ICD10 CHAPTER XV BAB O Kehamilan Persalinan Masa

ICD-10 CHAPTER XV BAB O Kehamilan, Persalinan & Masa Nifas 1

BAB XV (O 00 -O 99) KEHAMILAN, KELAHIRAN & MASA NIFAS [641 – 678] The codes included in this chapter are to be. . . Excl. : • Certain d. or injuries compl. preg. , childb. and puerp. cl. elsew. : external causes (for mortality) (V, W, X, Y) • Cedera, keracunan & konsekuensi lain akibat sebab luar (S 00 -T 88. 1, T 88. 6 -T 98) 2

(Lanjutan) • Gangguan mental & prilaku yang terkait masa nifas (F 53. -) • Tetanus obstetrik (A 34) • Nekrosis postpartum kelenjar pituitari (E 23. 0) • Osteomalacia postpartum (M 83. 0) • Supervisi dari: Kehamilan berisiko tinggi (Z 35 -) Kehamilan normal (Z 34. -) 3

Bab ini meliput 8 blok sebagai berikut: O 00 -O 08 O 10 -O 16 O 20 -O 29 O 30 -O 48 O 60 -O 75 O 80 -O 84 O 85 -O 92 O 95 -O 99 Kehamilan dengan abortus Edema, proteinuira & gangguan hipertensi pada kehamilan, kelahiran & nifas Gangguan-gangguan maternal lain yang utamanya terkait kehamilan. Asuhan maternal terkait janin, kantung ketuban yang kemungkinan menimbulkan masalah persalinan/kelahiran Komplikasi persalinan dan kelahiran Kelahiran/Metode persalinan Komplikasi yang utamanya berkaitan dengan masa nifas Kondisi-2 lain obstetrik, NEC 4

Kehamilan dengan hasil Abortus (O 00 -O 08) [642 – 647] EXCL. : kehamilan berlanjut setelah satu atau lebih dari satu janin gugur pada suatu kehamilan multipel. Tersedia karakter ke-4 sebagai subdivisi untuk dimanfaatkan melengkapi O 03 – O 06. Note: incomplete abortion includes retained products of conception following abortion. [642]. 0. 7 . 1 dan . 2. 8 . 3 . 4 . 5 . 6 . 9 5

(Lanjutan) Perhatikan: • O 00 Kehamilan di luar kandungan Incl. : … Use additional code dari …O 08. O 00. 0 ada Excl. : . . . O 00. 1; O 00. 2 dan O 00. 8; O 00. 9. • O 01 Mola hidatidiform Use additional code dari … O 08. Excl. : . . . O 01. 0; O 01. 1 dan O 01. 9 O 02 Other abnormal products of conception Use additional code dari … O 08. Excl. : . . . O 02. 0 dan O 02. 9. Pada O 02. 1, O 02. 8 ada Excl. : . . 6

(Lanjutan) • O 03 Spontaneous abortion [See before O 03 for subdivisions] Incl. : . . . • O 04 Medical abortion [See before O 03 for subdivisions] Incl. : termination of pregnancy: legal, therapuetic abortion • O 05 Other abortion [See before O 03 for subdivisions] • O 06 Unspecified abortion [See before O 03 for subdivisions] Incl. : induced abortion NOS 7

(Lanjutan) • O 07 Failed attempted abortion Incl. : . . . Excl. : . . . O 07. 0, O 07. 1, O 07. 2, O 07. 3, O 07. 5, O 07. 6, O 07. 7 dan O 07. 8 semua disertai: with cond. in O 08. Pada O 07. 4, O 07. 9 ada Failed attemp abortion. • O 08 Complicating following abortion & ectopic & molar pregnancy Note: This code is provided primary for morbidity coding. For use of this category reference should be made to the morbidity coding rules & quidelines in Volume 2. 8

(Lanjutan) O 08. 0 Genital tract and pelvic infect. follow. abort. and ectopic and molar preg. Ada tambah: septicaemia di bawah sepsis. Use add. Code (R 57. 2), . . . Excl. : . . . O 08. 1; O 08. 2; O 08. 4; O 08. 5; O 08. 6; O 08. 7 dan O 08. 8; O 08. 9 Pada O 08. 3 ada Excl. : septic shock (R 57. 2) 9

Oedema, proteinuria & hypertensive complicating disor. in preg. , childb. & the puer. (O 10 – O 16) [647 – 648] • O 10 Pre-existing hypertension. . . Incl. : the listed cond. with preexisting proteinuria Excl. : that with superimposed preexclampsia (O 11) O 10. 0; O 10. 1; O 10. 2; O 10. 3; O 10. 4 dan O 10. 9. • O 11. X Eclampsia superimposed on chronic hypertension Incl. : . . . 10

(Lanjutan) • O 12 Gestational [pregancy-induced] oedema and proteinuria without hypertention O 12. 0; O 12. 1 dan O 12. 2 • O 13. X Gestational [pregancy-induced] hypertention without signif. Proteinuria Incl. : gestational hypertension NOS pregnancy induced hypertension • O 14 Gestational [pregancy-induced] hypertention with signif. Proteinuria Excl. : . . . O 14. 0 Mild to moderate pre-eclampsia O 14. 1 Severe pre-eclamp. O 14. 2 dqn O 14. 9 11

(Lanjutan) • O 15 Eclampsia Incl. : convulsions following conditions in O 10 – O 14 and O 16 exclampsia with pregnancy-induced or pre-existing hypertension O 15. 0; O 15. 1; O 15. 2 dan O 15. 9. • O 16. X Unspecified maternal hypertension. 12

Other maternal disorders predominantly related to pregnancy (O 20 -O 29) [649 -653] Note: Categories O 24. - and O 25 include the listed conditions even if they occur during childbirth or the puerperium. Exclu. : maternal: care related to the fetus and amniotic cavity & possible delivery problems (O 30 -O 48) Disease classifiable elsewhere but complicating pregnancy, labour (labor) and delivery, and the puerperium. 13

(Lanjutan) Perhatikan definisi untuk: • O 20 Haemorrhage in early pregnancy Excl. : … O 20. 0 dan O 20. 8; (O 20. 9 • O 21 Excessive vomiting in pregnancy O 21. 0; O 21. 1 dan O 21. 9 Pada O 21. 2 ada Excl. : . . . Pada O 21. 8 ada Use additional code, if. . . • O 22 Venous complications in pregnancy Excl. : … O 22. 0; O 22. 1; O 22. 2; O 22. 3; O 22. 4; O 22. 5 dan O 22. 8; O 22. 9 14

(Lanjutan) • O 24 Diabetes mellitus in pregnancy Incl. : in childbirth and the puerperium O 24. 0, O 24. 1, O 24. 2, O 24. 3 (pre-existing DM. . . ) O 24. 4 Gestational DM NOS O 24. 9 DM in preg. unspecified. • O 25. X Malnutrition in pregnancy Incl. : malnutrition in child. and the puerp. • O 26 Maternal care for other condi. predom. Related to pregnancy O 26. 0, O 26. 2, O 26. 6 dan O 26. 7 ada Excl. : . . . O 26. 1; O 26. 3, O 26. 4, O 24. 5 dan O 26. 8; O 26. 9 15

(Lanjutan) • O 28 Abnormal find. on antenat. screening of m Excl. : diagnostic findings class. elsew. – see Alphab. Index maternal care related to the fetus and amniotic cavity and possible delivery problems (O 30 -O 48) O 28. 0; O 28. 1; O 28. 2; O 28. 3; O 28. 4; O 28. 5 dan O 28. 8; O 28. 9. • O 29 Complication of anaesthesia during preg. Incl. : … Excl. : . . . O 29. 0; O 29. 1; O 29. 2; O 29. 3; O 29. 4; O 29. 5; O 29. 6 dan O 29. 8; O 29. 9. 16

Maternal care related to the fetus & amniotic cavity & possible delivery problems (O 30 -O 48) [653 -660] • O 30 Multiple gestation Excl. : . . . O 30. 0; O 30. 1; O 30. 2 dan O 30. 8; O 30. 9 • O 31 Complications specific to mutiple gest. Excl. : conjoined twins causing. . . delayed delivery of 2 nd twin. . . malpresenttaion of one fetus or. . . with obstructed labour. . . O 31. 0; O 31. 1; O 31. 2 dan O 31. 8 17

(Lanjutan) • O 32 Maternal car for known or suspected malpres. Of fetus Incl. : . . . Excl. : . . . O 32. 0; O 32. 1; O 32. 2; O 32. 3; O 32. 4; O 32. 5 O 32. 6 dan O 32. 8; O 32. 9 • O 33 Maternal care for known or susp. disprop. Incl. : the listed conditions as a reason for observation, hospitalization or other obstet. care of the mother, or for C-S before onset of labour Excl. : . . . O 33. 0; O 33. 1 s/d O 33. 8; O 33. 9 18

(Lanjutan) • O 34 Maternal care for known or suspected abnormal. of pelv. Organs Incl. : . . . Excl. : . . . O 34. 0; O 34. 3; O 34. 4; O 34. 5; dan O 34. 8; O 34. 9. Pada O 34. 1, O 34. 2, O 34. 6, O 34. 7 ada Excl. : . . . • O 35 Maternal care for known or suspected fetal abnorm. and damage Incl. : . . . Excl. : . . . O 35. 0, O 35. 2 dan O 35. 5 ada Excl. : . . . O 35. 1; O 35. 3; O 35. 4; O 35. 6; O 35. 7 dan O 35. 8; O 35. 9. 19

(Lanjutan) • O 36 Maternal care for other known or suspect. fetal problems Incl. : . . . Excl. : . . . O 36. 0; O 36. 1; O 36. 2; O 36. 3; O 36. 5; O 36. 6; O 36. 7 dan O 36. 8; O 36. 9. Pada O 36. 4 ada Excl. : . . . • O 40. X Polyhydramios Incl. : . . . • O 41 Other disord. Of amn. fluid & membranes Excl. : . . . O 41. 0; O 41. 1 dan O 41. 8; O 41. 9. 20

(Lanjutan) • O 42 Premature rupture of membranee (KPD = ketuban pecah dini) K 42. 0; K 42. 2 dan K 42. 9 Pada K 42. 1 ada Excl. : with labour delayed by. . . • O 43 Placenta disorders Excl. : . . . K 43. 0; K 43. 1 dan K 43. 8; K 43. 9. Pada K 43. 2 Morbidity adherent placenta Use additional. . • O 44 Placenta praevia O 44. 0 (without haemorhage) Pada O 44. 1 ada Excl. : . . . 21

(Lanjutan) • O 45 Premature separation of placenta [abruptio placentae] O 45. 0; O 45. 8 dan O 45. 9 • O 46 Antepartum haemorrhage, NEC Excl. : . . . O 46. 0; O 46. 8 dan O 46. 9 • O 47 False labour O 47. 0 (<37 weeks); O 47. 1 (= atau > 37 weeks) O 47. 9 (unspecified) • O 48. X Prolonged pregnancy Incl. : post-dates; post-term 22

Complications of Labour & Delivery (O 60 -O 75) [661 - 669] • O 60 Preterm labour and delivery Incl. : onset (spontaneous) of labour before 37 completed weeks of gestation Perhatikan definisi pada masing nomor kode. O 60. 0; O 60. 1; O 60. 2 dan O 60. 3 • O 61 Failed inductiion of labour O 61. 0; O 61. 1 dan O 61. 8; O 61. 9 • O 62 Abnormalities of forces of labour O 62. 0; O 62. 1; O 62. 2; O 62. 3 dan O 62. 8; O 62. 9. Pada O 62. 4 ada Excl. : . . . 23

(Lanjutan) • O 63 Long labour Perhatikan hubungan long labour dengan kala persalinan. O 63. 0; O 63. 1; O 63. 2 dan O 63. 9 • O 64 Obstructed labour due to malposition & malpresentation of fetus (sebab adalah letak/presentasi janin) O 64. 0; O 64. 1; O 64. 2 ; O 64. 3; O 64. 5 dan O 64. 8; O 64. 9. Pada O 64. 4 ada Excl. : impected shoulders (O 66. 0) shoulder dystocia (O 66. 0) 24

(Lanjutan) • O 65 Obstructed. . . (sebab adalah pinggul bumil) O 65. 0; O 65. 1; O 65. 2 ; O 65. 3; O 65. 5; O 65. 8; O 65. 9 Pada O 65. 4 ada Excl. : . . • O 66 Other obstructed … O 66. 0; O 66. 1; O 66. 2 ; O 66. 3; O 66. 4; O 66. 5 dan O 66. 8; O 66. 9 • O 67 Persalinan & kelahiran terkomplikasi perdarahan intrapartum, yang NEC. O 67. 0 dan O 67. 8; O 67. 9 25

(Lanjutan) • O 68 L & D complic. by fetal stress [distress] Incl. : . . . O 68. 0 dan O 68. 1 ada Excl. : . . . O 68. 2; O 68. 3 dan O 68. 8; O 68. 9 • O 69 L&D complic. by umb. cord complicat. O 69. 0; O 69. 1; O 69. 2; O 69. 3; O 69. 4; O 69. 5 dan O 69. 8; O 69. 9 • O 70 Perineal laceration during delivery Incl. : . . . Excl. : Tambahan pada ICD-10 ed. Baru Vaginal sulcus laceration (O 71. 4) 26

(Lanjutan) O 70. 0 First degree perineal laceration during deliv. Ada tambahan di bawah: . Labia perisurethral tissue. Vagina low Ada tambahan Excl. : . . . periurethral lac. Involving urethra (O 71. 5) that with laceration - high vaginal wall (middle)(upperthird of vag. wall) (O 71. 4) - vaginal sulcus (O 71. 4) 27

(Lanjutan) O 71. 4 Obstetric high vaginal. . . Excl. : that of the lower vagina (O 70. -) O 71. 5 Other obstet. Injury to pelvic joints & lig. Ada tambahan Excl. : minor laceration involving peri-urethral tissue only (O 70. 0) O 71. 6; O 71. 7 dan O 71. 8; O 71. 9 • O 72 Postpartum haemorrhage Incl. : . . . Pada O 72. 0 ada Use additionalo code, if. . . O 72. 1; O 72. 2 dan O 72. 3 28

(Lanjutan) • O 73 Retained placenta & membranes, without haemorrhage. O 73. 0 ada Use additional code, if. . . O 37. 1 • O 74 Complications of anaesthesia during labour & delivery Incl. : … O 74. 0; O 74. 1 s/d O 74. 8; O 78. 9. • O 75 Other compl. of labour & deliv. , NEC. Excl. : puerp. : infection(O 86); sepsis (O 85) O 75. 0; O 75. 1; O 75. 2; O 75. 3; O 75. 5; O 75. 8; O 75. 9 Pada O 75. 4 dan O 75. 6 ada Excl. : . . . 29

Delivery (PERSALINAN) (O 80 -O 84) [669 -670] Note: Kode O 80 -O 84 tersedia untuk kepentingan code morbiditas. Kode-kode di blok ini hendaknya digunakan untuk kode primer morbiditas hanya apabila tidak ada kondisi lain yang terklasifikasi di bab XV ter-rekam. Bila kategori-kategori ini akan digunakan, rujuklah ke peraturan Morbidity Coding Rules di Volume 2. 30

(Lanjutan) • O 80 Single spontaneous delivery Incl. : cases with minimal or no assistance, with or without episiotomy delivery in a completely normal case. O 80. 0; O 80. 1 dan O 80. 8; O 80. 9. • O 81 Single delivery by forc. & vacuum extr. Excl. : . . . O 81. 0; O 81. 1; O 81. 2; O 81. 3; O 81. 4 dan O 81. 5. • O 82 Single delivery by caesarean section O 82. 0; O 82. 1; O 82. 2 dan O 82. 8; O 82. 9 31

(Lanjutan) • O 83 Other assisted single delivery O 83. 0; O 83. 1; O 83. 2 ; O 83. 3; O 83. 4 dan O 83. 8; O 83. 9. • O 84 Multiple delivery Use additional code (O 80 -O 83), if disired, to indicate the method of delivery of each fetus (janin) or infant (bayi) O 84. 0 Mult. deliv. all spontan. O 84. 1 Mult. deliv. all by forceps and vaccum extr. O 84. 2 Mult. deliv. all by caesarean section O 84. 8 Other mult. deliv. O 84. 9 Mult. Deliv. , unspecified. 32

Complications predominantly related to the puerperium (O 85 -O 92) [671 – 674] Komplikasi yang utamanya terkait masa nifas: Note: Categories O 88. -, O 91. -, O 92. - include the listed conditions even if they occur during pregnancy and childbirth. Excl. : mental & behavioural disorders associated with the puerperium (F 53. -) ostetrical tetanus (A 34) puerperal osteomalacia (M 83. 0) 33

(Lanjutan) • O 85. X Puerperal sepsis Incl. : puerperal: - endometritis, - fever, - peritonitis dan sepsis Use additional code (B 95 -B 97), if desired, to identify infection agent. Excl. : … • O 86 Other puerperal infection Use additional code (B 95 -B 98), if. . Excl. : infection during labour (O 75. 3) O 86. 0; O 86. 1; O 86. 2; O 86. 3 dan O 86. 8. Pada O 86. 4 ada Excl. : . . . 34

(Lanjutan) • O 87 Venous complic. in the puerperium Incl. : in labour, delivery, and the puerperium. Excl. : obstetric embolism (O 88. -) venous compl. in preg. (O 22. -) O 87. 0; O 87. 1; O 87. 2; O 87. 3; O 87. 8; O 87. 9. • O 88 Obstetric embolism Incl. : pulmonary emboli in pregnancy, childbirth or the puerperium Excl. : embolism complicating abortion or ectop. or molar pregnancy (O 00 -O 07. O 08. 2) O 88. 0; O 88. 1; O 88. 2; O 88. 3 dan O 88. 8. 35

(Lanjutan) • O 89 Complication of anesthesia during the puerperium Incl. : maternal complications arising from the administration of general or local anaesthetic, analgesic or other sedation during the puerperium. O 89. 0; O 89. 1; O 89. 2; O 89. 3; O 89. 4; O 89. 5; O 89. 6 dan O 89. 8; O 89. 9 • O 90 Complications of the puerperium, NEC O 90. 0; O 90. 1; O 90. 2; O 90. 3; O 90. 4; O 90. 5 dan O 90. 8; O 90. 9 36

(Lanjutan) • O 91 Infections of breast associated with childbirth Incl. : the listed conditions during pregnancy, the puerperium or lactation. O 91. 0 (infection nipple. . . ) O 91. 1 (Abscess of breast. . . ) O 91. 2 (Non-purulent mastitis. . . ) O 92 Other disorders of breast and lactation associated with childbirth. Incl. : the listed conditions during preg. . O 92. 0; O 92. 1; O 92. 2; O 92. 3; O 92. 4; O 92. 5; O 92. 7. Pada O 92. 6 ada Excl. : . . . 37

Other obstetric conditions, NEC (O 94 -O 99) [675 – 678] Note: For use of categories O 95 -O 97 reference should be made to the mortality coding rules and guidelines in Volume 2 • O 94 Sequelae of compl. of preg. Childb. and puerperium Note: . . . for morbiditas coding only to indicate. . . as the cause of sequelae. . . Not to be used for chronic. . Excl. : . . . 38

(Lanjutan) • O 95. X Obstetric death of unspecified cause Incl. : Maternal death from unspecified cause occurring during pregnancy, labour & delivery, or the puerp. • O 96 Death from any obstetric cause occurring > than 42 days but < than one year after delivery. Use additional code, if desired, to identify obstetric cause (direct or indirect) of death. O 96. 0 Death f. direct obstet. cause O 96. 1 Death f. indirect obstet. cause O 96. 9 Death f. Unspecified obstet. cause 39

(Lanjutan) • O 97 Death from sequelae of direct obstetric causes. Incl. : Death from any direct obstetric cause occurring one year or more after delivery. Use additional code, if disired, to identify. . O 97. 0; O 97. 1 dan O 97. 9 • O 98 Maternal Infectious & parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium Incl. : … Use additional code (Chapter I) if desired, to identify specific condition. Excl. : … 40

(Lanjutan) O 98. 0 O 98. 1 O 98. 2 O 98. 3 O 98. 4 O 98. 5 O 98. 6 O 98. 7 O 98. 8 O 98. 9 (Conditions in A 15 – A 19) (Conditions in A 50 – A 53) (Conditions in A 54) (Conditions in A 55 – A 64) (Conditions in B 15 – B 19) (Conditions in A 80 –B 09; B 25 – B 34) (Conditions in B 50 – B 64) (Conditions in B 20 – B 24) Other maternal infectious. . Unspecified. . 41

(Lanjutan) • O 99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium. Note: This categories includes conditions which complicate the pregnancy state, are aggravated by pregnancy or are a main reason for obstetric care and for which the Alphabetical Index does not indicate a specific rubric in Chapter XV. Use additional code, if desired, to identify specific condition. 42

(Lanjutan) Excl: infectious and parasitic diseases (O 98. -) injury, poisoning and certain other conseq. of external causes (S 00 -T 98) when the reason for maternal care is that the condition is known or suspected to have affected the fetus (O 35 -O 36) O 99. 0 (condition in D 50 – D 64) O 99. 1 (condition in D 65 – D 89) ada Excl. : . . . O 99. 2 (condition in E 00 – E 90) ada Excl. : . . . O 99. 3 (condition in F 00 – F 99 and G 00 – G 99) ada Excl. : . . . 43

(Lanjutan) • O 99. 4 (condition in I 00 – I 99) Excl. : . . . • O 99. 5 (condition in J 00 – J 99) • O 99. 6 (condition in K 00 – K 93) Excl: . . . • O 99. 7 (condition in L 00 – L 99) Excl. : . . . • O 99. 8 (condition in C 00 – D 48, H 00 – H 95, M 00 – M 99, N 00 – N 99, Q 00 – Q 99) Excl. : . . . 44

LATIHAN PENYELESAIAN SOAL-SOAL 1. Hamil dengan plasenta previa totalis dan perdarahan Seksio kaiser emergensi, Bayi tunggal hidup, cyanosis No: No: 2. Partus normal spontan, letsu Bayi tunggal hidup Bayi cenggeng, kurang ASI No: No: 3. Abortus spontan inkomplit, Infeksi post kuret No: 4. Partus kembar 2, spontan. I letkep, dan II letsu bayi prematur (BB < 1. 750) No: 45

(Lanjutan) 5. Hamil 71/2 bulan sakit febris typhoidea Partus spontan, Bayi prematur Ikterus fisiologis 6. Bumil 6 bulan, HIV positif No: No: No: 7. Postpartum thyroiditis No: 8. Partus lama, uterin fibroid No: 9. Partus macet karena bayi letak muka No: 10. Post partum haemorrhage akibat atoni uteri No: 46

SOAL LATIHAN MANDIRI 1. Partus seksio No: Kembar dempet terhubung di abdomen No: Berat badan kedua bayi di atas 2. 250 kg. No: Cengeng sulit menete ASI No: 2. Persalinan macet Myoma uteri Lahir Vakum Bayi cephalohematom 3. Partus spontan, cukup bulan, bayi sehat No: No: 47

(Lanjutan) 4. Persalinan induksi gagal dengan suntikan oxytocin No: Uterin inertia, akhirnya diseksio dengan hysterectomy No: Bayi Hydrosefalus toksoplasmosis No: 5. Solutio placentae, Seksio, bayi premature BB 490 g No: No: 48