SESI 13 PENGKODEAN MORTALITAS UMUM & PERINATAL

DESCRIPTION Pembahasan materi meliput pengenalan tentang pengkodean morbiditas dan mortalitas sebagai masukan ke sistem informasi morbiditas dan mortalitas yang dikembangkan

TUJUAN INSTRUKSIONAL UMUM Mampu menentukan mennetukan kode morbiditas dan mortalitas dengan presisi, akurat dan tepat, berhasil mengumpulkan, menyimpannya dan mengambil kembali bagi kepentingan penyelesaian sistem pelaporan rutin morbidtas dan mortalitas .

TUJUAN INSTRUKSIONAL KHUSUS Menjelaskan: - Cara penyelesaian surat kematian yang dikembangkan dan sertifikat kematian internasional. - Cara memilih kode underlying cause of death - Rule untuk seleksi cause of death ICD-10 WHO - Cara memilih kode cancer mortality - Sertifikat kematian perinatal internasional Latihan soal dengan bimbingan di kelas Latihan soal mandiri

MORTALITAS Statistik mortalitas merupakan satu sumber utama informasi kesehatan, pada beberapa negara statistik terkait merupakan data yang paling dapat dipercaya dari semua data kesehatan yang ada. Definisi Penyebab Kematian: WHA XX tahun 1967 mendefinisikan penyebab kematian yang dimasukkan ke dalam sertifikat kematian adalah: 1. Semua kondisi penyakit, keadaan sakit atau cedera yang dapat menimbulkan kematian dan 2. Kecelakaan atau kekerasan yng menimbulkan cedera yang mematikan.

MORTALITAS (Lanjutan) Oleh karenanya semua informasi yag relevans harus direkam di dalam sertifikat sesuai ketentuan runtunan cara penulisannya. Definisi dibuat untuk memastikan bahwa dokter (penulis sertifikat) menulis semua kondisi yang relevans dan tidak memilih hanya kondisi tertentu saja sedang kondisi lain diabaikan.

International Form of Medical Certificate of Cause of Death (Hal. 31) The medical Certificate is designed to facilitate the selection of the underlying cause of death when two or more causes are recorded. Part I: of the form is for diseases related to the train of event leading directly to death and Part II: is for unrelated but contributory condition.

Cara Penulisan Dalam Sertifikat Kematian Model WHO Definisi tidak mengikutsertakan istilah medis yang menggambarkan suatu simptom, dan “ mode of dying” (di antaranya: - gagal jantung, - gagal ginjal, - gagal napas dsb.).

Cara Penulisan Dalam ….. (Lanjutan) Apabila hanya ada satu keterangan tunggal yang ditulis sebagai sebab kematian, maka yang satu inilah yang dipilih untuk tabulasi data mortalitas. Apabila ada lebih dari satu kondisi yang ditulis sebagai sebab-2 kematian, maka pilihlah bedasarkan ketentuan RULES yang ada.

UNDERLYING CAUSE OF DEATH Sejak ICD revisi ke 6 sudah disepakati bahwa cause of death untuk tabulasi primary mewakili “underlying cause”-nya. Informasi data terkait diperlukan bagi kepentingan suatu tindakan prevensi kematian yang tujuan utamanya untuk mengupayakan memotong mata rantai kondisi-2 yang menjurus ke suatu kematian. Satu di antara tujuan utama kesehatan masyarakat yang efektif adalah mencegah penyebab itu terjadi/timbul.

UNDERLYING CAUSE OF DEATH (Lanjutan) Untuk itu definisi Underlying Cause of Death adalah: (a) Penyakit atau cedera yang memicu rangkaian even-even kesakitan (Morbids) yang mejurus ke suatu kematian. (b) Keadaan sekitar suatu cedera atau kecelakaan yang mengakibatkan suatu cedera fatal  kematian. Lihat contoh sertifikat kematian model WHO di ICD-10 Volume 2, halaman: 31, dan di halaman 90 untuk perinatal death.

Apabila ada lebih dari satu diagnoses yang ditulis/ Peraturan Memilih KODE MORTALITAS (ICD-10, WHO) untuk Sertifikat Sebab Kematian GENERAL PRINCIPLE Apabila ada lebih dari satu diagnoses yang ditulis/ ditempatkan di Part I sertifikat kematian, maka pilih yang ditulis di urutan paling bawah. 1. I. (a) Abses paru (b) lobar pneumonia II. - Pilih: Lobar pneumonia (J18.1) 2. I. (a) Gagal hati (b) Obstruksi saluran empedu (c) Kanker pakreas Pilih: Kanker pankreas (C25.9)

General Prinsiple (Lanjutan) 3. I. (a) Shok traumatik (b) Fraktur multiple ( c) Pengendara sepeda tertabrak bus (kecelakaan lalu-lintas) II. - Pilih: Pengendara sepeda tertabrak bus V14.1 4. I. (a) Bronkopnemonia (b) – (c) – II. Anemia sekunder dan leukemia limfatik kronik Pilih: Bronkopneumonia. Bisa juga menerapkan Rule 3  maka pilih: leukemia limfatik kronik. Apabila bronchopneumonia dan anemia sekunder diterima sebagai gejala sisa (squelae) langsung dari kondisi leukemia limfatik kronisnya.

General Principle (Lanjutan) 5. I. (a) Pericarditis (b) Uraemia dan pneumonia II. - Pilih: Uraemia. Pada kasus ini ada dua kondisi dilapor sebagai akibat terjadinya kondisi di Part I, bisa pericarditis akibat uraemia atau pericarditis akibat pneumonia. Pilih cause yang pertama disebut duluan, yakni: Uraemia. (Masih bisa menerapkan modifiokasi Rule D). 6. I. (a) Miokard infark akut (b) Atherosclerosis heart disease (c) Influenza Pilih: Penyakit jantung atherosclerosis. (Masih bisa menerapkan modifikasi Rule C).

RULE 1 If the General Principle does not apply and there is a reported sequence terminating in the condition first entered on the certificate, select the originating cause of this sequence. If there is more >1 such sequence terminating in the condition mentioned first, select the originating cause of the first-mentioned sequence.

CONTOH RULE 1: 1. I (a) Bronkopneumonia (b) Infark serebral (c) Penyakit jantung hipertensif Pilih: Infark serebral (I63.9) Pada kasus ini ada 2 kondisi (b) dan (c) yang bisa mengakibatkan timbulnya kondisi (a), maka pilih yang disebut pertama. 2. I. (a) Oesofagial varises dan gagal jantung kongestif (b) Gangguan jantung rematik kronis dan sirosis hepatis Pilih: Sirosis hati (K74.6). Runtunan diagnosis kondisi pasien yang mengakibatkan kondisi di (a) Part I adalah sirosis hepatis.

Rule 1 (Lanjutan-1) 3. I. (a) Infark otot jantung akut (b) Penyakit jantung aterosklerosik (c) Influenza Pilih: Penyakit jantung aterosklerosik. Pada kasus ini Infark miocard timbul akibat ateroskelorosik. (Bisa juga menerapkan Modification Rule C) Lihat halaman 46, example 45 ICD-10 Volume2

4. I. (a) Cerebral infarction & hypostatic penumonia (b) Hypertension & diabetes (c) Atherosclerosis Pilih: Atherosclerosis Pada kasus ini ada dua kondisi yang dilapor sebagai sebab terjadinya kondisi yang pertama disebut di Part I, maka pilih penyebab dari kondisi yang pertama disebut. (Infark serebri akibat hipertensi akibat atherosclerosis, dan infark serebri akibat diabetes.) (Masih bisa menerapkan Modification Rule C) Baca halaman 43 ICD-10, Volume 2.

(b) Uraemia dan pneumonia (c) - (d) - II. - Pilih: Uraemia. Rule 1 (Lanjutan-2) 5. I. (a) Pericarditis (b) Uraemia dan pneumonia (c) - (d) - II. - Pilih: Uraemia. Pada kasus ini ada 2 (dua) urutan diagnosis yang dinyatakan sebagai pemicu pericarditisnya: - pericarditis akibat uraemia - pericarditis akibat pneumonia Pilih penyebab yang disebut pertama (Uraemia) (Masih bisa menerapkan Modification Rule D)

RULE 2 If there is no reported sequence terminating in the condition first entered on the certificate, select the first mentioned condition. 1. Laki, 40 tahun I (a) Rematik dan penyakit jantung arterioskelortik II. - Pilih: Penyakit jantung rheumatic (I09.9) Pada kasus ini tidak ada pernyataan diagnosis yang dilapor di urutan ke 2, maka pilih yang ada di urutan pertama.

I. (a) Penyakit fibrokistik pankreas (b) Bronchitis dan bronchiectasis Rule 2 (Lanjutan-1) I. (a) Penyakit fibrokistik pankreas (b) Bronchitis dan bronchiectasis II. - Pilih: Penyakit fibrokistik pancreas Pada kasus ini tidak ditemukan laporan urutan kejadian

3. Wanita, 70 tahun I. (a) Senility & hipostatik pneumonia (b) Rematoid artritis Pilih: Senility . Pada kasus ini memang terlapor adanya hipostatik pneumonia akibat rematoid artritis, namun demikian, ini tidak mengakibatkan terjadinya senility. (Masih bisa menerapkan Modification Rule A)

4. I. (a) Bursitis dan ulcerative colitis (b) – II. - Pilih: Bursitis Rule 2 (Lanjutan-2) 4. I. (a) Bursitis dan ulcerative colitis (b) – II. - Pilih: Bursitis Pada kasus ini tidak ada diagnosis yang terlapor sebagai penyebab dari kondisi yang pertama disebut. (Masih bisa menerapkan Modification Rule B)

RULE 3 If the condition selected by General Principle or by Rule 1 or Rule 2 is obviously a direct consequence of another reported condition, whether in Part I, or Part II, select this primary condition. Assumed direct consequences of another condition 1. I. (a) Kaposi’s sarcoma II. AIDS Pilih HIV disease resulting in Kaposi’s sarcoma (B21.0)

Pilih: HIV disease resulting in mycobacterial infection (B20.0) RULE 3 (Lanjutan-1) 2. I. (a) Aspergillosis (b) Pneumonitis II. Penyakit HIV Pilih: HIV in aspergilosis pneumonitis (B20.5) (HIV disease resulting in other mycoses) 3. I. (a) TB II. Penyakit HIV Pilih: HIV disease resulting in mycobacterial infection (B20.0)

4. I. (a) Cerebral toksoplasmosis dan herpes zoster RULE 3 (Lanjutan-2) 4. I. (a) Cerebral toksoplasmosis dan herpes zoster (b) Burkitt’s lymphoma, HIV disease Pilih: HIV disease resulting in multiple diseases classified elsewhere (B22.7). Toksoplasmosis yang bisa dipilih sesuai Rule 2 gugur karena dianggap HIV adalah yang bertanggungjawab terhadap hadirnya toksoplasmosis. Baca peraturan penentuan kode diagnosis HIV/AIDS

5. I. (a) Cerebral haemorrhage (b) Hypertension Rule 3 (Lanjutan-2) 5. I. (a) Cerebral haemorrhage (b) Hypertension (c) Chronic peylonephritis & prostatic obstruction Pilih: prostatic obstruction (N40.x) Chronic pyelonephritis yang bisa dipilih sesuai Rule 1 gugur karena dianggap sebagai gejala sisa langsung dari prostate obstruction-nya.

(c) Bleeding of esophageal varices (d) Portal hypertension Rule 3 (Lanjutan-2) 6. I. (a) Acute anaemia (b) Haematemesis (c) Bleeding of esophageal varices (d) Portal hypertension II. Cirrhosis hepatis Pilih: Cirrhosis hepatis (K74.6). Portal hypertension yang bisa terpilih sesuai General Principle gugur karena (a) – (d) bisa diterima timbul akibat langsung dari cirrhosis hepatisnya

The Modification Rules Rule A. Senility and other ill-defined conditions Rule B. Trivial conditions Rule C. Linkage Rule D. Specificity Rule E. Early and late stages of disease Rule F. Sequelae  (Baca: ICD-10 Volume 2, hal. 42-66)

THE MODIFICATION RULES RULE A = Senility and other ill-defined conditions ( Chapter XVIII, kode R) RULE B = Trivial conditions (Kondisi ringan diutamakan namun ternyata ada kondisi yang lebih serious, maka pilih yang kondisi yang serious) RULE C = Linkage (Ada saling keterkaitan  gunakan code kombinasi)

THE MODIFICATION RULES (Lanjutan) Rule D = Specificity (Cari istilah kondisi yang lebih informatif tentang site atau sifat alamiah kondisi terlapor, Umumnya rule ini diterapkan apabila istilah adalah kata adjektif. RULE E = Early and late stages of disease (pilih yang advanced state, namun tidak berlaku untuk kronik akibat yang akut, kecuali ada instruksi khusus pada klasiifkasi ICD) RULE F = Sequelae (terklasifikasi di dalam ICD sebagai sequelae)

CANCER MORTALITY CODING Implication of malignancy Mention on the certificate that a neoplasm has produce metastases (secondary) means that it must be coded as malignant, even though this neoplasm without mention metatstases would be classified to some other section of Chpater II. (I) (a) Metastatic involvement of lymph nodes (= metatstase ke limfe nodi) (b) Malignant neoplasm of breast (= Neoplasma ganas payu dara) Code: Malignant neoplasm of breast (C50.9) M ?

CANCER MORTALITY CODING Sites with prefixes or imprecise definitions Neoplasms of sites prefixed by “peri-”, “para-”, “supra-”, “infra-”, etc. or described as in the “erea”, “region”, of a site, unless these terms are specifically indexed, should be coded as follow: For morphological types classifiable to one of the categories: C40, C41 (bone and articular cartilage), C43 (malignant melanoma of skin, C44 (other malignant neoplasm of skin, C45 (mesothelioma), C47 (peripheral nerve and anatomic nervous system)

CANCER MORTALITY CODING C49 (connective and soft tissue) C70 (meninges), C71 (brain) C72 (other parts of central nervous system) Code to the appropriate subdivision of that category, otherwise code to the appropriate subdivision of C76 (other and ill-defined sites) (I) (a) Fibrosarcoma in the region of the leg (= Fibrosarkoma pada regio tungkai bawah) Code to malignant neoplasm of connective and soft tissue of lower limb. Code: C49.2 M ?

CANCER MORTALITY CODING (Lanjutan-1) C. Malignant neoplasms of unspecified site with other reported conditions: When the site of the primary neoplasm is not specified, no assumption of the site should be made from the location of other reported conditions such as perforation, obstruction, or hemorrhage. These condition may arise in sites untreated to the neoplasm, e.g. intestinal obstruction may be caused by spread of an ovarian malignancy I. (a) Obstruction of intestine (= Obstruksi usus) (b) Carcinoma Karena tidak ada keterangan tentang site carcinoma-nya, maka pilih: Malignant neoplasm without specification of site C80  lihat [215] M ….? Baca NOTE No 1 di halaman [181]

CANCER MORTALITY CODING (Lanjutan-1) Malignant neoplasms with primary site indicated If a particular site is indicated as primary, it should be selected, regardless of the position on the certificate or whether in Part I or Part II. If the primary site is stated to be unknown, see E below. The primary site may be indicated in one of the following ways: Example: (a) The specification of one site as primary in either Part I or II I. (a) Carcinoma of bladder (= Ca k. kemih) II. (b) Primary in kidney (= primer di ginjal) Code: Malignant neoplasm of kidney (C64) M ….?

CANCER MORTALITY CODING (Lanjutan-2) (b) I. (a) Carcinoma mammae (b) Carcinoma sekunder di otak II. - (Ada kanker asal payu dara meluas ke otak) Code: Malignant neoplasm of breast C50.9 M…? (Rule 2 bisa digunakan)

CANCER MORTALITY CODING (Lanjutan-2) Morphology indicates a primary malignant neoplasm If a morphological type implies a primary site, such as a hepatoma, consider this as if the word “primary” had been included. I. (a) Metastatic carcinoma (b) Pseudomucinous adenocarcinoma Tumor ganas organ apa ini?

CANCER MORTALITY CODING (Lanjutan-3) Code to malignant neoplasm of ovary (C56), since pseudomucinous adenocarcinoma of unspecified site is assigned to the ovary in the Alphabetical Index.  (30) (M8470/3) unspecified  (C56)  [206] If two or more primary sites or morphologies are indicated these should be coded according to section F, G and H below.

CANCER MORTALITY CODING (Lanjutan-4) E. Primary site unknown If the statement, “primary site unknown”, or its equivalent, appears anywhere on a certificate, code to the category for unspecified site for the morphological type involved (e.g. adenocarcinoma C80, fibrosarcoma C49,9, osteosarcoma C41.9), regardless of the site(s( mentioned elsewhere on the certificate. Example: 7. (a) Secondary carcinoma of liver (b) Primary site unknown (c) ? Stomach or Colon? Pilih: Carcinoma without specification of site Code: C80

CANCER MORTALITY CODING (Lanjutan-3) 8. I (a) Generalized metastases (b) Melanoma of back (c) Primary site unknown Pilih: Malignant neoplasm of unspecified site C43.9

CANCER MORTALITY CODING (Lanjutan-4) F. Independent (primary) multiple sites (C97) The presence of more than one primary neoplasm could be indicated by mention of two different anatomical sites or two distinct morphological types (e.g. hypernephroma and intraductal carcinoma), or by a mix of a morphological type that implies a specific site, plus a second site. It is highly improbable that one primary would be due to another primary malignant neoplasm of lymphoid, haematopoietic and related tissue (C81-C96), within which one form of malignancy may terminate in another (e.g. leukemia may follow non-Hodgkin’s lymphoma)

CANCER MORTALITY CODING (Lanjutan-5) If two or more sites menioned in Part I are in the same organ system, see section H (p.83). If the site are not in the same organ system and there is no indication that any is primary or secondary, code to malignant neoplasms of independent (primary) multiple site (C97), unless all are classifiable to C81- C96, or one of the sites mentioned is a common site of metastases or the lung (see G below)

CANCER MORTALITY CODING (Lanjutan-6) Example: I (a) Cancer of stomach (b) Cancer of breast Pilih: Malignant neoplasm of independents (primary) multiple site C97 Baca NOTE [221] I (a) Hodgkin’s disease (b) Carcinoma of bladder Pilih: Malignant neoplasm of independent (primary) multiple sites C97

CANCER MORTALITY CODING (Lanjutan-7) Example: I (a) Acute lymphocytic leukemia (b) Non-Hodgkin’s lymphoma (C85.9) Code to non-Hodgkin’s lymphoma (C85.9), since both are classifiable to C81-C96 and the sequences acceptable. I (a) Leukemia (b) Non-hodgkin’s lymphoma (c) Carcinoma of ovary Pilih: Malignant neoplasm of independent (primary) multiple (C97).

CANCER MORTALITY CODING (Lanjutan-8) Example: I (a) Leukamia - II. Carcinoma of breast Pilih: Leukemia (C95.9) Code: C95.9 because the carcinoma of breast is in Part II. When dealing with multiple sites, only site in Part I of the certificate should be considered.

CANCER MORTALITY CODING (Lanjutan-8) Metastatic Neoplasms When a malignant neoplasms spread or metastasizes it generally retains the same morphology even though it may become less differentiated. Some metastases have such a characteristic microscopic appearance that the pathologist can infer the primary site with confidence, e.g. thyroid. Widespread metastasis of a carcinoma is often called carcinomatosis. If an unqualified non-specific term such as carcinoma or sarcoma appears with a term describing a more specific histology of the same broad group, code to the site of the more specific morphology, assuming the other to be metastatic. Baca selanjutnya di halaman 76 – 81 ICD-10 Volume 2.

CANCER MORTALITY CODING (Lanjutan-8) Example: I (a) Carcinoma of brain Code to malignant neoplasm of brain (C71.9) I (a) Carcinoma of bone (b) Metastatic Carcinoma of lung Pilih: Malignant neoplasm of lung (C34.9) since bone is on the list of common sites of metastases and lung can therefore be assumed to be primary Perhatikan penggunaan keterangan: Metastasis ke … Metastasis dari ….

CANCER MORTALITY CODING (Lanjutan-8) H. Multiple sites Baca selanjutnya ICD-10 Volume 2 halaman 81- 84 I. Infectious diseases and malignant neoplasm Baca selanjutnya ICD-10 Volume 2 halaman 84- 85 J. Malignant neoplasm and circulatory disease. Baca selanjutnya ICD-10 Volume 2 halaman 85

SERTIFIKAT KEMATIAN PERINATAL Certificate of Cause of Perinatal Death (Lihat: ICD-10 Volume 2 hal. 90)

Keterangan yang harus menyertai sertifikat kematian bayi perinatal a. Main disease or condition in fetus or infant b. Other diseases or conditions in fetus or infant c. Main maternal disease or condition affecting fetus or infant d. Other maternal diseases or conditions affecting fetus or infant c. Other relevant circumstances

RULE P1 Mode of death or prematurity entered in section (a) If heart failure or cardiac failure, asphyxia or anoxia (any condition in P20.-, P21.-) or prematurity (any condition in P07.-) is entered in section (a) and other conditions of the infant or fetus are entered in either section (a) or section (b), code the first mentioned of these other conditions as if it had been entered alone in section (a) and code the condition actually entered in section (a) as if it had been entered in section (b) Lihat contoh 1 dan 2 di ICD-10 Volume 2, halaman 94

RULE P2 Two or more conditions entered in section (a) or (c) If two or more conditions are entered in section (a) or section (c), code the first mentioned of these as if it had been entered alone in section (a) or (c) and code the others as if they had been entered in section (b) or (d) Lihat contoh 3 dan 4 di ICD-10 Volume 2 halaman 94

RULE P3 No entry in section (a) or (c) If there is no entry in section (a) but there are conditions of the infant or fetus entered in section (b), code the first- mentioned of these as if it had been entered in section (a); if there are no entries in either section (a) or section (b), either code P95 (Fetal death of unspecified cause) for stillbirth or code P96.9 (Condition originating n the perinatal period, unspecified) for early neonatal death should be used for section (a). Lihat contoh 5 dan 6 di ICD-10 Volume 2 halaman 95.

Similarly, if there is no entry in section © but there are RULE P3 (Cont.-) Similarly, if there is no entry in section © but there are maternal conditions entered in section (d), code the first- mentioned of these as if it had been entered in section (c); if there are no entries in either section (c) or section (d) use some artificial code.e.g. xxx.x for section (c) to indicate that no maternal condition was reported.

RULE P4 Conditions entered in wrong section If a maternal condition (i.e. conditions in P00-P04) is entered in section (a) or (b), or if a condition of the infant or fetus is entered in section (c) or section (d), code the conditions as if they had been entered in the respective correct section. If a condition classifiable as a condition of the infant or fetus or an maternal condition is mistakenly entered in section (c), code it as an Additional fetal or maternal condition in section (b) or (d) respectively. Lihat contoh 7 di ICD-10 Volume 2 halaman 96