TATA CARA KODING ICD-10 Lily Kresnowati

KODING Translasi dari suatu diagnosis, prosedur, jasa maupun pelayanan ke dalam kode numerik dan/atau alfanumerik untuk tujuan pelaporan statistik dan reimbursement. Membutuhkan pengetahuan tentang terminologi medis menyangkut diagnosis, dan prosedur untuk dapat mengalokasikan kode secara akurat Bahasa Inggris yang memadai, terutama terkait letak anatomik dan istilah2 medis

PROSEDUR KODING Persiapan koding : Alat bantu koding (Buku ICD-10 Vol.1 & 3, Kamus kedokteran/ Bhs Inggris) Dokumen Rekam Medis (RM) lengkap (post-assembled) Analisis dokumen RM untuk menentukan item yang harus di-kode Koding

VOLUME 1,2,3 DAFTAR TABULASI MANUAL INSTRUKSI INDEKS ALFABETIK

VOLUME 1 Bagian terbesar memuat klasifikasi utama, terdiri dari kategori tiga-karakter dan subkategori empat karakter dalam 22 Bab Tanda Baca ; inclusion, exclusion, NOS, NEC, dll Morfologi neoplasma Daftar tabulasi khusus (special tabulation lists) Definisi Regulasi nomenklatur Volume 1 berisikan klasifikasi yang menunjukkan kategori-kategori di mana suatu diagnosis akan dialokasikan guna mempermudah penyortiran dan penghitungan data untuk tujuan statistik. Volume tersebut juga dilengkapi dengan definisi-definisi dari isi tiap kategori, subkategori dan item dalam daftar tabulasi.

VOLUME 2 deskripsi tentang sejarah ICD struktur dan prinsip klasifikasi aturan-aturan koding morbiditas dan mortalitas presentasi statistik petunjuk praktis bagi pengguna ICD agar dapat memanfaatkan klasifikasi sebaik-baiknya.

VOLUME 3 SUSUNAN : terdiri dari 3 bagian (section) Sect I : Diseases & nature of injury Sect II : External causes of injury Sect III : Table of drugs & chemicals STRUKTUR : berisikan daftar lead term, modifiers, perkiraan kode (  cross-check dg volume 1) TANDA BACA : parentheses, NEC dan cross-references (see dan see also)

ANALISIS DOKUMEN REKAM MEDIS Tujuan : agar kode terpilih dapat merepresentasikan dengan tepat diagnosis Bagian RM yang dianalisis : Resume (Anamnesis, Pem. Fisik, Diagnosis, Terapi, Follow-up) Pemeriksaan Penunjang (Patologi Klinik, Patologi Anatomi, Radiologi, dll) Laporan lain (Operasi, Fisioterapi, dll)

PEDOMAN SEDERHANA DALAM KODING Identifikasi tipe pernyataan yang akan di-kode Lihat lead term  Vol 3 Baca seksama & ikuti petunjuk catatan yang muncul di bawah lead term

PENGGUNAAN Volume 3 (ALPHABETICAL INDEX) Perhatikan struktur diagnosis  lead term Tentukan penggolongan lead term dalam bagian yg sesuai (Vol.3) Perhatikan catatan & cross-reference (Vol.3)

PEDOMAN SEDERHANA DALAM KODING Baca istilah yg terdapat dlm tanda kurung “( )” sesudah lead term Ikuti secara hati-hati setiap ‘cross -references’ dan perhatikan ‘see’ & ‘see-also’ yg ada dlm indeks Lihat daftar tabulasi (Vol.1) untuk melihat kode yg paling tepat. Bila ada .-  cari karakter ke-4 Ikuti ‘inclusion’ dan ‘exclusion’ Kode

Apakah Lead term ? Lead Term atau Main Term adalah kata kunci yang menjadi acuan pencarian kode pada indeks alfabetik. Di Indeks  dicetak tebal di sisi kiri Merupakan masalah (diagnosis, cedera, dll) utama pada pasien. Umumnya merupakan kelainan, kondisi, gangguan

Letak Anatomik bukan ‘lead term’ Jika kita tetap menjadikan letak anatomik sebagai ‘lead term’ maka akan muncul istilah ‘see condition’ yang berarti coder harus merujuk pada kondisi si pasien dan bukan letak anatomiknya. Indeks alfabetik telah disusun sedemikian sehingga coder dapat mengalokasikan kode yang tepat dengan mencari lead term dari berbagai istilah yang berbeda

LEAD TERM Contoh : ‘Congestive Heart Failure’ akan dapat dirujuk menggunakan istilah ‘congestive’ ataupun ‘failure’ dan menemukan kode yang sama yaitu I50.0 Di bawah lead term akan disusun (list) sub term – sub term yang menjelaskan kondisi pasien lebih jauh. Umumnya berisikan ; Etiology (causa) Lokasi /site anatomik Tipe kelainan/penyakit Keterangan lebih lanjut ttg penyakitnya

Congestive Heart Failure Failure, failed - cardiac (see also Failure, heart) I50.9 - congestive (see also Failure, heart, congestive) I50.0 - heart (acute) (sudden) I50.9 - - with - - - acute pulmonary edema — see Failure, ventricular, left - - - decompensation (see also Failure, heart, congestive) I50.9 - congestive I50.0 Extracted from ICD-10 Second Edition, 2005, F.

Congestion, congestive (chronic) (passive) - bladder N32.8 - bowel K63.8 - general R68.8 - glottis J37.0 - heart (see also Failure, heart, congestive) I50.0 - hepatic K76.1   Extracted from ICD-10 Second Edition, 2005, C.

I50 Heart failure I50.0 Congestive heart failure Excludes: complicating: abortion or ectopic or molar pregnancy (O00–O07, O08.8) obstetric surgery and procedures (O75.4) due to hypertension (I11.0) with renal disease (I13.-) following cardiac surgery or due to presence of cardiac prosthesis (I97.1) neonatal cardiac failure (P29.0) I50.0 Congestive heart failure Congestive heart disease Right ventricular failure (secondary to left heart failure) Extracted from ICD-10 Second Edition, 2005, Diseases of the circulatory system.

Diagnosis Utama (Lead Term) Cara Menggunakan ICD-10 Kode Penyakit Diagnosis Utama (Lead Term) Volume 1 ICD-10 Volume 3 ICD-10 Cross Check

INGAT KONVENSI TANDA BACA Inclusion term Exclusion term Glossary descriptions Tanda kurung/ Parentheses ( ) Kurung besar/ Square brackets [ ] NOS (Not Otherwise Specified) NEC (Not Elsewhere Classified) And & Point Dash (.-) Kode rangkap : Dagger (+) & Asterisk (*)

TERMS INCLUSION EXCLUSION Pernyataan diagnostik yang diklasifikasikan dlm kelompok tsb. Dpt dipakai untuk kondisi yg berbeda atau sinonimnya Kondisi yang seolah terklasifikasi dlm kateg. ybs, namun ternyata terklasifikasi di tempat lain/ kode ditempat lain Kode yg benar adl yg diberi tanda dalam kurung yg mengikuti istilah tsb

Contoh Inclusion Diagnosis : CALCULUS OF TONSIL INDEX ALFABETIK SECTION I Calculus, calculi, calculous - ampulla of Vater (see also Choledocholithiasis) K80.5 - - Stensen's duct K11.5 - stomach K31.8 - sublingual duct or gland K11.5 - - congenital Q38.4 - submandibular duct, gland or region K11.5 - suburethral N21.8 - tonsil J35.8 Extracted from ICD-10 Second Edition, 2005, C.

Contoh Inclusion J35.8 Other chronic diseases of tonsils and adenoids TABULAR LIST VOL. 1 J35.8 Other chronic diseases of tonsils and adenoids Adenoid vegetations Amygdalolith Cicatrix of tonsil (and adenoid) Tonsillar tag Ulcer of tonsil Extracted from ICD-10 Second Edition, 2005, Diseases of the respiratory system.

Contoh Inclusion INDEKS ALFABETIK Amygdalolith J35.8 Extracted from ICD-10 Second Edition, 2005, A.

Contoh Inclusion L05 Pilonidal cyst Includes: fistula coccygeal or pilonidal sinus L05.0 Pilonidal cyst with abscess L05.9 Pilonidal cyst without abscess Pilonidal cyst NOS Extracted from ICD-10 Second Edition, 2005, Diseases of the skin and subcutaneous tissue.

J12 Viral pneumonia, not elsewhere classified Includes: bronchopneumonia due to viruses other than influenza viruses Excludes: congenital rubella pneumonitis (P35.0) pneumonia: - aspiration (due to): -NOS (J69.0) -anaesthesia during: -labour and delivery (O74.0) -pregnancy (O29.0) -puerperium (O89.0) -neonatal (P24.9) -solids and liquids (J69.-) - congenital (P23.0) - in influenza (J10.0, J11.0) - Interstitial NOS (J84.9) - lipid (J69.1) severe acute respiratory syndrome [SARS] (U04.9) Extracted from ICD-10 Second Edition, 2005, Diseases of the respiratory system.

Contoh Exclusion Q66 Congenital deformities of feet Excludes: reduction defects of feet (Q72.-) valgus deformities (acquired) (M21.0) varus deformities (acquired) (M21.1) Q66.0 Talipes equinovarus Q66.1 Talipes calcaneovarus Q66.2 Metatarsus varus Q66.3 Other congenital varus deformities of feet Hallux varus, congenital Extracted from ICD-10 Second Edition, 2005, Congenital malformations, deformations and chromosomal abnormalities.

KEKHUSUSAN BAB ICD-10 Setiap Bab dalam ICD-10 memiliki kekhususan berupa catatan-catatan yang perlu diperhatikan dalam menentukan kode penyakit. Umumnya catatan tersebut berupa tata cara pengalokasian kode, atau tambahan subklasifikasi. Dapat pula berupa keterangan mengenai kode tambahan opsional yang dapat diberikan terkait klasifikasi tertentu dalam bab tersebut.

Contoh Kekhususan Bab Certain infectious and parasitic diseases (A00–B99) Includes: diseases generally recognized as communicable or transmissible Excludes: carrier or suspected carrier of infectious disease (Z22.-) certain localized infections – see body system-related chapters infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium [except obstetrical tetanus and human immunodeficiency virus [HIV] disease] (O98.-) infectious and parasitic diseases specific to the perinatal period [except tetanus neonatorum, congenital syphilis, perinatal gonococcal infection and perinatal human immunodeficiency virus [HIV] disease] (P35–P39) influenza and other acute respiratory infections (J00–J22) Extracted from ICD-10 Second Edition, 2005, Certain infectious and parasitic diseases.

Factors influencing health status and contact with health services (Z00–Z99) Note: This chapter should not be used for international comparison or for primary mortality coding. Categories Z00–Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00–Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways: (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination or to discuss a problem which is in itself not a disease or injury. (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some illness or injury. Extracted from ICD-10 Second Edition, 2005, Factors influencing health status and contact with health services.

G81 Hemiplegia Note: For primary coding, this category is to be used only when hemiplegia (complete) (incomplete) is reported without further specification, or is stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these types of hemiplegia resulting from any cause. Excludes: congenital and infantile cerebral palsy (G80.-) G81.0 Flaccid hemiplegia G81.1 Spastic hemiplegia G81.9 Hemiplegia, unspecified Extracted from ICD-10 Second Edition, 2005, Diseases of the nervous system.

Delivery (O80–O84) Note: Codes O80-O84 are provided for morbidity coding purposes. Codes from this block should be used for primary morbidity coding only if no other condition classifiable to Chapter XV is recorded. For use of these categories reference should be made to the morbidity coding rules and guidelines in Volume 2. Extracted from ICD-10 Second Edition, 2005, Pregnancy, childbirth and the puerperium.

.0 With coma Diabetes mellitus (E10–E14) Use additional external cause code (Chapter XX), if desired, to identify drug, if drug-induced. The following fourth-character subdivisions are for use with categories E10-E14: .0 With coma Diabetic: coma with or without ketoacidosis hyperosmolar coma hypoglycaemic coma Hyperglycaemic coma NOS

Diabetes mellitus (E10–E14) The following fourth-character subdivisions are for use with categories E10-E14: .1 With ketoacidosis Diabetic: acidosis } without mention of coma ketoacidosis } .2† With renal complications Diabetic nephropathy (N08.3*) Intracapillary glomerulonephrosis (N08.3*) Kimmelstiel-Wilson syndrome (N08.3*) Extracted from ICD-10 Second Edition, 2005, Endocrine, nutritional and metabolic diseases.

S52 Fracture of forearm The following subdivisions are provided for optional use in a supplementary character position where it is not possible or not desired to use multiple coding to identify fracture and open wound; a fracture not indicated as closed or open should be classified as closed. 0 closed 1 open Extracted from ICD-10 Second Edition, 2005, Injury, poisoning and certain other consequences of external causes.

impacted } with or without delayed healing linear } march } simple } Fracture including: Fracture: closed: comminuted } depressed } elevated } fissured } greenstick } impacted } with or without delayed healing linear } march } simple } slipped epiphysis } spiral } dislocated } displaced } open: compound } infected } missile } with or without delayed healing puncture } with foreign body } Excludes: fracture: pathological (M84.4): with osteoporosis (M80.-) stress (M84.3-) malunion of fracture (M84.0) nonunion of fracture [pseudoarthrosis] (M84.1) Extracted from ICD-10 Second Edition, 2005, Injury, poisoning and certain other consequences of external causes.

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