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

1. LATIHAN KODING (1)

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. 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. 1. Hernia scrotal incarcerated, bilateral
Indeks Alfabetik Section 1  Hernia
Selanjutnya telusuri utk menemukan
modifier2 lain  scrotal, incarcerated,
bilateral

5. Extracted from ICD-10 Second Edition, 2005, H.

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. Setelah itu di- cross check ke Volume 1
Extracted from ICD-10 Second Edition, 2005, Diseases of the digestive system

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

10. 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)

11. 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.

12. 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

13. CATATAN KHUSUS
• Dalam koding .. adanya tambahan keterangan
tentang karakteristik pasien, misalnya umur,
dapat menjadi modifier pemilihan kode,
meskipun tidak selalu demikian

14. Urethritis gonorrhoea, wanita usia 30 th

15. Sifilis
congenital
pada anak
berumur 18
bulan

16. Bronchitis,
NOS