TATA CARA KODING ICD-10

dr. Rinda NK, M.Kes

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

1. Persiapan koding : – Alat bantu koding (Buku ICD-10 Vol.1

& 3, Kamus kedokteran/ Bhs Inggris)– Dokumen Rekam Medis (RM) lengkap

(post-assembled)

2. Analisis dokumen RM untuk menentukan item yang harus di-kode

3. Koding

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

1. Identifikasi tipe pernyataan yang akan di-kode

2. Lihat lead term Vol 33. Baca seksama & ikuti

petunjuk catatan yang muncul di bawah lead term

PENGGUNAAN Volume 3 (ALPHABETICAL INDEX)

1.Perhatikan struktur diagnosis lead term

2.Tentukan penggolongan lead term dalam bagian yg sesuai (Vol.3)

3.Perhatikan catatan & cross-reference (Vol.3)

PEDOMAN SEDERHANA DALAM KODING

4. Baca istilah yg terdapat dlm tanda kurung “( )” sesudah lead term

5. Ikuti secara hati-hati setiap ‘cross -references’ dan perhatikan ‘see’ & ‘see-also’ yg ada dlm indeks

6. Lihat daftar tabulasi (Vol.1) untuk melihat kode yg paling tepat. Bila ada .- cari karakter ke-4

7. 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 kiriMerupakan masalah (diagnosis, cedera,

dll) utama pada pasien.

Berbagai kata standar yang dapat digunakan sbg ‘lead term’

• Assault (=homicidal) Sect. II

• Complication• Disease• Delivery• Examination

• Fracture• Infection• Injury• Labour/labor• Pregnancy• Sequellae• Eponym

Catatan

EPONYM ;adalah penyebutan suatu penyakit, gangguan atau prosedur berdasarkan nama orang yang menemukan, meneliti atau mengembangkan prosedur, diagnosis atau gangguan tsb.Sbg contoh : Bell’s palsy, Hansen’s disease.Jadi lead term-nya bisa dirujuk dengan Bell atau Hansen (eponym) atau palsy atau disease (kondisi)

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.

Cara Menggunakan ICD-10

Diagnosis Utama

(Lead Term)

Volume 3 ICD-10

Volume 1 ICD-10

Kode Penyakit

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 • Pernyataan diagnostik

yang diklasifikasikan dlm kelompok tsb.

• Dpt dipakai untuk kondisi yg berbeda atau sinonimnya

EXCLUSION• 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 TONSILINDEX ALFABETIK SECTION ICalculus, 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

TABULAR LIST VOL. 1J35.8 Other chronic diseases of tonsils and adenoids

Adenoid vegetationsAmygdalolithCicatrix of tonsil (and adenoid)Tonsillar tagUlcer of tonsil

– Extracted from ICD-10 Second Edition, 2005, Diseases of the respiratory system.

Contoh Inclusion

INDEKS ALFABETIKAmygdalolith J35.8

Extracted from ICD-10 Second Edition, 2005, A.

Contoh Inclusion

L05 Pilonidal cystIncludes: fistula } coccygeal or pilonidal sinus } L05.0 Pilonidal cyst with abscessL05.9 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 virusesExcludes: 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 transmissibleExcludes: 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.

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 comaHyperglycaemic 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 closed1 open

Extracted from ICD-10 Second Edition, 2005, Injury, poisoning

and certain other consequences of external causes.