KLASIFIKASI KASUS KEHAMILAN PERSALINAN DAN MASA NIFAS ICD

KLASIFIKASI KASUS KEHAMILAN, PERSALINAN DAN MASA NIFAS (ICD 10 Bab 15) Pertemuan 7 Deasy Rosmala Dewi, SKM, MKes Prodi RMIK, Fakultas Ilmu-ilmu Kesehatan

KEMAMPUAN AKHIR YANG DIHARAPKAN • Menentukan nomor kode ICD 10 dan ICD 9 CM yang berkaitan dengan Kehamilan, persalinan dan masa nifas dengan presisi, benar dan tepat sesuai yang diderita pasien

BAB XV, KEHAMILAN, KELAHIRAN & MASA NIFAS (O 00 -O 99) 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)

• 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. -)

Bab ini meliput 8 blok sebagai berikut: O 00 -O 08 O 10 -O 16 O 20 -O 29 O 30 -O 48 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

Bab ini meliput 8 blok sebagai berikut: . . O 60 -O 75 O 80 -O 84 O 85 -O 92 O 95 -O 99 Komplikasi persalinan dan kelahiran Kelahiran/Metode persalinan Komplikasi yang utamanya berkaitan dengan masa nifas Kondisi-2 lain obstetrik, NEC

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. 8 . 2 . 3. 9 . 4 . 5 . 6

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. : . .

• 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

• 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.

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)

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 Incl. : . . . Eclampsia superimposed on chronic hypertension

• 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

• 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

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.

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

• 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. 3, O 26. 4, O 24. 5 dan O 26. 8; O 26. 9 O 26. 1;

• 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.

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

• 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

• 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.

• 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.

• 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. : . . .

• 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

LATIHAN 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Hamil dengan plasenta previa totalis dan perdarahan Abortus spontan inkomplit, Infeksi post kuret Hamil 71/2 bulan sakit febris typhoid Bumil 6 bulan, HIV positif Gestational Diabetes Gestational hypertension Hydatidiform mole Hyperemesis Gravidarum Hysterorrhexis Incompetent cervix Occiput posterior position / malposisi janin Pre eclamsia Rh incompatibility / T 80. 4 Transverse Presentation/O 32. 2 Definisi Lead Term ICD 10 O 44. 1 O 03. 4 O 86. 1 R 50. 9, O 98. 9 B 24, O 98. 7 O 24. 4 O 13 Oo 1. 9 O 21. 0 Ruptur uterus N 88. 3

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. : . . .

• 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)

• 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

• 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)

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)

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

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.

• 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. : . . .

• 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

• 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.

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)

• 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. : . . .

• 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.

• 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

• 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. : . . .

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. : . . .

• 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

• 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. : …

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

• 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.

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. : . . .

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

LATIHAN 1. Hamil dengan plasenta previa totalis dan perdarahan Seksio caiser emergensi, Bayi tunggal hidup, cyanosis No: o 44. 1 No: o 82. 1 No: p 21. 1 2. Partus normal spontan, letsu Bayi tunggal hidup Bayi cenggeng, kurang ASI No: o 80. 1 No: z 38. 0 No: p 74. 1 dehidrasi 3. Abortus spontan inkomplit, Infeksi post kuret No: o 03. 5 No: o 75. 3 4. Partus kembar 2, spontan. I letkep, dan II letsu bayi prematur (BB < 1. 750) No: o 84, o 60. 1 No: o 80. 0, o 80. 1 No: z 37. 2, z 38. 3, p 07. 1

Pragnancy Diagnostic Procedure, Operative and Laboratory Test No Istilah Procedures 1. Chorionic Villus Sampling/ CTV 2. Contraction Stress test/ CTS 3. Electronic Fetal Monitoring 4. Episiotomy 5. Pelvimetry 6. Pregnancy Test 7. Amniocentesis Amniography 8. Amnioscopy 9. Amniotomy 10. Cerclage Definisi Lead Term Kode ICD 9 CM