Daftar Kode Diagnosis dan Tindakan
Daftar Kode Diagnosis dan Tindakan
INA - CBG BPJS
Orthopaedi
Januari 2014
Residen wajib mengisi lembar RM 1, Lembar Verifikasi dan laporan operasi sesuai
dengan diagnosis dan tindakan yang tertera secara lengkap, setiap selesai operasi
DAFTAR DIAGNOSIS (ICD 10) DAN TINDAKAN (ICD 9)
DIVISI ORTHOPAEDI DAN TRAUMATOLOGI
Hand (kelainan dan luka di tangan)
Keterangan
Remove implant
ICD 10 Diagnosis
S52.90
Luka terbuka di tangan, crush
injury
S67.8 Crushing injury of other and
84.03 amputation through
unspecified parts of wrist and hand
hand.
S55.1 injury of radial artery at forearm
level
M65.8 Synovitis and tenosynovitis
82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
L.02.51 Cutaneus abscess of the hand. 82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
M67.4 ganglion
82.29 Excision of other lesion
of soft tissue of hand
14.952.975
Fracture pada pergelangan
tangan dan tangan
S62.8 fracture at wrist and hand level
12.485.355
Luka berat pada jari, tangan
(perlu amputasi)
S68 traumatic amputasion of wrist
84.04 amputation and
and hand level
disarticulation of hand
S55.1 injury of radial artery at forearm
Luka kotor /infeksi di jaringan
lunak
Infeksi jaringan
ganglion
ICD 9 Prosedur
78.69 removal implant
device from the bone
79.34 open reduction of
fracture with internal fixation
, carpals and metacarpals.
Plafon
3.765.791
8.403.235
8.403.235
12.485.355
14.952.971
Deformitas/ kelainan pada jari
level
M20.0 Deformity of finger
Jepitan pada syaraf/carpal
tunnel syndrome
Syndactili
84.03 amputation and
disarticulation of Hand
9099.408
S64 injury of nerves at wrist and hand
level
Q70 Syndactili
05.9 other operation on
nervous system
86.85 correction of
syndactyly
11.164.055
Dislokasi pada jari
S63.1 dislocation and sprain of joints
and ligaments at wrist and hand level
79.84 open reduction of
dislocation of hand and
finger
12.485.355
Tumor ganas pada ekstremitas
atas
C40.1 malignant neoplasm of short
84.03 amputation of through
bones of upper limb
hand
S55.1 injury of radial artery at forearm
leve
14.952.975
Infeksi pada sendi
M00 Pyogenic infection
8.404.231
Kerusakan sendi krn rematik
M05 .38 rheumatoid arthritis with
rheumatoid factor
M65.80 other synovitis and
tenosynovitis
81.29 arthhrodesis of other
specified joints
86.66 homograft to skin
81.29 arthhrodesis of other
specified joints
86.66 homograft to skin
Kerusakan sendi bukan karena
rematik
M06 other rheumatoid arthritis
8.403.235
Deformitas/ kelainan pada jari
M20.0 Deformity of finger
81.29 arthhrodesis of other
specified joints
86.72 pedicle or flap graft,
not otherwise specified
82.8 other plastic operation
12.485.355
8.403.235
12.485.355
on hand,
kontracture
M24.59 contracture unspecified site
82.3 other excision of soft
tissue of hand;
12.485.355
polidactili
Q69 polidactyli
84.03 amputation and
disarticulation of finger:
86.66 homograft to skin
8.403.235
Raw surface, defek soft tissue,
sural flap, semua tindakan flap
L98.9 other disorders of skin and
subcutaneous tissue, not elsewhere
Traumatic amputasi perlu
replantasi
82.8 other plastic operation
on hand
86.72 pedicle or flap graft,
not otherwise spesified
S68.9 traumatic amputasion of wrist
84.22 finger reattachment
and hand level
86.72 pedicle or flap graft,
S55.1 injury of radial artery at forearm not otherwise spesified
leve
8.403.235
ICD 10 Diagnosis
M84.90 disorder of continuity of
bone , unspecified
S42 fracture of shoulder and upper
arm
S.06.9 intracranial injury
S42 fracture of shoulder and upper
arm
ICD 9 Prosedur
78.69 bone graft
86.66 homograft to skin
79.30 ORIF,unspecified site
Plafon
8.403.235
79.30 ORIF,unspecified site
7.691.543
8.403.235
Trauma (Fracture)
No
1.
Keterangan
Non union perlu bone graft
2.
Fracture clavikula
3.
Fracture clavikula dengan
cedera kepala
3.835.376
4.
Fracture tibia/fibula
S82.21 Fracture of shaft tibia
79.36 ORIF , tibia and fibula
21.963.542
5.
Fracture distal tibia
S82.2 Fracture of shaft tibia
79.36 ORIF
21.963.542
6.
Fracture femur
S72.31 fracture shaft femur
79.35 ORIF , femur
7.
Fracture radius
S52.3 fracture shaft radius
79.32 ORIF , radius and ulna
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
12.485.355
8.
Fracture ulna
S52.2 fracture shaft ulna
79.32 ORIF , radius and ulna
12.485.355
9. Fr antebrachii
10. Fracture humerus
S52.7 fracture shaft forearm
S42.3 fracture shaft humerus
79.32 ORIF , radius and ulna
79.31 ORIF humerus
12.485.355
12.485.355
11. Fracture pada tangan,
metacarpal, phalang
12. Fracture subtrochanter femur
perlu ORIF
S62 fracture at wrist and hand level
79.34 ORIF phalank of hand
12.485.355
S72.2 subtrochanteric fracture of
femur
79.35 ORIF , femur
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
13. Fracture intercondylar femur,
14. Fracture intertrochanter femur
S72 fracture shaft femur
M81.65 Osteoporosis
S72.14 Intertrochanteric fracture of
femure
79.35 ORIF , femur
Hip implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
79.35 ORIF , femur
Knee implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
6000.000
12.485.355
15. Fracture galeazi
S52.3 fracture shaft radius
79.32 ORIF , radius and ulna ;
16. Fracture montegia
S52.2 shaft ulna
79.32 ORIF , radius and ulna
;,
12.485.355
17. Fracture prksimal humerus,neck
humerus
18. OA Sendi lutut perlu TKR
S42.20 fracture of upper end of
humerus
M17.4 other secondary gonarthrosis ,
bilateral
M19.26 secondary of the joint , lower
leg
79.31 ORIF humerus
12.485.355
81.54 Total Knee
Replacement
5.978.592
19. OA Sendi perlu TKR
M17.4 other secondary gonarthrosis ,
bilateral
M19.26 secondary of the joint , lower
leg
81.47 other repair of knee
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
20. OA sendi Hip perlu THR
M19.26 secondary of the joint , lower
leg
81.51 Total Hip Replacement
21. OA Sendi perlu THR
M19.26 secondary of the joint , lower
leg
81.40 Repair of hip, not
elsewhere classified
Knee replacement
3.000.000
5.978.592
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
22. Fracture collum femur,
M81.65 Osteoporosis
81.40 Repair of hip, not
Klas 1= 8.898.656
S72.0 fracture of head and neck of
femur
23. Fracture plateau tibia
24. Fracture acetabulum
S82 Fracture of tibia
)
S32.4 fracture acetabulum
elsewhere classified
79.36 ORIF , tibia and fibula
79.30 ORIF , unspecified site
05.9 other operation on
nervous system
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
3000.000
21.963.542
11.164.055
25. Fracture
pedis,metacarpale,ankle
26. Fracture patella
S82.90 Fracture of lower leg ,
including ankle
822.1 fracture of patella,open
79.37 ORIF tarsal,metatarsal
Hip implant :
6000.000
8.855.736
81.44 patellar stabilization
21.963.542
27. Infeksi pada sendi,
M01 direct infection of joint in
infectious and parasitic disease
classified elsewhere
81.9 other operation on joint
structure
86.66 homograft to skin
28. Infeksi tulang, tromboemboli
M86 Osteomyelitis,
29. Dislokasi pinggul
S73.0 Dislocationand sprain of joint
and ligament of hip
79.6 debridement of open
fracture site ;
86.72 pedicle or flap graft,
not otherwise specified
79.75 closed reduction of
dislocation , hip
30. Dislokasi bahu
S43.0 Dislocation and sprain of joint
and ligament of shoulder
79.71 closed reduction of
dislocation shoulder
1.948.000
31. Dislokasi siku
S53.1 Dislocation and sprain of joint
and ligament of elbow
79.72 closed reduction of
dislocation , elbow
1.948.000
3481.352
32. Fracture neglected
M84.9 disorder of continuity of
bone,unspesified
78.4 other repair of plastic
operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
33. Ruptur Tendon Achilles
Paediatrik (kelainan dan fracture pada anak < 15 th)
No
1.
Keterangan
Reposisi dan pasang gip
ekstremitas atas dengan GA
ICD 10 Diagnosis
S62.80 fracture at wrist and hand
level
ICD 9 Prosedur
79.04 closed reduction of
fracture without internal
fixation
Plafon
1.948.000
2
Reposisi dan pasang gip
ekstremitas bawah dengan GA
S82.7 fracture of lower leg
79.07 closed reduction of
fracture without internal
fixation
1.948.000
3
Rekonstruksi ibu jari kaki , halux
valgus
M20.1 halux valgus/acquired
82.89 other plastic operation
on hand
77.51 other buninectomy
8.855.731
4
Fracture neglected
M84.9 disorder of continuity of
bone,unspesified
5
Kelainan congenital,CTEV,Blount Q66.3 other congenital varus
78.4 other repair of plastic
operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
78.4 other repair of plastic
12.485.355
6
disease
deformities of feet,
operation of bone
Pemanjangan tulang
Q66.3 other congenital varus
deformities of feet,
78.3 limb lengthening
procedure
21.953.542
Tumor Tulang
No
1.
Keterangan
Biopsi tumor
ICD 10 Diagnosis
D21.9 other benign neoplasm and
other soft tissue
ICD 9 Prosedur
80.31 biopsy of joint
structure
plafon
2.049.737
2
Eksisi tumor
Amputasi tumor di atas
lutut(above knee)
82.29 excision of other
lesion of hand
84.17 amputation above
knee/transfemoral
12.485.355
3
4
Amputasi tumor di bawah lutut
(below knee)
84.15amputation below knee
9.099.400
5
Eksisi luas (wide eksisi)
C40.9 malignant neoplasm of bone
and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
D49.2 neoplasm of unspecified
behavior of bone , soft tissue , skin
S85.0 injury of popliteal artery
12.485.355
6
Fraktur dengan tumor tulang
7.
Operasi tumor ganas
77.60 local excision of lesion
or tissue of bone unspecified
site
86.66 homograft to skin
79.3 ORIF
86.66 homograft to skin
78.4 other repair of plastic
operation of bone;
86.72 pedicle or flap graft,
not otherwise spesified
C40.9 malignant neoplasm of bone
and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
9.099.400
8.403.235
8
Ganti sendi pada kasus tumor
tulang/AMP
C79.9 secondary malignant neoplasm
of unspecified site
81.40 repair of hip
8.403.235
Arthroscopy , Shoulder (bahu) dan Knee (lutut)
No
1.
Keterangan
Infeksi sendi lutut,
ICD 10 Diagnosis
M17.9 Gonarthrosis , unspecified
M01.56 arthritis in other bacterial
disease lower leg
M35.4 diffuse fasciitis
ICD 9 Prosedur
81.47 other repair of knee
plafon
21.000.000
2
Bahu kaku/frozen shoulder/
adhesive capsulitis
M75.0 adhesive capsulitis of shoulder
M35.4 diffuse fasciitis
80.21 arthroscopy shoulder
7.691.547
3
Mengeluarkan benda asing di
lutut/loose bodies
M25.68 stiffness of joint
M65.26 calcific tendinitis
81.47 other repair of knee
21.000.000
4
5
Debridement shoulder
M25.68 stiffness of joint
M65.26 calcific tendinitis M35.4
diffuse fasciitis
80.21 arthroscopy shoulder;
Klas 3 = 7.691.547
Klass 2 =9226.000
Klass1: 10.768.160
6
7
Rotator cuff tear
M75.1 complete rotator cuff tear or
rupture not specified as traumatic
80.21 arthroscopy shoulder;
80.49 division of joint,
9.229.852
M35.4 diffuse fascitis
ligament or cartilage of other
specified site
8
Rupture meniscus
M23.2 dearrangement of meniscus
due to old tear or injury
81.47 other operation of
knee
21.000.000
9
Osteoarthritis lutut derajat
ringan (1-2)/ artroscopy
debridement
S83.2 tear of meniscus,current
M35.8 other specified systemic
involvement connective tissue
81.47 other operation of
knee
21.000.000
Ligament ACL/PCL lutut putus
M23.61 other spontaneous disruption
of ligament of knee, ACL /Anterior
horn medial meniscus
81.47 other operation of
cruciate ligament
Klas 3= 21.963.542
Klas 2= 26.356.251
Klas 1= 30.748.959
10
11
Implant knee :
6000.000
12
13
14
Ganti sendi lutut/ total knee
arthroplasty/osteoarthritis
derajat berat
Rematik di lutut derajat berat
perlu ganti sendi
M17 osteoartritis of knee
)
M05.661 rhaumatoid arthritis of left
knee with involvement of other organ
and system
81.47 other operation of
knee
81.47 other operation of
knee
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000
15
Spine/ Tulang Belakang
No
1.
Keterangan
scoliosis
ICD 10 Diagnosis
M41.55 scoliosis
S25.9 injury of unspecified blood
vessel of thorax
M43.54 vertebral subluxation
ICD 9 Prosedur
81.60 , 360 degree spinal
fusion, single incision
approach
83.74 reattachment of
muscle
77.31 other division of
scapula, clavicle,and thorax
(rib and sternum)
plafon
34.590.151
2
Spondilolisthesis, canal stenosis
M43.15 spondilolisthesis; M48.05
spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
3.
Tumor tulang belakang
C41.2 malignant neoplasm of
vertebral column ; M48.05 spinal
stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
4
HNP/canal stenosis di cervical
dengan tetraparese dengan
implan
M50.1 cervical disc disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
03.09 other exploration and
decompression of spinal
canal
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
G82.4 flaccid tetraplegia
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
5
HNP/canal stenosis di
thorakal/lumbal dengan implan
M51.1 thoraxic , thoracolumbal and
lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
6
HNP/Canal stenosis di cervical
tetraparese tanpa implan
M50.1 cervical disc disorder;
M48.02 spinal stenosis
M48.52 collapse vertebrae
G82.4 flaccid tetraplegia
03.09 other exploration and
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
25.165.278
7
HNP/canal stenosis di
thorakal/lumbal tanpa implant
M51.1 thoraxic , thoracolumbal and
lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
03.09 other exploration and
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
19.950.055
8
Fraktur tulang belakang dengan
implan
S32.7 fracture of lumbar spine and
pelvis;
M48.0 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
INA - CBG BPJS
Orthopaedi
Januari 2014
Residen wajib mengisi lembar RM 1, Lembar Verifikasi dan laporan operasi sesuai
dengan diagnosis dan tindakan yang tertera secara lengkap, setiap selesai operasi
DAFTAR DIAGNOSIS (ICD 10) DAN TINDAKAN (ICD 9)
DIVISI ORTHOPAEDI DAN TRAUMATOLOGI
Hand (kelainan dan luka di tangan)
Keterangan
Remove implant
ICD 10 Diagnosis
S52.90
Luka terbuka di tangan, crush
injury
S67.8 Crushing injury of other and
84.03 amputation through
unspecified parts of wrist and hand
hand.
S55.1 injury of radial artery at forearm
level
M65.8 Synovitis and tenosynovitis
82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
L.02.51 Cutaneus abscess of the hand. 82.04 incision and drainage
of palmar at thenar space,
86.66 homograft to skin
M67.4 ganglion
82.29 Excision of other lesion
of soft tissue of hand
14.952.975
Fracture pada pergelangan
tangan dan tangan
S62.8 fracture at wrist and hand level
12.485.355
Luka berat pada jari, tangan
(perlu amputasi)
S68 traumatic amputasion of wrist
84.04 amputation and
and hand level
disarticulation of hand
S55.1 injury of radial artery at forearm
Luka kotor /infeksi di jaringan
lunak
Infeksi jaringan
ganglion
ICD 9 Prosedur
78.69 removal implant
device from the bone
79.34 open reduction of
fracture with internal fixation
, carpals and metacarpals.
Plafon
3.765.791
8.403.235
8.403.235
12.485.355
14.952.971
Deformitas/ kelainan pada jari
level
M20.0 Deformity of finger
Jepitan pada syaraf/carpal
tunnel syndrome
Syndactili
84.03 amputation and
disarticulation of Hand
9099.408
S64 injury of nerves at wrist and hand
level
Q70 Syndactili
05.9 other operation on
nervous system
86.85 correction of
syndactyly
11.164.055
Dislokasi pada jari
S63.1 dislocation and sprain of joints
and ligaments at wrist and hand level
79.84 open reduction of
dislocation of hand and
finger
12.485.355
Tumor ganas pada ekstremitas
atas
C40.1 malignant neoplasm of short
84.03 amputation of through
bones of upper limb
hand
S55.1 injury of radial artery at forearm
leve
14.952.975
Infeksi pada sendi
M00 Pyogenic infection
8.404.231
Kerusakan sendi krn rematik
M05 .38 rheumatoid arthritis with
rheumatoid factor
M65.80 other synovitis and
tenosynovitis
81.29 arthhrodesis of other
specified joints
86.66 homograft to skin
81.29 arthhrodesis of other
specified joints
86.66 homograft to skin
Kerusakan sendi bukan karena
rematik
M06 other rheumatoid arthritis
8.403.235
Deformitas/ kelainan pada jari
M20.0 Deformity of finger
81.29 arthhrodesis of other
specified joints
86.72 pedicle or flap graft,
not otherwise specified
82.8 other plastic operation
12.485.355
8.403.235
12.485.355
on hand,
kontracture
M24.59 contracture unspecified site
82.3 other excision of soft
tissue of hand;
12.485.355
polidactili
Q69 polidactyli
84.03 amputation and
disarticulation of finger:
86.66 homograft to skin
8.403.235
Raw surface, defek soft tissue,
sural flap, semua tindakan flap
L98.9 other disorders of skin and
subcutaneous tissue, not elsewhere
Traumatic amputasi perlu
replantasi
82.8 other plastic operation
on hand
86.72 pedicle or flap graft,
not otherwise spesified
S68.9 traumatic amputasion of wrist
84.22 finger reattachment
and hand level
86.72 pedicle or flap graft,
S55.1 injury of radial artery at forearm not otherwise spesified
leve
8.403.235
ICD 10 Diagnosis
M84.90 disorder of continuity of
bone , unspecified
S42 fracture of shoulder and upper
arm
S.06.9 intracranial injury
S42 fracture of shoulder and upper
arm
ICD 9 Prosedur
78.69 bone graft
86.66 homograft to skin
79.30 ORIF,unspecified site
Plafon
8.403.235
79.30 ORIF,unspecified site
7.691.543
8.403.235
Trauma (Fracture)
No
1.
Keterangan
Non union perlu bone graft
2.
Fracture clavikula
3.
Fracture clavikula dengan
cedera kepala
3.835.376
4.
Fracture tibia/fibula
S82.21 Fracture of shaft tibia
79.36 ORIF , tibia and fibula
21.963.542
5.
Fracture distal tibia
S82.2 Fracture of shaft tibia
79.36 ORIF
21.963.542
6.
Fracture femur
S72.31 fracture shaft femur
79.35 ORIF , femur
7.
Fracture radius
S52.3 fracture shaft radius
79.32 ORIF , radius and ulna
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
12.485.355
8.
Fracture ulna
S52.2 fracture shaft ulna
79.32 ORIF , radius and ulna
12.485.355
9. Fr antebrachii
10. Fracture humerus
S52.7 fracture shaft forearm
S42.3 fracture shaft humerus
79.32 ORIF , radius and ulna
79.31 ORIF humerus
12.485.355
12.485.355
11. Fracture pada tangan,
metacarpal, phalang
12. Fracture subtrochanter femur
perlu ORIF
S62 fracture at wrist and hand level
79.34 ORIF phalank of hand
12.485.355
S72.2 subtrochanteric fracture of
femur
79.35 ORIF , femur
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
13. Fracture intercondylar femur,
14. Fracture intertrochanter femur
S72 fracture shaft femur
M81.65 Osteoporosis
S72.14 Intertrochanteric fracture of
femure
79.35 ORIF , femur
Hip implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
79.35 ORIF , femur
Knee implant :
6000.000
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
6000.000
12.485.355
15. Fracture galeazi
S52.3 fracture shaft radius
79.32 ORIF , radius and ulna ;
16. Fracture montegia
S52.2 shaft ulna
79.32 ORIF , radius and ulna
;,
12.485.355
17. Fracture prksimal humerus,neck
humerus
18. OA Sendi lutut perlu TKR
S42.20 fracture of upper end of
humerus
M17.4 other secondary gonarthrosis ,
bilateral
M19.26 secondary of the joint , lower
leg
79.31 ORIF humerus
12.485.355
81.54 Total Knee
Replacement
5.978.592
19. OA Sendi perlu TKR
M17.4 other secondary gonarthrosis ,
bilateral
M19.26 secondary of the joint , lower
leg
81.47 other repair of knee
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
20. OA sendi Hip perlu THR
M19.26 secondary of the joint , lower
leg
81.51 Total Hip Replacement
21. OA Sendi perlu THR
M19.26 secondary of the joint , lower
leg
81.40 Repair of hip, not
elsewhere classified
Knee replacement
3.000.000
5.978.592
Klas 1= 8.898.656
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
22. Fracture collum femur,
M81.65 Osteoporosis
81.40 Repair of hip, not
Klas 1= 8.898.656
S72.0 fracture of head and neck of
femur
23. Fracture plateau tibia
24. Fracture acetabulum
S82 Fracture of tibia
)
S32.4 fracture acetabulum
elsewhere classified
79.36 ORIF , tibia and fibula
79.30 ORIF , unspecified site
05.9 other operation on
nervous system
Klas 2 = 7.627.420
Klas 3 = 6 .356.183
Hip implant :
3000.000
21.963.542
11.164.055
25. Fracture
pedis,metacarpale,ankle
26. Fracture patella
S82.90 Fracture of lower leg ,
including ankle
822.1 fracture of patella,open
79.37 ORIF tarsal,metatarsal
Hip implant :
6000.000
8.855.736
81.44 patellar stabilization
21.963.542
27. Infeksi pada sendi,
M01 direct infection of joint in
infectious and parasitic disease
classified elsewhere
81.9 other operation on joint
structure
86.66 homograft to skin
28. Infeksi tulang, tromboemboli
M86 Osteomyelitis,
29. Dislokasi pinggul
S73.0 Dislocationand sprain of joint
and ligament of hip
79.6 debridement of open
fracture site ;
86.72 pedicle or flap graft,
not otherwise specified
79.75 closed reduction of
dislocation , hip
30. Dislokasi bahu
S43.0 Dislocation and sprain of joint
and ligament of shoulder
79.71 closed reduction of
dislocation shoulder
1.948.000
31. Dislokasi siku
S53.1 Dislocation and sprain of joint
and ligament of elbow
79.72 closed reduction of
dislocation , elbow
1.948.000
3481.352
32. Fracture neglected
M84.9 disorder of continuity of
bone,unspesified
78.4 other repair of plastic
operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
33. Ruptur Tendon Achilles
Paediatrik (kelainan dan fracture pada anak < 15 th)
No
1.
Keterangan
Reposisi dan pasang gip
ekstremitas atas dengan GA
ICD 10 Diagnosis
S62.80 fracture at wrist and hand
level
ICD 9 Prosedur
79.04 closed reduction of
fracture without internal
fixation
Plafon
1.948.000
2
Reposisi dan pasang gip
ekstremitas bawah dengan GA
S82.7 fracture of lower leg
79.07 closed reduction of
fracture without internal
fixation
1.948.000
3
Rekonstruksi ibu jari kaki , halux
valgus
M20.1 halux valgus/acquired
82.89 other plastic operation
on hand
77.51 other buninectomy
8.855.731
4
Fracture neglected
M84.9 disorder of continuity of
bone,unspesified
5
Kelainan congenital,CTEV,Blount Q66.3 other congenital varus
78.4 other repair of plastic
operation of bone
78.70 osteoclasis,unspecified
site
86.66 homograft to skin
78.4 other repair of plastic
12.485.355
6
disease
deformities of feet,
operation of bone
Pemanjangan tulang
Q66.3 other congenital varus
deformities of feet,
78.3 limb lengthening
procedure
21.953.542
Tumor Tulang
No
1.
Keterangan
Biopsi tumor
ICD 10 Diagnosis
D21.9 other benign neoplasm and
other soft tissue
ICD 9 Prosedur
80.31 biopsy of joint
structure
plafon
2.049.737
2
Eksisi tumor
Amputasi tumor di atas
lutut(above knee)
82.29 excision of other
lesion of hand
84.17 amputation above
knee/transfemoral
12.485.355
3
4
Amputasi tumor di bawah lutut
(below knee)
84.15amputation below knee
9.099.400
5
Eksisi luas (wide eksisi)
C40.9 malignant neoplasm of bone
and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
D49.2 neoplasm of unspecified
behavior of bone , soft tissue , skin
S85.0 injury of popliteal artery
12.485.355
6
Fraktur dengan tumor tulang
7.
Operasi tumor ganas
77.60 local excision of lesion
or tissue of bone unspecified
site
86.66 homograft to skin
79.3 ORIF
86.66 homograft to skin
78.4 other repair of plastic
operation of bone;
86.72 pedicle or flap graft,
not otherwise spesified
C40.9 malignant neoplasm of bone
and articular cartilage of limb,.
C40.9 malignant neoplasm of bone
and articular cartilage of limb,. S85.0
injury of popliteal artery
9.099.400
8.403.235
8
Ganti sendi pada kasus tumor
tulang/AMP
C79.9 secondary malignant neoplasm
of unspecified site
81.40 repair of hip
8.403.235
Arthroscopy , Shoulder (bahu) dan Knee (lutut)
No
1.
Keterangan
Infeksi sendi lutut,
ICD 10 Diagnosis
M17.9 Gonarthrosis , unspecified
M01.56 arthritis in other bacterial
disease lower leg
M35.4 diffuse fasciitis
ICD 9 Prosedur
81.47 other repair of knee
plafon
21.000.000
2
Bahu kaku/frozen shoulder/
adhesive capsulitis
M75.0 adhesive capsulitis of shoulder
M35.4 diffuse fasciitis
80.21 arthroscopy shoulder
7.691.547
3
Mengeluarkan benda asing di
lutut/loose bodies
M25.68 stiffness of joint
M65.26 calcific tendinitis
81.47 other repair of knee
21.000.000
4
5
Debridement shoulder
M25.68 stiffness of joint
M65.26 calcific tendinitis M35.4
diffuse fasciitis
80.21 arthroscopy shoulder;
Klas 3 = 7.691.547
Klass 2 =9226.000
Klass1: 10.768.160
6
7
Rotator cuff tear
M75.1 complete rotator cuff tear or
rupture not specified as traumatic
80.21 arthroscopy shoulder;
80.49 division of joint,
9.229.852
M35.4 diffuse fascitis
ligament or cartilage of other
specified site
8
Rupture meniscus
M23.2 dearrangement of meniscus
due to old tear or injury
81.47 other operation of
knee
21.000.000
9
Osteoarthritis lutut derajat
ringan (1-2)/ artroscopy
debridement
S83.2 tear of meniscus,current
M35.8 other specified systemic
involvement connective tissue
81.47 other operation of
knee
21.000.000
Ligament ACL/PCL lutut putus
M23.61 other spontaneous disruption
of ligament of knee, ACL /Anterior
horn medial meniscus
81.47 other operation of
cruciate ligament
Klas 3= 21.963.542
Klas 2= 26.356.251
Klas 1= 30.748.959
10
11
Implant knee :
6000.000
12
13
14
Ganti sendi lutut/ total knee
arthroplasty/osteoarthritis
derajat berat
Rematik di lutut derajat berat
perlu ganti sendi
M17 osteoartritis of knee
)
M05.661 rhaumatoid arthritis of left
knee with involvement of other organ
and system
81.47 other operation of
knee
81.47 other operation of
knee
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000
Klas 1: 30.748.959
Klas 2:26.353.251
Klas 3: 21.963.542
Knee replacement
3.000.000
15
Spine/ Tulang Belakang
No
1.
Keterangan
scoliosis
ICD 10 Diagnosis
M41.55 scoliosis
S25.9 injury of unspecified blood
vessel of thorax
M43.54 vertebral subluxation
ICD 9 Prosedur
81.60 , 360 degree spinal
fusion, single incision
approach
83.74 reattachment of
muscle
77.31 other division of
scapula, clavicle,and thorax
(rib and sternum)
plafon
34.590.151
2
Spondilolisthesis, canal stenosis
M43.15 spondilolisthesis; M48.05
spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
3.
Tumor tulang belakang
C41.2 malignant neoplasm of
vertebral column ; M48.05 spinal
stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
4
HNP/canal stenosis di cervical
dengan tetraparese dengan
implan
M50.1 cervical disc disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
03.09 other exploration and
decompression of spinal
canal
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
G82.4 flaccid tetraplegia
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
5
HNP/canal stenosis di
thorakal/lumbal dengan implan
M51.1 thoraxic , thoracolumbal and
lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390
6
HNP/Canal stenosis di cervical
tetraparese tanpa implan
M50.1 cervical disc disorder;
M48.02 spinal stenosis
M48.52 collapse vertebrae
G82.4 flaccid tetraplegia
03.09 other exploration and
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
25.165.278
7
HNP/canal stenosis di
thorakal/lumbal tanpa implant
M51.1 thoraxic , thoracolumbal and
lumbosacral intervertebral disc
disorder;
M48.05 spinal stenosis
M48.54 collapse vertebrae
03.09 other exploration and
decompression of spinal
canal
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
19.950.055
8
Fraktur tulang belakang dengan
implan
S32.7 fracture of lumbar spine and
pelvis;
M48.0 spinal stenosis
M48.54 collapse vertebrae
S25.8 injury of other blood vessel of
thorax
03.09 other exploration and
decompression of spinal
canal
84.51 insertion of other
spinal device;
81.62 fusion of 2-3 vertebrae
81.04 Dorsal fusion
Klass 3= 25.165.278
Klass 2= 30.000.000
Klass 1 = 35.231.390