SESI 11 PENGENALAN ICPM, ICHI & ICD-9-CM Volume 3 Disusun oleh Dr Mayang Anggraini Naga

DESCRIPTION Pembahasan materi meliput pengenalan istilah sebutan berbagai prosedur/tindakan medis operasi terapi dan diagnostik, cara menentukan kode yang akurat, tepat dan berhasilguna menunjang sistem informasi tindakan operasi/medis, diagnostik maupun terapuetik.

TUJUAN INSTRUKSIONAL UMUM Mampu menentukan kode tindakan operasi/ terapi, diagnostik ataupun terapuetik dengan presisi, akurat dan tepat, berhasil mengumpulkan, menyimpannya dan mengambil kembali bagi kepentingan penyelesaian pelaporan rutin tindakan pelayanan ataupun yang suatu waktu diperlukan oleh manajemen medis ataupun manajemen kesehatan.

TUJUAN INSTRUKSIONAL KHUSUS Menjelaskan: - ICPM - Bab 5 (kode bedah) ICPM yang di-Indonesiakan - ICHI - ICD-9-CM volume 3

ICOPIM International Classification of Procedures in Medicine Buku klasifikasi prosedur tindakan medis yang, memuat pengelompokan berbagai prosedur tindakan dari berbagai cabang ilmu medis, disusun oleh WHO sebagai suplement dan bukan bagian integral dari ICD-9. (10 April 1971, Chicago, AHA, USA)

(b) harus aplikabel bagi pasien rawat inap maupun rawat jalan ICOPIM (Lanjutan-1) Lingkup & Form (a) memungkinan ekspansi bagi yang meng-inginkan yang lebih rinci, namun juga harus dapat digunakan sebagai form yang terpampatkan. (b) harus aplikabel bagi pasien rawat inap maupun rawat jalan (c) harus memuat juga semua tipe prosedur yang harus terrekam bagi kepentingan statistik, adminstrasi, tujuan klinis maupun riset, meliput tindakan ekplorasi, radiologik, operasi dan tindakan lain-lain diagnostik, profilaksis ataupun bentuk terapuetik.

Klasifikasi terbagi dalam 9 Bab: 1. Prosedur tindakan medis diagnostik ICOPIM (Lanjutan-2) Klasifikasi terbagi dalam 9 Bab: 1. Prosedur tindakan medis diagnostik 2. Prosedur laboratoris 3. Radiologii dan aplikasi lain dari kedokteran fisik 4. Prosedur tindakan preventif 5 Operasi pembedahan 6 & 7 Obat, agen medikamens dan biologis 8 Prosedur terapuetik lain 9/ Prosedur penunjang.

Penomoran kategori dimulai dari 1-100 s/d STRUKTUR: Struktur mirip dengan ICD: tersusun dari satu daftar tabulasi dan satu daftar indeks alfabetik. Penomoran kategori dimulai dari 1-100 s/d 9-823, dengan digit pertama menunjukkan nomor Bab klasifikasi, dengan penomoran dengan 3 digit, dan rincian dan ketepatan pada digit ke-4. Digit ke-5 optional sebagai nomor kode subdivisi bagi kategori-kategori tertentu.

SUMBER: Bab 1 Sumber istilah: - AMA, Canada: Schedul of unit value, - Ontario MA: List of fee dan - Nomenclatur des acies professionels (France) Bab 2 Berdasarkan prosedur laboratoris French project yang ditata untuk memberi kemungkinan penambahan di kemudian hari. Bab 3 Berdasarkan klasifikasi Swedish, French, Switzerland yang kemudian dimodifikasi.

Berdasarkan pelaporan pusat kesehatan dari beberapa negara. Sumber (Lanjutan-1) Bab 4 Berdasarkan pelaporan pusat kesehatan dari beberapa negara. Bab 5 Berdasarkan klasifikasi revisi ke 8 Klasifikasi Tidakan (Adapted) (US Public Health sErvice Publication No; 1693) berserta yang diambil dari Dutch code (Algemene Ziekenfondsen, 1968), dan klasifikasi Office of Population Censuses and Surveys (England and Wales, 1974) dan dari dokumen=dokumen administratif kesehatan masyarakat berbagai regio. Pengurutan kategori atas dasar topografi, bukan spesilisasi bedahnya.

Sumber (Lanjutan-2) Bab 6 & 7 Dikembangkan selaras dengan ICD-9 960-979 yang mengklasifikasi efek keracunan. Nomor kode diambil dari ICD-9 dengan menghilangkan digit pertamanya. 960.0 untuk penisilin menjadi 6-00 pada klasifikasi obat dan subdivisi 6-000-6-009 untuk identifikasi berbagai penisilin. Bab 8 Termasuk di sini prosedur medis terapuetiks NEC. Aksis klasifikasi mengacu ke intervensi bukan sistem anatomik.

Sumber (Lanjutan-3) Bab 9 Terdiri dari semua prosedur yang tidak termasuk ke bab-bab lain. Terdiri dari koleksi aktifitas penunjang yang mungkin saja nampak tidak berkaitan dengan tujuan dari pegguna klasifikasi. Klasifikasi disediakan dengan adanya kemungkinan tindakan-2 terkait mempunyai pengaruh terhadap aktivitas klinis yang profesional.

MODE of UTILIZATION Urutan tindakan pengkodean sama dengan ICD PPerhatikan tabular list dan inedks alfabetnya agar dapat menemukan kode yang tepat Di dalam daftar tabulasi kode terurut secara numerik, kadang ada yang melompt urutannya untuk kemungkinan penmabhan pada masa mendatang. Sistem penomorannya satu angka diikuti – dan 3 angka berikutnya. Untuk keperluan tertentu Bab-bab tertentu bisa berdiri sendiri: Radioterapi, laboratoris, prenventive yang tidak emmpengaruhi pelayanan terapi, Bab 6 dan Farmasi,

Mode of Utilization (Lanjutan-1) Mengingat pasien kemungkinan menerima berbagai jenis prosedur tindakan, aturan umum koding multiple adalah esensial, dalam satu bab atau beberapa bab. Secara ideal semua tindakan harus dikode, Hal ini yang diperlukan bidang administratif (tagihan dsb) serta untuk keperluan statistik  berapa jenis yang diplerkukan diserahkan kepada masing institusi. Penggunaan nomor kode berdigit 4 akan lebih rinci. Desain formulir sistem pengumpulan data sangat bergantung kepada nomor kode dan aspek lain pemrosesan data. Form untuk antry data sangat bergantung pada kebutuhan institusi, oleh karenanya dipersilahkan mengembangkan sesuai kebutuhan.

Mode of Utilization (Lanjutan-2) Mengkode berdasarkan ICPM lebih sederhana dibanding dengan ICD, mengingat di ICPM tidak ada aturan khusus seperti pada ICD, ada rules morbidity dan mortality. Komentar dan Usulan: Bisa dikirim ke:  baca di Buku Volume 1 halaman: ix.

Bab 1: Prosedur Diagnostik Medis Medical Services Tersedia subdivisi digit ke 4, 0. 1. 2, 3, 4, dan 9 Initial Medical Attention Termasuk rekaman terkait: riwayat sakit, pem. fisik, program diagnostik yang akan dijalankan, dan R/ pada permulaan episode pelayanan yang berjalan. Subsequent Medical Attention Consultation Newborn Sevices Examination of Special System Examination of Other Special System

Physiological Function Tests Exploratory Diagnostic Procrdures Bab 1: (Lanjutan) Biopsy Surgical Biopsy Endoscopy Physiological Function Tests Exploratory Diagnostic Procrdures Other Procedures for Diagnosis

2. Laboratory Procedures Clinical Chemistry of Blood Clinical Function Tests Microbiology Mycology and Parasitology Hematology General Pathology

4. Preventive Procedures Certain Health Examinations Screening Examination Prevention and Control of Infectious Diseases Control of Local Conditions Maternal and Child Health Care

Surgical Procedures (Bab ini telah diterjemahkan ke dalam Bahasa Indonesia) Excludes: biopsies (1-4 & 1-5), performed as independent procedures. Operations on the Nervous System Operations on the Eyes Operations on Nose, Mouth and Pharynx Operations on the Cardiovascular System Operations on the Digestive System Operations on the Urinary Tract Operation on the Male Genital Organs

Operation on Female Genital Organs Obstetric Operations Operations on The Musculoskeletal System Operations on The Breast Disruption of Tissue Optional Surgery Ill-defined Operations

8. Other Therapeutic Procedures Removal of Unwanted Material Correction of Misplacement Immobilization and Support Skeletal and Other Traction Other therapy by Physical Agents\ Respiratory Procedures Procedures Affecting Circulatory System Pre- and Postoperative Procedures Monitoring of Patient

9. Ancillary Procedures Other Therapy Other Care Anatomy-Physiological Assistance Physiotherapeutic and Related Techniques Other Rehabilitation Psychotherapy Long term and Follow-up Procedures

Volume 2 3. Radiology and Certain Other Application of Physics In Medicine Tersedia subdivisi digit-5 dan digit-6 yang optional bagi beberapa grup kategori. Penomoran dengan 3-digit masih signifikan. Digit-5 dan digit-6 karena optional maka tidak muncul pada indeks alfabetik. Bab 3 ini ada 3 grup (a) 3-00 s/d 3-09 untuk merekam aktivitas umum beserta upaya fisik dalam kedokteran, dan mewakili aksis lain klasifikasi yang termasuk di grup lain.

Volume 2 3. Radiology and Certain Other Application of Physics In Medicine (Lanjutan) (b) Kategori 3-10 s/d 3-02 dan 3-63 s/d 3-99 untuk mengkode prosedur khusus yang terklasifikasi hanya di dapal bab ini. (c) Kategori 3-63 dan 3-64 grup prosedur diagnostik tertentu yang juga terklasifikasi di Bab 1. Oleh karenanya kategori ini digunakan hanya bila Bab 1 tidak dimanfaatkan. Kode 3-63 dan 3-64 tidak muncul di dalam indeks alfabetik Bab 3; apabila diperlukan, cari di daftar tabulasi.

3-00 – 3-99 General Aspects Radiography (tersedia subdivisi digit ke 5 dan ke 6) Contrast Radiography Other Contrast Radiography (tersedia subdivisi digit ke 5) Other X-ray Diagnostic Procedures (tersedia subdivisi digit ke 5) Diagnostic Nuclear Medicine (tersedia subdivisi digit ke 5. Other Diagnostic Procedures from Physics

External Radiotherapy (tersedia subdivisi digit ke 5 dan ke 6) 3-00 – 3-99 (Lanjutan) External Radiotherapy (tersedia subdivisi digit ke 5 dan ke 6) Other Therapeutic Nuclear Medicine (tersedia 4 grup subdivisi digit ke 5 yang optional) Other Therapeutic Procedures from Physics.

6 & 7 Drugs, Medicaments, and Biological Agents Notes: Aksi obat bisa berubah sesuai rute pemberiannya, Local anesthetics dibagi utama sesuai model pengunaannya (permukaan, infiltrasim memblokir saraf, dan spinal), ada anestesi lokal yang pengguna-annya bisa lebih dari satu cara. 3 anestetik yang diguga terbanyak digunakan terdaftar pada masing-masing model penggunaannya. Anestetik lain dialkoasik sesuai cara penggunaan yang diduga paling umum.

Kode ganda obat juga menduduki rincian perekaman kombinasi. 6 & 7 Drugs … (Lanjutan-1) Dalam praktik, indeks kode bisa mesleading apabila nomor kode diambil kembali pada hari kemudian, sebagai contoh: kode menunjukkan anestesi spinal, padhal anestetiknya dilaksanakan secara topikal. Untuk inilah koder hendaknya harus memperhatikan aspek mana yang paling penting alasannya – sifat kekhususannya, model pemberiannya. Apabila kedua aspek tersebut diperlukan, buatlah kode ganda untuk menyimpan dan menghasilkan infomasi lebih rinci dan tepat. Kode ganda obat juga menduduki rincian perekaman kombinasi.

Other Anti-Infective Drugs Hormones & Synthetic Substitutes 6 & 7 Drugs … (Lanjutan-2) Antibiotics Other Anti-Infective Drugs Hormones & Synthetic Substitutes Systematic Agents Drugs Primarily Affecting Blood Constituents Analgetics, Antiseptics, and Antirheumatics Sedatives & Hypnotics Central Nervous System Depressants Psychotic Drugs Central Nervous System Stimulants

Drugs Primarily Affective The Autonomic Nervous System 6 & 7 Drugs … (Lanjutan-3) Drugs Primarily Affective The Autonomic Nervous System Drugs Primarily Affecting the Gastrointestinal System Water, Mineral, and Uric Acid Metabolism Drugs Drugs Acting Primarily on The Smooth and Skeletal Muscle and Respiratory System Drugs Acting Locally Other Drugs and Medicaments Bacterial Vaccines

Disusun oleh dr Mayang Anggraini Naga National Centre for Classification in Health - Australia INTERNATIONAL CLASSIFICATION of HEALTH INTERVENTIONS ICHI Disusun oleh dr Mayang Anggraini Naga

I C H I Struktur Isi: Introduksi Konvensi yang diberlakukan dalam Daftar Tabulasi Konvensi yang diberlakukan dalam Daftar Indeks Alfabetik Prosedur/Tindakan. Daftar Kode Daftar Tabulasi Prosedur/Tindakan Indeks Alfabetik Prosedur/Tindakan.

Daftar Tabulasi Prosedur /Tindakan: I. Procedures on Nervous System ICHI (Lanjutan) Daftar Tabulasi Prosedur /Tindakan: I. Procedures on Nervous System II. Procedures on Endocrine System III. Procedures on Eye and Adnexa IV. Procedures on Ear and Mastoid Process V. Procedures on Nose, Mouth and Pharynx VI. Dental Services VII. Procedures on Respiratory System VIII. Procedures on Cardiovascular System IX. Procedures on Blood and Bllood-Forming Organs X. Procedures on Digestive System

XI. Procedures on Urinary System Lanjutan XI. Procedures on Urinary System XII. Procedures on Male Genital Organs XIII. Gynaecological Procedures XIV. Obstetric Procedures XV. Procedures on Musculoskeletal System XVI. Dermatological and Plastic Procedures XVII. Procedures on Breast XVIII. Radiation Oncology Procedures XIX. Non-invasive, Cognitive and Other Interventions, NEC. XX. Imaging Services

INTRODUKSI Beta-ICHI dikreasi oleh National Centre for Classification in Health, Australia, sebagai anggota ICD-FIC, WHO. Klasifikasi didisain untuk digunakan bersama dengan ICD-10 bagi yang memerlukan klasifikasi tindakan dan intervensi yang ringkas dan sederhana. Klasifikasi terdiri dari berbagai intervensi bedah dan non-bedah. ICHI menampung kurang lebih 1.400 kode tindakan spesifik berserta terms tindakan yang inclusion. Struktur dan konvensi untuk indeks sama dengan klasifikasi procedure WHO.

Introduksi (Lanjutan) ICHI in its alpha-version was known as the Australian Classification of Health Interventions Adapted for International Use, or ACHI-1. The edition of ICHI is derived from the Fourth Edition of the Australian Classification of Health Interventions (ACHI) which forms volumes three and four of the Fourth Edition of the ICD, 10th, Australian Modification -ICD-10-AM (2004). Baca selanjutnya pada buku ICHI, 2004.

Petikan dari ICD-9-CM, HCIA Baltimore, Maryland, 1992 ICD-9-CM Volume 3 Petikan dari ICD-9-CM, HCIA Baltimore, Maryland, 1992

PROCEDURES TABULAR LIST and ICD-9-CM Volume 3 PROCEDURES TABULAR LIST and ALPHABETIC INDEX Introduction Conventions used in the Procedure Classification Preface to the Annotated ICD-9-CM Sybolsw and Annotations in Volume 3 Tabular List 1. Operations on the Nervous System (01.-05.9) 2. Operations on the Endocrine System (06.-07.99) 3. Operations on the Eye (08.-016.99) 4. Operations on the Ear (18.-20.99) 5. Operations on the Nose, Mouth, and Pharynx (21.-29.99)

ICD-9-CM Tabular List (Cont.-) 6. Operations on the Respiratory System (30.-34.99) 7. Operations on the Cardiovascular System (35.-  39.99) 8. Operations on the Hemic and Lymphatic System (40.-  41.99) 9. Operations on the Digestive System (42.- 54.99) 10. Operations on the Urinary System (55.-59.99) 11. Operations on the Male Genital Organs (60.-64.99) 12. Operations on the Female Genital Org. (65.-71.9) 13. Obstetrical Procedures (72.-  75.99) 14. Operations on the Musculoskeletal Sys.(76.-84.99) 15. Operations on the Integumentary Sys. (85.- 86.99) 16. Miscellaneous Diagnostic & Therapeutic Procedures (87.- 99.99) Alphabetic Index

7. OPERATIONS ON THE CARDIOVASCULAR SYSTEM (35.-  39.-) (hal69-92) Op. on Valves & Septa of Heart Includes: sternotomy (median)(transverse) thoracotomy } as operative approach Code also cardiopulmonary bypass [extracorporal circulation] [heart-lung machine] (39.61) 35.0 Closed heart valvotomy Excludes: percutaneous (balloon) valvuloplasty (35.96)

35 Operation on Valves and Septa of Heart 35.0 Closed heart valvotomy Excudes: percutaneous (balloon) (valvuloplasty)(35.96) 35.00 Closed heart valvotomy, unspecified valve 35.01 Closed heart valvotomy aortic valve 35.02 Closed heart valvotomy, mitral valve 35.03 Closed heart valvotomy, pulmonary valve 35.04 Closed heart valvotomy, tricuspid valve 35.1 Open Heart Valvuloplasty without Replacement Includes: open heart valvotomy Excludes: percutaneous (balloon) valvuloplasty (35.96) (cont.- ) 

Excludes: percutaneous (balloon) valvuloplasty (35.96) 35.1 Open Heart Valvuloplasty without Replacement Includes: open heart valvotomy Excludes: percutaneous (balloon) valvuloplasty (35.96) that associated with repair of: endocardial cushen defect (35.54, 35.63, 35.73) valvular defect ass. with atrial & ventricular septal defect (35.54, 35.63, 35.73) Code also cardiopulmonary bypass [extracorporal circulation] [heart –lung machinal] (39.61) 35.10 Open heart valvuloplasty without replacement, unspecified valve 35.11 Open heart valvuloplasty of aortic valve without replacement 35.12 Open heart valvuloplasty of mitral valve without replacement 35.13 Open heart valvuloplasty of pulm. valve without replacement 35.14 Open heart valvuloplasty of tricus. valve without replacement 35.2 Replacement of Valve

SYMBOLS and ANNOTATIONS in VOLUME 3 The use of DRGs to determine prospective payment and Medicare Code Edits (MCEs) to show inconsistencies in patient information make certain aspects coding particularly important. To make sure you assign the right DRG for each patient, you must code the PRINCIPAL DIAGNOSIS fully and correctly; you must also include all SECONDARY DIAGNOSES and all PROCEDURES. The DRG grouper assumes all patient information is correct. The MCEs alert you to errors, inconsistencies, and nonspecific information, for resolution before you group the record.

Symbols and Annotations in Volume 3 (CONT.-1) To keep these factors in front of you and simplify the coding process, ICD-9-CM have color-coded the diagnosis and procedure tabular lists. In volume 3. the annotations are as follows: _____ A non specific code which should not be used when more precise information is obtainable A code considered by MCE to be sex-specific O To be used only for male patients o To be used only for female patients A code for a procedure not normally covered by Medicare

Symbols and Annotations in Volume 3 (Cont.- 2) -------- A code which is NOT considered by the grouper to be an operating room procedure. When a code is boxed and shaded, the box is in black ink to differentiate it more easily from the green shading. Our annotations and other explanatory materials reflect the latest DRG information available as of publication date. We have taken every precaution to safeguard the accuracy of this edition, nonetheless, the provider of service holds the ultimate responsibility for accurate coding.

SYMBOLS & ANNOTATIONS in VOLUME 1 A code which should not usually be used as PRINCIPAL DIAGNOSIS: +++ For all codes on page 1-917, indicates nonspecific code. === For codes 7981, 798.2, 789.9, and all codes on page 918-969, indicates UNACCEPTABLE PRINCIPAL DIAGNOSIS CODE. Q ____ Questionable admission (entire book) (italicized manifestation codes and E-codes are other codes not to be used as PRINCIPAL DIAGNOSIS) A Code considered by the MCE to be age-specific. B To be used only for patients less than one year old

SYMBOLS & ANNOTATIONS in VOLUME 1 (Cont.-1) A Code considered by the MCE to be age-specific. B To be used only for patients less than one year old P To be used only for patients less than eighteen year old M To be used only for patients between twelve and fifty-five years old A To be used only for patients more than fourteen years old A code considered by the MCE to be sex-specific O To be used only for male patients o To be used only for female patients

SYMBOLS & ANNOTATIONS in VOLUME 1 (Cont.-2) ----- A code considered by the DRG grouper to be a complication or comorbidity. When a code is boxed and shaded, box is in black ink to differentiate it more easily from the green shading. ____ A code which signals the necessity to be absolutely certain that all secondary diagnoses and complications are coded well. This condition occurs when this code is used as principal diagnosis for a patient who has no operating procedure.

NOTES Because of the typography of Volume 1 of ICD-9-CM, it is not always possible to indicate clearly with color coding the various types of information to be imparted. This is especially true in those areas where common fifth-digits apply to several four digit codes. In some cases the color coding applies to all relevant fifth digits (e.g in the classification of tuberculosis, when one five-digit code is designated as a comorbidity, all five-digit code in sequence are comorbidities), but in other cases, some of the fifth-digit codes in the sequence are classified differently from other fifth-digit codes in the same sequence (e.g. 250.01 is a comorbidity, but 250.00 is not). In order to make it easier to understand, the following table shows those cases where the various five-digit codes within a sequence are classified. (Lihat hal.xvii – xix, ICD-9-CM vol. 1)

CONTOH – ICD-9-CM Volume 1 403 Hypertension renal disease Includes: arteriolar nephritis arteriosclerosis of: kidney renal arterioles arteriosclerotic nephritis (chronic)(interstitial) hypertensive nephropathy renal failure’ uremia (chronic) nephrosclerosis renal sclerosis with hypertension any condition classifiable to 585, 586, 0r 587 with any condition classifiable to 401. Excludes: acute renal failure (584,5 – 584.9) renal disease stated as not due to hypertension renovascular hypertension (405.0 – 405.9 with fifth-digit 1)

ICD-9-CM yang diperkenalkan di Indonesia (Contoh) CLASSIFICATION OF PROCEDURES

OPERATIONS ON THE NERVOUS SYSTEM (01 – 05) 01 Incision and excision of skull, brain and cerebral meninges 01.0 Cranial puncture 01.01 Cisternal puncture Cisternal tap pneumosternogram (87.02) 01.02 Ventriculopuncture through previuosly implanted catheter Puncture of ventricul shunt tubing 01-09 Other cranial puncture Aspiration of: dst.

01.1 Diagnostic procedures on skull, brain, and cerebral meninges Lanjutan-1 01.1 Diagnostic procedures on skull, brain, and cerebral meninges 01.11 Closed [ecutaneous] [needle] biopsy of cerebral meninges Burr hole approach 01.12 Open biopsy of cerebral meninges 01.13 Closed [percutaneous] [needle] [biopsy] of brain Stereotactic method 01.14 Open biopsy of brain 01.15 Biopsy of skull .

Lanjutan-2 01.18 Other diagnostic procedures on brain and cerebral meninges cerebral arteriography (88.41) thermography (88,81) contrast radiogram of brain (87.01-87.02) echoenchaphalogram (88.71) dst 01.19 Other diagnostic procedures on skull transillumination pf skull (89.16) x-ray of skull (87.17 01.2 Craniotomy and craniectomy decompression of skull fracture (02.02) exploration oforbit (16.01 – 16.09) that as operative approach – omit code