes: diabetes mellitus (in): -malnutrition-related (E12.-) -neonatal (P70.2) -pregnancy, childbirth and the puerperium (O24.-) -glycosuria: -NOS (R81) -renal (E74.8) impaired glucose tolerance (R73.0) postsurgical hypoinsulinaemia (E89.1) Extracted from ICD-10 Second Edition, 2005, Endocrine, nutritional and metabolic diseases.
  11. 11. Diabetes mellitus (E10–E14) The following fourth-character subdivisions are for use with categories E10-E14: .4† With neurological complications Diabetic: • amyotrophy (G73.0*) • autonomic neuropathy (G99.0*) • mononeuropathy (G59.0*) • polyneuropathy (G63.2*) • autonomic (G99.0*) .5 With peripheral circulatory complications Diabetic: • gangrene • peripheral angiopathy† (I79.2*) • ulcer
  12. 12. CATATAN KHUSUS • Dalam koding .. adanya tambahan keterangan tentang karakteristik pasien, misalnya umur, dapat menjadi modifier pemilihan kode, meskipun tidak selalu demikian
  13. 13. Urethritis gonorrhoea, wanita usia 30 th
  14. 14. Sifilis congenital pada anak berumur 18 bulan
  15. 15. Bronchitis, NOS

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