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1 ICD-10 CHAPTER XV BAB O Kehamilan, Persalinan & Masa Nifas.

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Presentasi berjudul: "1 ICD-10 CHAPTER XV BAB O Kehamilan, Persalinan & Masa Nifas."— Transcript presentasi:

1 1 ICD-10 CHAPTER XV BAB O Kehamilan, Persalinan & Masa Nifas

2 2 BAB XV (O00-O99) KEHAMILAN, KELAHIRAN & MASA NIFAS [641 – 678] The codes included in this chapter are to be... Excl.: Certain d. or injuries compl. preg., childb. and puerp. cl. elsew.: external causes (for mortality) (V, W, X, Y) Cedera, keracunan & konsekuensi lain akibat sebab luar (S00-T88.1, T88.6-T98)

3 (Lanjutan) Gangguan mental & prilaku yang terkait masa nifas (F53.-) Tetanus obstetrik (A34) Nekrosis postpartum kelenjar pituitari (E23.0) Osteomalacia postpartum (M83.0) Supervisi dari: Kehamilan berisiko tinggi (Z35-) Kehamilan normal (Z34.-) 3

4 4 Bab ini meliput 8 blok sebagai berikut: O00-O08Kehamilan dengan abortus O10-O16Edema, proteinuira & gangguan hipertensi pada kehamilan, kelahiran & nifas O20-O29Gangguan-gangguan maternal lain yang utamanya terkait kehamilan. O30-O48Asuhan maternal terkait janin, kantung ketuban yang kemungkinan menimbulkan masalah persalinan/kelahiran O60-O75Komplikasi persalinan dan kelahiran O80-O84Kelahiran/Metode persalinan O85-O92Komplikasi yang utamanya berkaitan dengan masa nifas O95-O99Kondisi-2 lain obstetrik, NEC

5 5 Kehamilan dengan hasil Abortus (O00-O08) [642 – 647] EXCL.: kehamilan berlanjut setelah satu atau lebih dari satu janin gugur pada suatu kehamilan multipel. Tersedia karakter ke-4 sebagai subdivisi untuk dimanfaatkan melengkapi O03 – O06. Note: incomplete abortion includes retained products of conception following abortion. [642] dan.8.9

6 (Lanjutan) Perhatikan: O00Kehamilan di luar kandungan Incl.: … Use additional code dari …O08.- O00.0 ada Excl.:... O00.1; O00.2 dan O00.8; O00.9. O01 Mola hidatidiform Use additional code dari … O08.- Excl.:... O01.0; O01.1 dan O01.9 O02Other abnormal products of conception Use additional code dari … O08.- Excl.:... O02.0 dan O02.9. Pada O02.1, O02.8 ada Excl.:.. 6

7 (Lanjutan) O03Spontaneous abortion [See before O03 for subdivisions] Incl.:... O04Medical abortion [See before O03 for subdivisions] Incl.: termination of pregnancy: legal, therap. therapuetic abortion O05Other abortion [See before O03 for subdivisions] O06Unspecified abortion [See before O03 for subdivisions] Incl.: induced abortion NOS 7

8 8 (Lanjutan) O07Failed attempted abortion Incl.:...Excl.:... O07.0, O07.1, O07.2, O07.3, O07.5, O07.6, O07.7 dan O07.8 semua disertai: with cond. in O08.- Pada O07.4, O07.9 ada Failed attemp abortion. O08Complicating following abortion & ectopic & molar pregnancy Note: This code is provided primary for morbidity coding. For use of this category reference should be made to the morbidity coding rules & quidelines in Volume 2.

9 (Lanjutan) O08.0 Genital tract and pelvic infect. follow. abort. and ectopic and molar preg. Ada tambah: septicaemia di bawah sepsis. Use add. Code (R57.2),... Excl.:... O08.1; O08.2; O08.4; O08.5; O08.6; O08.7 dan O08.8; O08.9 Pada O08.3 ada Excl.: septic shock (R57.2) 9

10 Oedema, proteinuria & hypertensive complicating disor. in preg., childb. & the puer. (O10 – O16) [647 – 648] O10Pre-existing hypertension... Incl.: the listed cond. with preexisting proteinuria Excl.: that with superimposed preexclampsia (O11) O10.0; O10.1; O10.2; O10.3; O10.4 dan O10.9. O11.XEclampsia superimposed on chronic hypertension Incl.:... 10

11 (Lanjutan) O12Gestational [pregancy-induced] oedema and proteinuria without hypertention O12.0; O12.1 dan O12.2 O13.XGestational [pregancy-induced] hyper- tention without signif. Proteinuria Incl.: gestational hypertension NOS pregnancy induced hypertension O14Gestational [pregancy-induced] hyper- tention with signif. Proteinuria Excl.:... O14.0 Mild to moderate pre-eclampsia O14.1 Severe pre-eclamp. O14.2 dqn O

12 (Lanjutan) O15Eclampsia Incl.: convulsions following conditions in O10 – O14 and O16 exclampsia with pregnancy-induced or pre-existing hypertension O15.0; O15.1; O15.2 dan O15.9. O16.XUnspecified maternal hypertension. 12

13 13 Other maternal disorders predominantly related to pregnancy (O20-O29) [ ] Note: Categories O24.- and O25 include the listed conditions even if they occur during childbirth or the puerperium. Exclu.: maternal: -care related to the fetus and amniotic cavity & possible deli- very problems (O30-O48) -Disease classifiable elsewhere but complicating pregnancy, labour (labor) and delivery, and the puerperium.

14 14 (Lanjutan) Perhatikan definisi untuk: O20 Haemorrhage in early pregnancy Excl.: … O20.0 dan O20.8; (O20.9 O21 Excessive vomiting in pregnancy O21.0; O21.1 dan O21.9 Pada O21.2 ada Excl.:... Pada O21.8 ada Use additional code, if... O22 Venous complications in pregnancy Excl.: … O22.0; O22.1; O22.2; O22.3; O22.4; O22.5 dan O22.8; O22.9

15 (Lanjutan) O24Diabetes mellitus in pregnancy Incl.: in childbirth and the puerperium O24.0, O24.1, O24.2, O24.3 (pre-existing DM...) O24.4 Gestational DM NOS O24.9 DM in preg. unspecified. O25.XMalnutrition in pregnancy Incl.: malnutrition in child. and the puerp. O26Maternal care for other condi. predom. Related to pregnancy O26.0, O26.2, O26.6 dan O26.7 ada Excl.:... O26.1; O26.3, O26.4, O24.5 dan O26.8; O

16 (Lanjutan) O28Abnormal find. on antenat. screening of m Excl.: diagnostic findings class. elsew. – see Alphab. Index maternal care related to the fetus and amniotic cavity and possible delivery problems (O30-O48) O28.0; O28.1; O28.2; O28.3; O28.4; O28.5 dan O28.8; O28.9. O29 Complication of anaesthesia during preg. Incl.: … Excl.:... O29.0; O29.1; O29.2; O29.3; O29.4; O29.5; O29.6 dan O29.8; O

17 17 Maternal care related to the fetus & amniotic cavity & possible delivery problems (O30-O48) [ ] O30Multiple gestation Excl.:... O30.0; O30.1; O30.2 dan O30.8; O30.9 O31Complications specific to mutiple gest. Excl.: conjoined twins causing... delayed delivery of 2nd twin... malpresenttaion of one fetus or... with obstructed labour... O31.0; O31.1; O31.2 dan O31.8

18 (Lanjutan) O32 Maternal car for known or suspected malpres. Of fetus Incl.:...Excl.:... O32.0; O32.1; O32.2; O32.3; O32.4; O32.5 O32.6 dan O32.8; O32.9 O33Maternal care for known or susp. disprop. Incl.: the listed conditions as a reason for observation, hospitalization or other obstet. care of the mother, or for C-S before onset of labour Excl.:... O33.0; O33.1 s/d O33.8; O

19 (Lanjutan) O34Maternal care for known or suspected abnormal. of pelv. Organs Incl.:...Excl.:... O34.0; O34.3; O34.4; O34.5; dan O34.8; O34.9. Pada O34.1, O34.2, O34.6, O34.7 ada Excl.:... O35Maternal care for known or suspected fetal abnorm. and damage Incl.:...Excl.:... O35.0, O35.2 dan O35.5 ada Excl.:... O35.1; O35.3; O35.4; O35.6; O35.7 dan O35.8; O

20 (Lanjutan) O36Maternal care for other known or suspect. fetal problems Incl.:...Excl.:... O36.0; O36.1; O36.2; O36.3; O36.5; O36.6; O36.7 dan O36.8; O36.9. Pada O36.4 ada Excl.:... O40.XPolyhydramios Incl.:... O41Other disord. Of amn. fluid & membranes Excl.:... O41.0; O41.1 dan O41.8; O

21 (Lanjutan) O42Premature rupture of membranee (KPD = ketuban pecah dini) K42.0; K42.2 dan K42.9 Pada K42.1 ada Excl.: with labour delayed by... O43Placenta disorders Excl.:... K43.0; K43.1 dan K43.8; K43.9. Pada K43.2 Morbidity adherent placenta Use additional.... O44Placenta praevia O44.0 (without haemorhage) Pada O44.1 ada Excl.:... 21

22 (Lanjutan) O45Premature separation of placenta [abruptio placentae] O45.0; O45.8 dan O45.9 O46Antepartum haemorrhage, NEC Excl.:... O46.0; O46.8 dan O46.9 O47False labour O47.0 ( 37 weeks) O47.9 (unspecified) O48.XProlonged pregnancy Incl.: post-dates; post-term 22

23 23 Complications of Labour & Delivery (O60-O75) [ ] O60Preterm labour and delivery Incl.: onset (spontaneous) of labour before 37 completed weeks of gestation Perhatikan definisi pada masing nomor kode. O60.0; O60.1; O60.2 dan O60.3 O61Failed inductiion of labour O61.0; O61.1 dan O61.8; O61.9 O62Abnormalities of forces of labour O62.0; O62.1; O62.2; O62.3 dan O62.8; O62.9. Pada O62.4 ada Excl.:...

24 (Lanjutan) O63 Long labour Perhatikan hubungan long labour dengan kala persalinan. O63.0; O63.1; O63.2 dan O63.9 O64 Obstructed labour due to malposition & malpresentation of fetus (sebab adalah letak/presentasi janin) O64.0; O64.1; O64.2 ; O64.3; O64.5 dan O64.8; O64.9. Pada O64.4 ada Excl.: impected shoulders (O66.0) shoulder dystocia (O66.0) 24

25 (Lanjutan) O65 Obstructed...(sebab adalah pinggul bumil) O65.0; O65.1; O65.2 ; O65.3; O65.5; O65.8; O65.9 Pada O65.4 ada Excl.:.... O66 Other obstructed … O66.0; O66.1; O66.2 ; O66.3; O66.4; O66.5 dan O66.8; O66.9 O67 Persalinan & kelahiran terkomplikasi perdarahan intrapartum, yang NEC. O67.0 dan O67.8; O

26 26 (Lanjutan) O68L & D complic. by fetal stress [distress] Incl.:... O68.0 dan O68.1 ada Excl.:... O68.2; O68.3 dan O68.8; O68.9 O69L&D complic. by umb. cord complicat. O69.0; O69.1; O69.2; O69.3; O69.4; O69.5 dan O69.8; O69.9 O70Perineal laceration during delivery Incl.:... Excl.: Tambahan pada ICD-10 ed. Baru Vaginal sulcus laceration (O71.4)

27 (Lanjutan) O70.0 First degree perineal laceration during deliv. Ada tambahan di bawah:. Labia perisurethral tissue. Vagina low Ada tambahan Excl.:... periurethral lac. Involving urethra (O71.5) that with laceration - high vaginal wall (middle)(upperthird of vag. wall) (O71.4) - vaginal sulcus (O71.4) 27

28 (Lanjutan) O71.4 Obstetric high vaginal... Excl.: that of the lower vagina (O70.-) O71.5 Other obstet. Injury to pelvic joints & lig. Ada tambahan Excl.: minor laceration involving peri-urethral tissue only (O70.0) O71.6; O71.7 dan O71.8; O71.9 O72Postpartum haemorrhage Incl.:... Pada O72.0 ada Use additionalo code, if... O72.1; O72.2 dan O

29 29 (Lanjutan) O73Retained placenta & membranes, without haemorrhage. O73.0 ada Use additional code, if... O37.1 O74Complications of anaesthesia during labour & delivery Incl.: … O74.0; O74.1 s/d O74.8; O78.9. O75Other compl. of labour & deliv., NEC. Excl.: puerp.:infection(O86);sepsis (O85) O75.0; O75.1; O75.2; O75.3; O75.5; O75.8; O75.9 Pada O75.4 dan O75.6 ada Excl.:...

30 30 Delivery (PERSALINAN) (O80-O84) [ ] Note: Kode O80-O84 tersedia untuk kepentingan code morbiditas. Kode-kode di blok ini hendaknya digunakan untuk kode primer morbiditas hanya apabila tidak ada kondisi lain yang terklasifikasi di bab XV ter-rekam. Bila kategori-kategori ini akan digunakan, rujuklah ke peraturan Morbidity Coding Rules di Volume 2.

31 (Lanjutan) O80Single spontaneous delivery Incl.: cases with minimal or no assistance, with or without episiotomy delivery in a completely normal case. O80.0; O80.1 dan O80.8; O80.9. O81Single delivery by forc. & vacuum extr. Excl.:... O81.0; O81.1; O81.2; O81.3; O81.4 dan O81.5. O82Single delivery by caesarean section O82.0; O82.1; O82.2 dan O82.8; O

32 (Lanjutan) O83Other assisted single delivery O83.0; O83.1; O83.2 ; O83.3; O83.4 dan O83.8; O83.9. O84Multiple delivery Use additional code (O80-O83), if disired, to indicate the method of delivery of each fetus (janin) or infant (bayi) O84.0 Mult. deliv. all spontan. O84.1 Mult. deliv. all by forceps and vaccum extr. O84.2 Mult. deliv. all by caesarean section O84.8 Other mult. deliv. O84.9 Mult. Deliv., unspecified. 32

33 33 Complications predominantly related to the puerperium (O85-O92) [671 – 674] Komplikasi yang utamanya terkait masa nifas: Note: Categories O88.-, O91.-,O92.- include the listed conditions even if they occur during pregnancy and childbirth. Excl.: mental & behavioural disorders associated with the puerperium (F53.-) ostetrical tetanus (A34) puerperal osteomalacia (M83.0)

34 (Lanjutan) O85.XPuerperal sepsis Incl.: puerperal: - endometritis, - fever, - peritonitis dan sepsis Use additional code (B95-B97), if desired, to identify infection agent. Excl.: … O86Other puerperal infection Use additional code (B95-B98), if.... Excl.: infection during labour (O75.3) O86.0; O86.1; O86.2; O86.3 dan O86.8. Pada O86.4 ada Excl.:... 34

35 35 (Lanjutan) O87Venous complic. in the puerperium Incl.: in labour, delivery, and the puerperium. Excl.: obstetric embolism (O88.-) venous compl.in preg. (O22.-) O87.0; O87.1; O87.2; O87.3; O87.8; O87.9. O88Obstetric embolism Incl.: pulmonary emboli in pregnancy, childbirth or the puerperium Excl.: embolism complicating abortion or ectop.or molar pregnancy (O00-O07. O08.2) O88.0; O88.1; O88.2; O88.3 dan O88.8.

36 (Lanjutan) O89Complication of anesthesia during the puerperium Incl.: maternal complications arising from the administration of general or local anaesthetic, analgesic or other sedation during the puerperium. O89.0; O89.1; O89.2; O89.3; O89.4; O89.5; O89.6 dan O89.8; O89.9 O90Complications of the puerperium, NEC O90.0; O90.1; O90.2; O90.3; O90.4; O90.5 dan O90.8; O

37 (Lanjutan) O91Infections of breast associated with childbirth Incl.: the listed conditions during pregnancy, the puerperium or lactation. O91.0 (infection nipple... ) O91.1 (Abscess of breast... ) O91.2 (Non-purulent mastitis...) O92Other disorders of breast and lactation associated with childbirth. Incl.: the listed conditions during preg.... O92.0; O92.1; O92.2; O92.3; O92.4; O92.5; O92.7. Pada O92.6 ada Excl.:... 37

38 38 Other obstetric conditions, NEC (O94-O99) [675 – 678] Note:For use of categories O95-O97 reference should be made to the mortality coding rules and guidelines in Volume 2 O94Sequelae of compl. of preg. Childb. and puerperium Note:...  for morbiditas coding only to indicate...  as the cause of sequelae... Not to be used for chronic.... Excl.:...

39 (Lanjutan) O95.XObstetric death of unspecified cause Incl.: Maternal death from unspecified cause occurring during pregnancy, labour & delivery, or the puerp. O96Death from any obstetric cause occurring > than 42 days but < than one year after delivery. Use additional code, if desired, to identify obstetric cause (direct or indirect) of death. O96.0 Death f. direct obstet. cause O96.1 Death f. indirect obstet. cause O96.9 Death f. Unspecified obstet. cause 39

40 (Lanjutan) O97Death from sequelae of direct obstetric causes. Incl.: Death from any direct obstetric cause occurring one year or more after delivery. Use additional code, if disired, to identify.... O97.0; O97.1 dan O97.9 O98Maternal Infectious & parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium Incl.: … Use additional code (Chapter I) if desired, to identify specific condition. Excl.: … 40

41 (Lanjutan) O98.0 (Conditions in A15 – A19) O98.1 (Conditions in A50 – A53) O98.2 (Conditions in A54) O98.3 (Conditions in A55 – A64) O98.4 (Conditions in B15 – B19) O98.5 (Conditions in A80 –B09; B25 – B34) O98.6 (Conditions in B50 – B64) O98.7 (Conditions in B20 – B24) O98.8 Other maternal infectious.... O98.9 Unspecified

42 42 (Lanjutan) O99Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium. Note: This categories includes conditions which complicate the pregnancy state, are aggravated by pregnancy or are a main reason for obstetric care and for which the Alphabetical Index does not indicate a specific rubric in Chapter XV. Use additional code, if desired, to identify specific condition.

43 (Lanjutan) Excl: infectious and parasitic diseases (O98.-) injury, poisoning and certain other conseq. of external causes (S00-T98) when the reason for maternal care is that the condition is known or suspected to have affected the fetus (O35-O36) O99.0 (condition in D50 – D64) O99.1 (condition in D65 – D89) ada Excl.:... O99.2 (condition in E00 – E90) ada Excl.:... O99.3 (condition in F00 – F99 and G00 – G99) ada Excl.:... 43

44 (Lanjutan) O99.4(condition in I00 – I99) Excl.:... O99.5(condition in J00 – J99) O99.6(condition in K00 – K93) Excl:... O99.7(condition in L00 – L99) Excl.:... O99.8(condition in C00 – D48, H00 – H95, M00 – M99, N00 – N99, Q00 – Q99) Excl.:... 44

45 45 LATIHAN PENYELESAIAN SOAL-SOAL 1.Hamil dengan plasenta previa totalis dan perdarahan No: Seksio kaiser emergensi, No: Bayi tunggal hidup, cyanosis No: 2.Partus normal spontan, letsu No: Bayi tunggal hidup No: Bayi cenggeng, kurang ASI No: 3.Abortus spontan inkomplit, No: Infeksi post kuret No: 4. Partus kembar 2, spontan. Iletkep, dan II letsu No: bayi prematur (BB < 1.750) No:

46 (Lanjutan) 5. Hamil 71/2 bulan sakit febris typhoidea No: Partus spontan, No: Bayi prematur No: Ikterus fisiologis No: 6.Bumil 6 bulan, HIV positif No: 7. Postpartum thyroiditisNo: 8. Partus lama, uterin fibroidNo: 9. Partus macet karena bayi letak mukaNo: 10. Post partum haemorrhage akibat atoni uteri No: 46

47 47 SOAL LATIHAN MANDIRI 1.Partus seksio No: Kembar dempet terhubung di abdomen No: Berat badan kedua bayi di atas kg. No: Cengeng sulit menete ASI No: 2.Persalinan macet No: Myoma uteri No: Lahir Vakum No: Bayi cephalohematom No: 3.Partus spontan, cukup bulan, bayi sehat No: No:

48 (Lanjutan) 4.Persalinan induksi gagal dengan suntikan oxytocin No: Uterin inertia, akhirnya diseksio dengan hysterectomy No: Bayi Hydrosefalus toksoplasmosis No: 5.Solutio placentae, Seksio, bayi premature BB 490g No: No: 48


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