KLASIFIKASI KASUS KONGINETAL ICD 10 Bab 17 Pertemuan

KLASIFIKASI KASUS KONGINETAL (ICD 10 Bab 17) Pertemuan 10 Deasy Rosmala Dewi, SKM, MKes Prodi RMIK, Fakultas Ilmu-ilmu Kesehatan

KEMAMPUAN AKHIR YANG DIHARAPKAN • Mahasiswa mampu menentukan Kode ICD-10 dan ICD 9 CM tentang kondisi terkait congenital malformations, deformations, & chromosomal abnormalities

BAB XVII CONGENITAL MALFORMATIONS, DEFORMATIONS, & CHROMOSOMAL ABNORMALITIES (Q 00 Q 99) [707] Excl. inborn errors of metabolism (E 70 -E 90) BLOCKS: Q 00 -Q 07 Q 10 -Q 18 Q 20 -Q 28 Q 30 -Q 34 Congenital malformations of the nervous system Congenital malformations of eye, ear, face & neck Cong. malf. of the circulatory system Cong. malf. of the respiratory system

KEMAMPUAN AKHIR YANG DIHARAPKAN Q 35 -Q 37 Cleft lip & cleft palate Q 38 -Q 45 Other cong. malf. of the digestive syst. Q 50 -Q 56 Congenital malf. of genital organs Q 60 -Q 64 Congenital malf. of the urinary system Q 65 -Q 79 Cong. Malf. & deformations of the musculoskeletal system Q 80 -Q 89 Other congenital malformations Q 90 -Q 99 Chromosomal abnormalities, NEC

BEBERAPA ISTILAH GANGGUAN KONGENITAL • An-encephaly = tidak memiliki kepala, pertumbuhan kepala tidak sempurna (48) Q 00. 0 [708] acephaly; acrania; amyelencephaly; hemianencephaly; hemicephalia • Enchephal/o-cele = hernia di kepala (253) Q 01. 9 - frontal Q 01. 0 - nasofrontal Q 01. 1 - occipital Q 01. 2 - specified NEC Q 01. 8 [708] - encephalocele, unspecified Q 01. 9

• Micro-cephaly = ukuran kepala kecil dari normal (424) microcephalus, microcephalic Q 02 [708] Incl: hydromicrocephaly microencephalon Excl. : Meckel-Gruber syndrome (Q 61. 9) • Hydro-cephalus = ukuran kepala > besar disertai adanya cairan di rongga tegnkorak kepala, bisa kongenital (327) (acquired)(external)(internal)(malignant) (recurrent) G 91. 9 Congenital (external)(internal) Q 03. 9

Hydrocephalus congenital (external)(internal) Q 03. 9 - cong. with spina bifida - see also Spina bifida, with hydrocephalus - dst. Spina bifida = (bisa pada cervical, thoracal, lumbar, sacral) Kegagalan menutup di bagian ujung canalis spinalis sehingga terbelah dua, menonjol dan berisi hernia meninges dan chorda spinalis (585) Spina bifida (aperta) Q 05. 9 [710]

• Malformasi (Malformation) = salah bentuk, pembentukan kurang sempurna (410) Malforkmation (congenital) – see also Anomaly (52) Anomaly, anomaloma (congenital)(unspecified type) Q 89. 9 [752] Q 89. 9 Congenital malformation, unspecified Congenital: - anomaly NOS - deformity NOS • Atresia = lobang buntu (tidak terbentuk) (69) Atresia, atretic belum ada nomor kode ICD-nya

• Glaucoma = tekanan bola mata meningkat, dan cataracta (kekeruhan lensa) mata bisa kongenital. (297) Glaucoma H 40. 9 - congenital Q 15. 0 [714] Q 15. 0 Congenital glaucoma • Cardiac septa = sekat jantung dan klep jantung bisa bocor sejak lahir. (97) Cardiac see also condition

• Cleft lip = bibir sumbing cheiloschisis, labioschisis Palatoschisis sumbing s/d langit-2 (108) Cleft lip (unilateral) Q 36. 9 median Q 36. 1 bilateral Q 36. 3 [724 -725] Cleft lip: Incl. : cheiloschisis congenital fissure of lip harelip labium leporinum Excl. : cleft lip with cleft palate (Q 37. -) Q 37. 0; Q 37. 1 dan Q 37. 9

• Agenesis = tidak tumbuh. (37) Agenesis (harus disebut apa yang agenesis!) dst. • Conjoined twins = kembar dempet. (152) Q 89. 4 [752] Conjoined twins Craniopagus Dicephaly Double monster Pygopagus Thoracopagus

Congenital malformations of the Nervous System (Q 00 – Q 07) [708 -711] Q 00 Anencephaly & similar malformations Q 00. 0; Q 00. 1 dan Q 00. 2 Q 01 Encephalocele Incl. : . . . Excl. : . . . Q 01. 0; Q 01. 1; Q 01. 2 dan Q 01. 8; Q 01. 9 Q 02 Microcephaly Incl. : . . Excl. : . . .

Q 03 Congenital hydrocephalus Incl. : . . . Excl. : . . . Q 03. 0; Q 03. 1 dan Q 03. 8; Q 03. 9 Q 04 Other congenital malformation of brain Excl. : . . . Q 04. 0; Q 04. 1; Q 04. 2 dan Q 04. 4; Q 04. 5 dan Q 04. 8; Q 04. 9 Pada Q 04. 3 dan Q 04. 6 ada Excl. : . . .

Q 05 Spine bifida Incl. : . . . Excl. : . . . Q 05. 0 s/d Q 05. 9 Q 06 Other congenital malform. of spinal cord Q 06. 0 s/d Q 06. 4 dan Q 06. 8; Q 06. 9 Q 07 Other congen. malform. of nerv. system Excl. : . . . Q 07. 0 dan Q 07. 8; Q 07. 9

Congenital malformations of eye, ear, face & neck (Q 10 -Q 18) [711 -716] Excl. : . . . Q 10 Q 11 Q 12 Congen. malf. of eyelid, lacrm. app. & orbit Excl. : . . . Q 10. 0 s/d Q 10. 7 Anophthal. Microphthal. & Macrophthal. Q 11. 0; Q 11. 1; Pada Q 11. 2 dan Q 11. 3 ada Excl. : . . Congenital lens malformations Q 12. 0 s/d Q 12. 4 dan Q 12. 8; Q 12. 9

Q 13 Congenital malf. of anterior segm. of eye Q 13. 0 s/d Q 13. 5 dan Q 12. 8; Q 12. 9 Q 14 Congenital malf. of posterior segm. of eye Q 14. 0 s/d Q 14. 3 dan Q 14. 8; Q 14. 9 Q 15 Other congenital malformation of eye Excl. : . . . Q 15. 0 dan Q 15. 8; Q 15. 9 Q 16 Cong. malf. of ear causing impairm. of hear. Excl. : . . . Q 16. 0 s/d Q 16. 5 dan Q 16. 9

Q 17 Other congenital malformation of ear Excl. : . . . Q 17. 0 s/d Q 17. 3 dan Q 17. 5; Q 17. 8; Q 17. 9 Pada Q 17. 4 ada Excl. : . . . Q 18 Other cong. malf. Of face and neck Excl. : . . . Q 18. 0 s/d Q 18. 9

Congenital malformations of the Circulatory system (Q 20 - Q 28) [716 – 722] Q 20 Congenital malf. of card. chambers & con. Excl. : . . . Q 20. 0 s/d Q 20. 6 dan Q 20. 8; Q 20. 9 Q 21 Congenital malf. Of cardiac septa Excl. : . . . Q 21. 0 s/d Q 21. 4 dan Q 21. 9 Pada Q 21. 8 ada Excl. : Q 22 Cong. malf. of pulmonary & tricuspid v. Q 22. 0 s/d Q 22. 6 dan Q 22. 8; Q 22. 9

Q 23 Congenital malf. of aortic & mitral valv. Pada Q 23. 0 ada Excl. : . . . Q 23. 1 s/d Q 23. 3. Pada Q 23. 4 ada penjelasan. Q 23. 8; Q 23. 9 Q 24 Other cong. malf. of heart Excl. : . . . Q 24. 0 ada Excl. : . . Q 24. 1 ada penjelasan. Q 24. 2 s/d Q 24. 6 dan Q 24. 8; Q 24. 9 Q 25 Congenital malf. of great arteries Q 25. 0 s/d Q 25. 2 Pada Q 25. 3 dan Q 25. 4 ada Excl. : . . . Q 25. 5; Q 25. 6 dan Q 25. 8; Q 25. 9

Q 26 Congenital malf. of great veins Q 26. 0 s/d Q 26. 6 dan Q 26. 8; Q 26. 9 Q 27 Other cong. Malf. Of peripheral vasc. syst. Excl. : . . Q 27. 0 s/d Q 27. 2; Q 27. 4 dan Q 27. 8; Q 27. 9 Pada Q 27. 3 ada Excl. : . . . Q 28 Other cong. malf. of circul. system. Excl. : . . . Q 28. 0 s/d Q 28. 3 dan Q 28. 8; Q 28. 9

Congenital malformation of the respiratory System (Q 30 – Q 34) [722 -724] Q 30 Congenital malformations of nose Excl. : congenital deviated of nasal septum (Q 67. 4) Q 30. 0 s/d Q 30. 3 dan Q 30. 8; Q 30. 9 Q 31 Congenital malformations of larynx Excl. : congenital (laryngeal) stridor NOS (P 28. 8) Q 31. 0 s/d Q 31. 3, dan Q 31. 5; Q 31. 8; Q 31. 9 Q 32 Cong. malf. of trachea and bronchus Excl. : congenital bronchiectasis (Q 33. 4) Q 32. 0 s/d Q 32. 4

Q 33 Congenital malformation of lung Q 33. 0 ada Excl. : . . . Q 33. 1 s/d Q 33. 6 dan Q 33. 8; Q 33. 9 Q 34 Other congenital malf. of resp. System Q 34. 0; Q 34. 1 dan Q 34. 8; Q 34. 9

Cleft lip and cleft palate (Q 35 – Q 37) [724 – 725] Use additional code (Q 30. 2) if desired to. . . Excl. : Robin syndrome (Q 87. 0) Q 35 Cleft palate Incl. : . . . Excl. : . . . Q 35. 1; Q 35. 3; Q 35. 5; Q 35. 7 dan Q 35. 9 Q 36 Cleft lip Incl. : . . . Excl. : . . . Q 36. 0; Q 36. 1 dan Q 36, 9

Q 37 Cleft palate with cleft lip Q 37. 0 Cl. hard palate with bilat. cl. lip Q 37. 1 Cl. hard palate with unilat. cl. lip Q 37. 2 Cl. soft palate with bilat. cl. lip Q 37. 3 Cl. soft palate with unil. cl. lip Q 37. 4 Cl. hard & soft palate with bil. cl. lip Q 37. 5 Cl. hard & soft palate with unilat. cl. l. Q 37. 8 Unspec. cl. palate w. bilat. cl. lip Q 37. 9 Unspec. cl. palate w. unilat cl. lip

Other congenital malformations of the digestive system (Q 38 – Q 45) [725 -730] Q 38 Other cong. malf. Of tongue. mouth & phar. Excl. : macrostomia (Q 18. 4); microstomia (Q 18. 5) Q 38. 0; Q 38. 5 dan Q 38. 7 ada Excl. : . . . Q 38. 1 s/d Q 38. 4; Q 38. 6 dan Q 38. 8 Q 39 Congenital malformations of oesophagus Q 39. 0 s/d Q 39. 6 dan Q 39. 8; Q 39. 9 Q 40 Other cong. malf. Of upper alimentary tract Q 40. 0; Q 40. 2; Q 40. 3 dan Q 40. 8; Q 40. 9 Pada Q 40. 1 ada Excl. : . . .

Q 41 Cong. absence, atresia & stenosis of sm. intest. Incl. : . . . Excl. : . . . Q 41. 0; Q 41. 1; Q 41. 2 dan Q 41. 8; Q 41. 9 Q 42 Cong. absence, atresia & stenosis of large intest. Incl. : . . . Q 42. 0; Q 42. 1; Q 42. 2; Q 42. 3 dan Q 42. 8; Q 42. 9 Q 43 Other cong. malf. Of intestine Q 43. 0 s/d Q 43. 5 dan Q 43. 7; Q 43. 8; Q 43. 9 Pada Q 43. 6 ada Excl. : . . .

Q 44 Cong. malf. Of gallbladder, bile ducts & liv. Q 44. 0 s/d Q 44. 7 Q 45 Other cong. malf. of digest. syst. Excl. : congenital: - diaphragmatic hernia (Q 79. 0) - hiatus hernia (Q 40. 1) Q 45. 0 s/d Q 45. 2 dan Q 45. 8; Q 45. 9 Pada Q 45. 3 ada Excl. : . . .

Congenital malformation of genital organs (Q 50 – Q 56) [731 – 734] Excl. : . . . Q 50 Cong. malf. Of ovaries, fallop. t. & br. lig. Pada Q 50. 0 ada Excl. : . . . Q 50. 1 s/d Q 50. 6 Q 51 Cong. malf. of uterus & cervix Q 51. 0 s/d Q 51. 9 Q 52 Other cong. malf. of female gen. Q 52. 0; Q 52. 3 s/d Q 52. 9 Pada Q 52. 1 dan Q 52. 2 ada Excl. : . . .

Q 56 Indeterminate sex & pseudohermaphroditism Excl. : pseudohermaphroditism - female, with. . . (E 25. -) - male, with. . . (E 34. 5) - with spec. . (Q 96 -Q 99) Q 56. 0 s/d Q 56. 4

Congenital malformations of urinary system (Q 60 – Q 64) [734 -737] Q 60 Q 61 Renal agenesis & reduction defects of kid. Incl. : . . . Q 60. 0 s/d Q 60. 6 Cystic kidney disease Excl. : . . . Q 61. 0 s/d Q 61. 3 dan Q 61. 5; Q 61. 8; Q 61. 9 Pada Q 61. 4 ada Excl. : . . .

Q 62 Congenital obst. defects of ren. pelv. And cong. malf. Of ureter Q 621. 0 s/d Q 62. 8 Q 63 Other cong. malf. of kidney Excl. : . . . Q 63. 0 s/d Q 63. 3 dan Q 63. 8; Q 63. 9 Q 64 Other cong. malf. of urin. System Pada Q 64. 0 ada Excl. : . . . Q 64. 1 s/d Q 64. 9

Q 53 Undescended testicle Q 53. 0; Q 53. 1; Q 53. 2 dan Q 52. 9 Q 54 Hypospadias Excl. : . . . Q 54. 0 s/d Q 54. 4 dan Q 54. 8; Q 54. 9 Q 55 Other cong. malf. of male gen. Organs Excl. : cong. hydrocele (P 83. 5) hypospadias (Q 54. -) Q 55. 0 s/d Q 55. 6 dan Q 55. 8; Q 55. 9

Congenital malformations & deformations of the musculoskeletal system (Q 65 – Q 79) [737 – 746] Q 65 Q 66 Congenital deformities of hip Excl. : . . . Q 65. 0 s/d Q 65. 6 dan Q 65. 8; Q 65. 9 Congenital deormities of feet Excl. : reduction def. of feet (Q 72. -) dst. Q 66. 0 s/d Q 66. 9

Q 67 Cong. Musculos. Deformities of head, face, spine and chest Excl. : . . . Q 67. 0 s/d Q 67. 3 dan Q 67. 6; Q 67. 8; Q 67. 9 Pada Q 67. 4 dan Q 67. 5 ada Excl. : . . . Q 68 Other cong. Musculoskel. Deformities Excl. : . . . Q 68. 0 s/d Q 68. 2; Q 68. 4; Q 68. 5; Q 68. 8; Q 68. 9 Pada Q 68. 3 ada Excl. : . . .

Q 69 Polydactyly Q 69. 0; Q 69. 1; Q 69. 2 dan Q 69. 9 Q 70 Syndactyly Q 70. 0 s/d Q 70. 4 dan Q 70. 9 Q 71 Reduction defects of upper limb Q 71. 0 s/d Q 71. 6 dan Q 71. 8; Q 71. 9 Q 72 Reduction defects of lower limb Q 72. 0 s/d Q 72. 9

Q 73 Reduction defects of unspecified limb Q 73. 0; Q 73. 1 dan Q 73. 8 Q 74 Other congenital malf. of limbs Excl. : . . . Q 74. 0; Q 74. 3 dan Q 74. 8; Q 74. 9 Pada Q 74. 1; Q 74. 2 ada Excl. : . . . Q 75 Other cong. malf. of skull & face bones Excl. : . . . Q 75. 0 s/d Q 75. 5 dan Q 75. 8; Q 75. 9

Q 76 Congenital malf. of spine and bony thorax Excl. : . . . Q 76. 0 ; Q 76. 2 dan Q 76. 6 ada Excl. : . . . Q 76. 1; Q 76. 3; Q 76. 4; Q 76. 5; Q 76. 7; Q 76. 8; Q 76. 9 Q 77 Osteochondrodysplasia with def. of growth of tubular bones & spine Excl. : . . . Q 77. 0 s/d Q 77. 9

Q 78 Other osteochondrodysplasias Q 78. 0 s/d Q 78. 6 dan Q 78. 8; Q 78. 9 Q 79 Congenital malf. of the musculoskeletal syst. NEC Excl. : . . . Q 79. 1; Q 79. 3; Q 79. 4; Q 79. 6; Q 79. 8; Q 79. 9. Pada Q 79. 0; Q 79. 2; Q 79. 5 ada Excl. : . . .

Other congenital malformations (Q 80 – Q 89) [747 – 752] Q 80 Congenital ichthyosis Excl. : . . . Q 80. 0 s/d Q 80. 4 dan Q 80. 8; Q 80. 9 Q 81 Epidermolysis bullosa Pada Q 81. 0 ada Excl. : . . . Q 81. 1; Q 81. 2 dan Q 81. 8; Q 81. 9 Q 82 Other congenital malf. Of skin Excl. : . . Q 82. 0; Q 82. 1; Q 82. 3; Q 82. 9 Pada Q 82. 2; Q 82. 4; Q 82. 5 dan Q 82. 8 ada Excl. : . . .

Q 83 Congenital malformation of breast Excl. : . . . Q 83. 0; Q 83. 1; Q 83. 2; Q 82. 3 dan Q 82. 8; Q 82. 9 Q 84 Other cong. malf. of integument Q 84. 0; Q 84. 2; Q 84. 4; Q 84. 5; Q 84. 6 dan Q 84. 8; Q 84. 9 Pada Q 84. 1 dan Q 84. 3 ada Excl. : . . . Q 85 Phakomatoses, NEC. Ada Excl. : . . . Q 85. 0; Q 85. 1 dan Q 85. 9. Pada Q 85. 8 ada Excl. : . . .

Q 86 Cong. malf. Syndromes due to known exogenous causes, NEC Excl. : . . . Q 86. 0; Q 86. 1; Q 86. 2 dan Q 86. 8 Q 87 Other spec. cong. malf. syndr. aff. Q 87. 0 s/d Q 87. 5 dan Q 87. 8 Q 88 Other cong. malf. , NEC Q 89. 0; Q 89. 1; Q 89. 3 dan Q 89. 7 ada Excl. : . . . Q 89. 2; Q 89. 4 dan Q 89. 8; Q 89. 9 mult. s.

Chromosomal abnormalities, NEC (Q 90 – Q 99) [753 -756] Q 90 Down syndrome Q 90. 0; Q 90. 1; Q 90. 2 dan Q 90. 9 Q 91 Edwards syndr. & Patau syndr. Q 91. 0 s/d Q 91. 7 Q 92 Other trisomies & partial trisomies of the autosomes NEC Incl. : . . . Excl. : . . . Q 92. 0 s/d Q 92. 9

Q 93 Monosomies & deletions fr. the autos. NEC Q 93. 0 s/d Q 93. 9 Q 95 Balanced rearrang. &struct. markers, NEC Incl. : . . . Q 95. 0 s/d Q 95. 5 dan Q 95. 8; Q 95. 9 Q 96 Turner syndrome Excl. : . . . Q 96. 0 s/d Q 96. 4 dan Q 96. 8; Q 96. 9

Q 97 Other sex chrom. abn. female pheno. NEC Excl. : Turner syndrome (Q 96. -) Q 97. 0 s/d Q 97. 3 dan Q 97. 8; Q 97. 9 Q 98 Other sex chrom. abnor. male pheno. NEC Q 98. 0 s/d Q 98. 9 Q 99 Other chrom. abnor. NEC Q 99. 0 Chimera 46, XX/46, XY Q 99. 1 46. XX true hermaphrodite Q 99. 2 Fragile X chrom. Q 99. 8 dan Q 99. 9

SOAL-SOAL LATIHAN 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Occipital encephalocele Congenital ectropion Anisocoria congenital Macrotia DORV(double outlet right ventricle) AVSD(atrioventricular septal defect) Coartation aortae Cyptorchism NOS Multiple congenital malformations Down’s syndrome (Trisomy 21) Definisi Main Term Kode. ICD 10

SOAL-SOAL LATIHAN MANDIRI 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Spina bifida lumbar & hidrosefalus Saluran air mata tersumbat kongen. Afakia kongenital Telinga tidak tumbuh sejak lahir Tetralogi Fallot Jari-jari tangan tumbuh saling melekat seperti kaki Kaki tumbuh mirip tongkat golf Kembar siam dua, dempet di kepala Albino generelized Pes fagus Definisi Main Term Kode. ICD 10

LATIHAN ICD 9 CM Definisi 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. CT Scan Angiography MRI Pembedahan reseleksi Embolisasi Endovascular Radiosurgery Operasi korektif Transfutasi darah Laminectomy Echoencepalogram Main Term Kode. ICD 10