ICD 10, CHAPTER XV (PERSALINAN DAN MASA NIFAS ) PERTEMUAN 10 TIM KKPMT IV PRODI RMIK DAN MIK, FAKULTAS ILMU-ILMU KESEHATAN

KEMAMPUAN AKHIR YANG DIHARAPKAN Mahasiswa mampu menentukan Kode ICD-10 tentang kondisi terkait persalinan dan masa nifas

BAB XV (O60-O99) 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)

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.-)

Bab ini meliput 8 blok sebagai berikut: .... O60-O75 Komplikasi persalinan dan kelahiran O80-O84 Kelahiran/Metode persalinan O85-O92 Komplikasi yang utamanya berkaitan dengan masa nifas O95-O99 Kondisi-2 lain obstetrik, NEC

Complications of Labour & Delivery (O60-O75) [661 - 669] O60 Preterm 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 O61 Failed inductiion of labour O61.0; O61.1 dan O61.8; O61.9 O62 Abnormalities of forces of labour O62.0; O62.1; O62.2; O62.3 dan O62.8; O62.9. Pada O62.4 ada Excl.: ...

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)

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; O67.9

O68 L & D complic. by fetal stress [distress] Incl.: ... O68.0 dan O68.1 ada Excl.: ... O68.2; O68.3 dan O68.8; O68.9 O69 L&D complic. by umb. cord complicat. O69.0; O69.1; O69.2; O69.3; O69.4; O69.5 dan O69.8; O69.9 O70 Perineal laceration during delivery Excl.: Tambahan pada ICD-10 ed. Baru Vaginal sulcus laceration (O71.4)

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)

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 O72 Postpartum haemorrhage Incl.: ... Pada O72.0 ada Use additionalo code, if ... O72.1; O72.2 dan O72.3

Delivery (PERSALINAN) (O80-O84) [669 -670] 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.

O73 Retained placenta & membranes, without haemorrhage. O73.0 ada Use additional code, if ... O37.1 O74 Complications of anaesthesia during labour & delivery Incl.: … O74.0; O74.1 s/d O74.8; O78.9. O75 Other 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.: ...

O80 Single 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. O81 Single delivery by forc. & vacuum extr. Excl.: ... O81.0; O81.1; O81.2; O81.3; O81.4 dan O81.5. O82 Single delivery by caesarean section O82.0; O82.1; O82.2 dan O82.8; O82.9

O83 Other assisted single delivery O83.0; O83.1; O83.2 ; O83.3; O83.4 dan O83.8; O83.9. O84 Multiple 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.

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)

O85.X Puerperal sepsis Incl.: puerperal: - endometritis, - fever, - peritonitis dan sepsis Use additional code (B95-B97), if desired, to identify infection agent. Excl.: … O86 Other 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.: ...

O87 Venous 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. O88 Obstetric 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.

O89 Complication 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 O90 Complications of the puerperium, NEC O90.0; O90.1; O90.2; O90.3; O90.4; O90.5 dan O90.8; O90.9

O91 Infections 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 ...) O92 Other 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.: ...

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 O94 Sequelae 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.: ...

O95.X Obstetric death of unspecified cause Incl.: Maternal death from unspecified cause occurring during pregnancy, labour & delivery, or the puerp. O96 Death 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

O97 Death 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 O98 Maternal 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.: …

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 ....

O99 Other 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.

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) O99.3 (condition in F00 – F99 and G00 – G99)

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) O99.8 (condition in C00 – D48, H00 – H95, M00 – M99, N00 – N99, Q00 – Q99)

LATIHAN Hamil dengan plasenta previa totalis dan perdarahan No: Seksio caiser emergensi, No: Bayi tunggal hidup, cyanosis No: 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. No: I letkep, dan II letsu No: bayi prematur (BB < 1.750) No:

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 thyroiditis No: 8. Partus lama, uterin fibroid No: 9. Partus macet karena bayi letak muka No: 10. Post partum haemorrhage akibat atoni uteri No:

Partus seksio No: Kembar dempet terhubung di abdomen No: Berat badan kedua bayi di atas 2.250 kg. No: Cengeng sulit menete ASI No: Persalinan macet No: Myoma uteri No: Lahir Vakum No: Bayi cephalohematom No: Partus spontan, cukup bulan, bayi sehat No: No:

Persalinan induksi gagal dengan suntikan oxytocin No: Uterin inertia, akhirnya diseksio dengan hysterectomy No: Bayi Hydrosefalus toksoplasmosis No: Solutio placentae, Seksio, bayi premature BB 490g No: No: