FORM SELF ASSESMENT DIAGNOSA NON SPESIALISTIK LUARAN APLIKASI HFIS

Nama FKTP
Alamat
Jenis FKTP
Waktu Assessment
KC BPJS Kesehatan

NO Nama & Kode Diagnosa

1 A01.0 - Typhoid fever

2 A06.0 - Acute amoebic dysentery
3 A09.0 - Other and unspecified gastroenteritis and colitis of infectious origin
4 A15.0 - Respiratory tuberculosis, bacteriologically and histologically confirmed
5 A27.9 - Leptospirosis, unspecified
6 A30.0 - Indeterminate leprosy
7 A35 - Other tetanus
8 A54.9 - Gonococcal infection, unspecified
9 A90 - Dengue fever [classical dengue]
10 A91 - Dengue haemorrhagic fever
11 B00.9 - Herpesviral infection, unspecified
12 B01.9 - Varicella without complication
13 B02.9 - Zoster without complication
14 B05.9 - Measles without complication
15 B07 - Viral warts
16 B08.1 - Molluscum contagiosum
17 B15 - Acute hepatitis A
18 B26.0 - Mumps orchitis
19 B35 - Dermatophytosis
20 B35.0 - Tinea barbae and tinea capitis
21 B35.1 - Tinea unguium
22 B35.2 - Tinea manuum
23 B35.3 - Tinea pedis
24 B35.4 - Tinea corporis
25 B35.6 - Tinea cruris
26 B35.8 - Other dermatophytoses
27 B36.0 - Pityriasis versicolor
28 B37.9 - Candidiasis, unspecified
29 B54 - Unspecified malaria
30 B65.0 - Schistosom due schis haematobium [urin schistosom]
31 B65.2 - Schistosomiasis due to Schistosoma japonicum
32 B65.9 - Schistosomiasis, unspecified
33 B68.0 - Taenia solium taeniasis
34 B68.9 - Taeniasis, unspecified
35 B74.0 - Filariasis due to wuchereria bancrofti
36 B76.0 - Ancylostomiasis
37 B76.9 - Hookworm disease, unspecified
38 B77.9 - Ascariasis, unspecified
39 B78.0 - Intestinal strongyloidiasis
40 B78.9 - Strongyloidiasis, unspecified
41 B85.0 - Pediculosis due to pediculus humanus capitis
42 B85.3 - Phthiriasis
43 B86 - Scabies
44 D17.9 - Benign lipomatous neoplasm, unspecified
45 D50.0 - Iron deficiency anaemia secondary to blood loss (chronic)
46 D50.9 - Iron deficiency anaemia, unspecified
47 E11.9 - Non-insulin-dependent diabetes mellitus without complications
48 E16.2 - Hypoglycaemia, unspecified
49 E46 - Unspecified protein-energy malnutrition
50 E66.9 - Obesity, unspecified
51 E78.5 - Hyperlipidaemia, unspecified
52 E79.0 - Hyperuricaem without sign inflamm arthritis+tophaceous dis
53 F45.0 - Somatization disorder
54 F51.0 - Nonorganic insomnia
55 G43.0 - Migraine without aura [common migraine]
56 G43.9 - Migraine, unspecified
57 G44.2 - Tension-type headache
58 G51.0 - Bell's palsy
59 H00.0 - Hordeolum and other deep inflammation of eyelid
60 H01.0 - Blepharitis
61 H02.0 - Entropion and trichiasis of eyelid
62 H04.1 - Other disorders of lacrimal gland
63 H10.1 - Acute atopic conjunctivitis
64 H10.9 - Conjunctivitis, unspecified
65 H15.1 - Episcleritis
66 H52.0 - Hypermetropia
67 H52.1 - Myopia
68 H52.2 - Astigmatism
69 H52.4 - Presbyopia
70 H53.6 - Night blindness
71 H57.8 - Other specified disorders of eye and adnexa
72 H60.9 - Otitis externa, unspecified
73 H61.2 - Impacted cerumen
74 H65.0 - Acute serous otitis media
75 H65.1 - Other acute nonsuppurative otitis media
76 H66.0 - Acute suppurative otitis media
77 I10 - Essential (primary) hypertension
78 I83.9 - Varicose veins lower extremities without ulcer or inflamm
79 I84.0 - Internal thrombosed haemorrhoids
80 I84.2 - Internal haemorrhoids without complication
81 I84.9 - Unspecified haemorrhoids without complication
82 J00 - Acute nasopharyngitis [common cold]
 83 J02 - Acute pharyngitis
84 J02.9 - Acute pharyngitis, unspecified
85 J03 - Acute tonsillitis
86 J03.9 - Acute tonsillitis, unspecified
87 J04.0 - Acute laryngitis
88 J11.0 - Influenza, virus not identified
89 J18.0 - Bronchopneumonia, unspecified
90 J18.9 - Pneumonia, unspecified
91 J20.9 - Acute bronchitis, unspecified
92 J30.0 - Vasomotor rhinitis
93 J30.4 - Allergic rhinitis, unspecified
94 J34.0 - Abscess, furuncle and carbuncle of nose
95 J35.0 - Chronic tonsillitis
96 J45.9 - Asthma, unspecified
97 K12 - Stomatitis and related lesions
98 K21.9 - Gastro-oesophageal reflux disease without oesophagitis
99 K29.7 - Gastritis, unspecified
100 K90.4 - Malabsorption due to intolerance, not elsewhere classified
101 L01.0 - Impetigo [any organism] [any site]
102 L02.0 - Cutaneous abscess, furuncle and carbuncle of face
103 L02.2 - Cutaneous abscess, furuncle and carbuncle of trunk
104 L02.8 - Cutaneous abscess, furuncle and carbuncle of other sites
105 L04.9 - Acute lymphadenitis, unspecified
106 L08.0 - Pyoderma
107 L08.1 - Erythrasma
108 L20.8 - Other atopic dermatitis
109 L21.0 - Seborrhoea capitis
110 L22 - Diaper [napkin] dermatitis
111 L24.0 - Irritant contact dermatitis due to detergents
112 L27.0 - Generalized skin eruption due to drugs and medicaments
113 L27.2 - Dermatitis due to ingested food
114 L42 - Pityriasis rosea
115 L50.0 - Allergic urticaria
116 L50.9 - Atrophic disorder of skin, unspecified
117 L70.0 - Acne vulgaris
118 L71.0 - Perioral dermatitis
119 L73.2 - Hidradenitis suppurativa
120 L74.3 - Miliaria, unspecified
121 L97 - Ulcer of lower limb, not elsewhere classified
122 M10 - Gout
123 N10 - Acute tubulo-interstitial nephritis
124 N39.0 - Urinary tract infection, site not specified
125 N47 - Redundant prepuce, phimosis and paraphimosis
126 N61 - Inflammatory disorders of breast
127 N76.0 - Acute vaginitis
128 N98.9 - Complication associated with artificial fertilization, unspecified
129 O03.9 - Spontaneous abortion, Complete or unspecified, without complication
130 O70.0 - First degree perineal laceration during delivery
131 O80.9 - Single spontaneous delivery, unspecified
132 O92.0 - Retracted nipple associated with childbirth
133 P38 - Omphalitis of newborn with or without mild haemorrhage
134 R04.0 - Epistaxis
135 R42 - Dizziness and giddiness
136 R56.0 - Febrile convulsions
137 T14 - Injury of unspecified body region
138 T14.1 - Open wound of unspecified body region
139 T15.9 - Foreign body on external eye, part unspecified
140 T17.1 - Foreign body in nostril
141 T30.1 - Burn of first degree, body region unspecified
142 T30.2 - Burn of second degree, body region unspecified
143 T63.4 - Venom of other arthropods
144 T78.2 - Anaphylactic shock, unspecified
145 Z21 - Asymptomatic human immunodeficiency virus [HIV] infection status

Mengetahui ,
……………………., September 2018

Kepala/Pimpinan FKTP
STIK LUARAN APLIKASI HFIS
:
:
:
:
:
Tuntas Ditangani di FKTP
Ya Tidak
er 2018
Dokter FKTP