TGL TANGGAL BY DU INACBG BY VERIFIKASI

NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

1 12/5/2022 12/8/2022
0503R0011222V000410 RITL Kelas 1 J441 J180 - Bronchopneumonia, 8744 - Routine chest x-ray, so
unspecified;I119 - described;8952 -
Hypertensive heart disease Electrocardiogram;9039 - Other
without (congestive) heart microscopic examination of
failure specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic
J-4-17-III 6,099,000 PPOK-Pneumonia. Diagnosa J440
Kombinasi kode dengan J44.0.
Penunjang spirometri untuk
penegakan diagnosa PPOK?
I11.9 8744 - Routine chest x-ray, so
described;8952 -
Electrocardiogram;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic
J-4-17-I 3,881,000 2,218,000 Sesuai BA kesepakatan
2019, Halaman 15 Aspek
Koding No.18, Kode ICD-10
sudah sesuai dengan
diagnosa di Resume Medis
(PPOK Exacerbasi Akut
J44.1 + BP J18.0)

2 12/20/2022 12/25/2022 0503R0011222V001941 RITL Kelas 3 J441 K30 - Dyspepsia;I159 - 8744 - Routine chest x-ray, so
Secondary hypertension, described;9039 - Other
unspecified;J180 - microscopic examination of
Bronchopneumonia, specimen from ear, nose, throat,
unspecified;R42 - and larynx;9059 - Other
Dizziness and giddiness microscopic examination of
blood;9394 - Respiratory
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic
J-4-17-III 4,356,400 PPOK-Pneumonia. Diagnosa J440
Kombinasi kode dengan J44.0.
Penunjang spirometri untuk
penegakan diagnosa PPOK?
K30 - Dyspepsia;I159 - 8744 - Routine chest x-ray, so J-4-17-I 2,772,100 1,584,300 Sesuai BA kesepakatan
Secondary hypertension, described;9039 - Other 2019, Halaman 15 Aspek
unspecified;R42 - microscopic examination of Koding No.18, Kode ICD-10
Dizziness and giddiness specimen from ear, nose, throat, sudah sesuai dengan
and larynx;9059 - Other diagnosa di Resume Medis
microscopic examination of (PPOK Exacerbasi Akut
blood;9394 - Respiratory J44.1 + BP J18.0)
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic

3 12/6/2022 12/6/2022
0503R0011222V000481 RJTL 0 Z098 E115 - Non-insulin- 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
dependent diabetes wound, infection, or burn;9357 - dependent diabetes
mellitus with peripheral Application of other wound mellitus with peripheral
circulatory complications dressing;9659 - Other irrigation of circulatory complications
wound

4 12/14/2022 12/14/2022 0503R0011222V001292 RJTL Z098 E115 - Non-insulin- 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
dependent diabetes wound, infection, or burn;9357 - dependent diabetes
mellitus with peripheral Application of other wound mellitus with peripheral
circulatory complications dressing;9659 - Other irrigation of circulatory complications
wound

5 12/6/2022 12/6/2022
0503R0011222V000476 RJTL
Z098 D539 - Nutritional anaemia, 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 D539 - Nutritional anaemia, 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
unspecified;E119 - Non- wound, infection, or burn;9059 - unspecified;E119 - Non-
insulin-dependent diabetes Other microscopic examination of insulin-dependent diabetes
mellitus without blood;9357 - Application of other mellitus without
complications;I139 - wound dressing;9659 - Other complications;I139 -
Hypertensive heart and irrigation of wound;9789 - Hypertensive heart and
renal disease, Removal of other therapeutic renal disease,
unspecified;I739 - device unspecified;I739 -
Peripheral vascular Peripheral vascular
disease, unspecified;S984 - disease, unspecified;S984
Traumatic amputation of - Traumatic amputation of
foot, level unspecified;Z488 foot, level unspecified;Z488
- Other specified surgical - Other specified surgical
follow-up care follow-up care

6 12/20/2022 12/20/2022 0503R0011222V001891 RJTL Z488 S980 - Traumatic 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 S980 - Traumatic 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
amputation of foot at ankle wound, infection, or burn;9357 - amputation of foot at ankle
level Application of other wound level
dressing;9659 - Other irrigation of
wound;9789 - Removal of other
therapeutic device
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

7 12/6/2022 12/6/2022
0503R0011222V000496 RJTL
Z488 N40 - Hyperplasia of 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 N40 - Hyperplasia of 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
prostate wound, infection, or burn;9357 - prostate
Application of other wound
dressing;9659 - Other irrigation of
wound

8 12/7/2022 12/7/2022
0503R0011222V000587 RJTL
Z488 K409 - Unilateral or
unspecified inguinal hernia,
without obstruction or
gangrene
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 K409 - Unilateral or 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - unspecified inguinal hernia,
Application of other wound without obstruction or
dressing;9659 - Other irrigation of gangrene
wound

9 12/30/2022 12/30/2022 0503R0011222V002851 RJTL Z488 K358 - Acute appendicitis, 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 K358 - Acute appendicitis, 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
other and unspecified wound, infection, or burn;9357 - other and unspecified
Application of other wound
dressing;9659 - Other irrigation of
wound;9789 - Removal of other
therapeutic device

10 12/6/2022 12/6/2022 0503R0011222V000460 RJTL Z098 T814 - Infection following a 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 T814 - Infection following a 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
procedure, not elsewhere wound, infection, or burn;9357 - procedure, not elsewhere
classified Application of other wound classified
dressing;9659 - Other irrigation of
wound

11 12/6/2022 12/6/2022 0503R0011222V000480 RJTL Z098 E115 - Non-insulin-
dependent diabetes
mellitus with peripheral
circulatory complications
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - dependent diabetes
Application of other wound mellitus with peripheral
dressing;9659 - Other irrigation of circulatory complications
wound

12 12/5/2022 12/5/2022 0503R0011222V000293 RJTL Z488 E115 - Non-insulin-
dependent diabetes
mellitus with peripheral
circulatory complications
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - dependent diabetes
Application of other wound mellitus with peripheral
dressing;9659 - Other irrigation of circulatory complications
wound

13 12/7/2022 12/7/2022 0503R0011222V000579 RJTL Z488 C509 - Malignant neoplasm 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 C509 - Malignant 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
of breast, unspecified wound, infection, or burn;9357 - neoplasm of breast,
Application of other wound unspecified
dressing;9659 - Other irrigation of
wound

14 12/9/2022 12/9/2022 0503R0011222V000714 RJTL Z488 D24 - Benign neoplasm of 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 D24 - Benign neoplasm of 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
breast wound, infection, or burn;9357 - breast
Application of other wound
dressing;9659 - Other irrigation of
wound

15 12/7/2022 12/7/2022 0503R0011222V000569 RJTL Z358 O210 - Mild hyperemesis 8878 - Diagnostic ultrasound of Z-3-25-0 300,000 USG dilakukan 2x dalam Z358 O210 - Mild hyperemesis Q-5-44-0 183,500 116,500 Bersedia Mengembalikan
gravidarum gravid uterus sebulan tidak sesuai dgn PMK gravidarum
dan dilakukan post ranap

16 12/12/2022 12/12/2022 0503R0011222V000933 RJTL Z488 H445 - Degenerated 8911 - Tonometry;9501 - Limited H-3-12-0 213,700 Fragmentasi dari rawat inap tgl Z488 H445 - Degenerated Q-5-44-0 183,500 30,200 Bersedia Mengembalikan
conditions of globe;H259 - eye examination 8/12/2022, sesuai dgn PMK 26 conditions of globe;H259 -
Senile cataract, fragmentasi < 7 hari Senile cataract,
unspecified;H402 - Primary unspecified;H402 - Primary
angle-closure glaucoma angle-closure glaucoma
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

17 12/22/2022 12/22/2022 0503R0011222V002136 RJTL Z358 O159 - Eclampsia, 8878 - Diagnostic ultrasound of Z-3-25-0 300,000 USG dilakukan 2x dalam Z358 O159 - Eclampsia, Q-5-44-0 183,500 116,500 Bersedia Mengembalikan
unspecified as to time gravid uterus sebulan tidak sesuai dgn PMK unspecified as to time
period;O441 - Placenta period;O441 - Placenta
praevia with haemorrhage praevia with haemorrhage

18 December December 0503R0011222V000062 RJTL A162 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
1, 2022 1, 2022 skin lesion or defect;8744 - penjaminan. FKTP juga bisa
Routine chest x-ray, so described pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

19 December December 0503R0011222V000096 RJTL Z098 G560 - Carpal tunnel 0480 - Peripheral nerve injection, G-3-11-0 321,400 Koding injeksi tidak sesuai Z098 G560 - Carpal tunnel 9929 Q-5-44-0 183,500 137,900 Bersedia Mengembalikan
2, 2022 2, 2022 syndrome not otherwise specified syndrome

20 December December 0503R0011222V000103 RJTL Z098 R11 - Nausea and 8602 - Injection or tattooing of L-3-12-0 207,200 Koding prosedur tidak sesuai Z098 R11 - Nausea and Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
2, 2022 2, 2022 vomiting;J180 - skin lesion or defect vomiting;J180 -
Bronchopneumonia, Bronchopneumonia,
unspecified unspecified

21 December December 0503R0011222V000292 RJTL Z098 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
5, 2022 5, 2022 lung, without mention of skin lesion or defect penjaminan. FKTP juga bisa
bacteriological or pemeriksaan untuk TB. TB
histological masuk dalam 144 dx yang
confirmation;J180 - harus selesai di FKTP
Bronchopneumonia,
unspecified;Z030 -
Observation for suspected
tuberculosis;J459 -
Asthma, unspecified

22 December December 0503R0011222V000304 RJTL M171 8192 - Injection of therapeutic M-3-11-0 409,800 Koding injeksi tidak sesuai M171 0 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
5, 2022 5, 2022 substance into joint or ligament

23 December December 0503R0011222V000350 RJTL Z098 H358 - Other specified 9503 - Extended ophthalmologic H-3-12-0 213,700 cek koding prosedur. Cek Z098 H358 - Other specified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
5, 2022 5, 2022 retinal disorders;N309 - work-up kesesuaian dengan PNPK. retinal disorders;N309 - 16.21
Cystitis, unspecified Koding 95.01 Cystitis, unspecified
24 December December 0503R0011222V000369 RJTL Z098 H309 - Chorioretinal 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H309 - Chorioretinal 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
5, 2022 5, 2022 inflammation, unspecified work-up inflammation, unspecified 16.21

25 December December 0503R0011222V000461 RJTL Z098 R05 - Cough;J189 - 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam Z098 R05 - Cough;J189 - Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
6, 2022 6, 2022 Pneumonia, skin lesion or defect penjaminan. FKTP juga bisa Pneumonia,
unspecified;E46 - pemeriksaan untuk TB. TB unspecified;E46 -
Unspecified protein-energy masuk dalam 144 dx yang Unspecified protein-energy
malnutrition harus selesai di FKTP malnutrition

26 December December 0503R0011222V000566 RJTL E143 H360 - Diabetic 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai E143 H360 - Diabetic 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
7, 2022 7, 2022 retinopathy;H040 - work-up retinopathy;H040 - 16.21
Dacryoadenitis Dacryoadenitis
27 December December 0503R0011222V000568 RJTL Z098 H351 - Retinopathy of 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H351 - Retinopathy of 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
7, 2022 7, 2022 prematurity work-up prematurity 16.21
28 December December 0503R0011222V000689 RJTL Z098 E143 - Unspecified 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 E143 - Unspecified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
9, 2022 9, 2022 diabetes mellitus with work-up diabetes mellitus with 16.21
ophthalmic ophthalmic
complications;H360 - complications;H360 -
Diabetic retinopathy;H259 - Diabetic retinopathy;H259 -
Senile cataract, unspecified Senile cataract,
unspecified

29 December December 0503R0011222V000690 RJTL Z098 H401 - Primary open-angle 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H401 - Primary open-angle 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
9, 2022 9, 2022 glaucoma;H259 - Senile work-up glaucoma;H259 - Senile 16.21
cataract, unspecified cataract, unspecified
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

30 December December 0503R0011222V000970 RJTL Z098 E143 - Unspecified 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 E143 - Unspecified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
12, 2022 12, 2022 diabetes mellitus with work-up diabetes mellitus with 16.21
ophthalmic ophthalmic
complications;H259 - complications;H259 -
Senile cataract, Senile cataract,
unspecified;H360 - Diabetic unspecified;H360 -
retinopathy Diabetic retinopathy

31 December December 0503R0011222V001063 RJTL Z098 M179 - narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M179 - narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
13, 2022 13, 2022 unspecified;I10 - Essential substance into joint or unspecified;I10 - Essential
(primary) hypertension;I64 - ligament;8827 - Skeletal x-ray of (primary) hypertension;I64
Stroke, not specified as thigh, knee, and lower leg - Stroke, not specified as
haemorrhage or infarction haemorrhage or infarction

32 December December 0503R0011222V001181 RJTL Z098 H109 - Conjunctivitis, 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H109 - Conjunctivitis, 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
14, 2022 14, 2022 unspecified;H401 - Primary work-up unspecified;H401 - Primary 16.21
open-angle glaucoma open-angle glaucoma

33 December December 0503R0011222V001232 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 bilateral;G570 - Lesion of substance into joint or ligament bilateral;G570 - Lesion of
sciatic nerve sciatic nerve

34 December December 0503R0011222V001272 RJTL Z098 M512 - Other specified 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M512 - Other specified 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 intervertebral disc substance into joint or ligament intervertebral disc
displacement;M170 - displacement;M170 -
Primary narthrosis, bilateral Primary narthrosis, bilateral

35 December December 0503R0011222V001274 RJTL Z098 M653 - Trigger finger 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 substance into tendon
36 December December 0503R0011222V001335 RJTL M653 M750 - Adhesive capsulitis 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai M653 M750 - Adhesive capsulitis 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
15, 2022 15, 2022 of shoulder substance into tendon of shoulder
37 December December 0503R0011222V001756 RJTL Z098 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 207,200 Bersedia Mengembalikan
19, 2022 19, 2022 lung, without mention of skin lesion or defect;8744 - penjaminan. FKTP juga bisa
bacteriological or Routine chest x-ray, so described pemeriksaan untuk TB. TB
histological confirmation masuk dalam 144 dx yang
harus selesai di FKTP

38 December December 0503R0011222V001758 RJTL A162 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
19, 2022 19, 2022 skin lesion or defect;8744 - penjaminan. FKTP juga bisa
Routine chest x-ray, so described pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

39 December December 0503R0011222V001789 RJTL Z098 J180 - Bronchopneumonia, 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam Z098 J180 - Bronchopneumonia, Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
19, 2022 19, 2022 unspecified skin lesion or defect;9059 - Other penjaminan. FKTP juga bisa unspecified
microscopic examination of blood pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

40 December December 0503R0011222V001861 RJTL Z098 M513 - Other specified 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M513 - Other specified 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
20, 2022 20, 2022 intervertebral disc substance into tendon intervertebral disc
degeneration;M171 - Other degeneration;M171 - Other
primary narthrosis;M653 - primary narthrosis;M653 -
Trigger finger Trigger finger

41 December December 0503R0011222V001883 RJTL Z098 H309 - Chorioretinal 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H309 - Chorioretinal 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
20, 2022 20, 2022 inflammation, unspecified work-up inflammation, unspecified 16.21

42 December December 0503R0011222V001886 RJTL Z098 M653 - Trigger finger;I633 - 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger;I633 - 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
20, 2022 20, 2022 Cerebral infarction due to substance into tendon Cerebral infarction due to
thrombosis of cerebral thrombosis of cerebral
arteries;F019 - Vascular arteries;F019 - Vascular
dementia, unspecified dementia, unspecified
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

43 December December 0503R0011222V001980 RJTL Z098 G632 - Diabetic 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 G632 - Diabetic 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
21, 2022 21, 2022 polyneuropathy;E144 - substance into joint or ligament polyneuropathy;E144 -
Unspecified diabetes Unspecified diabetes
mellitus with neurological mellitus with neurological
complications;M170 - complications;M170 -
Primary narthrosis, Primary narthrosis,
bilateral;M750 - Adhesive bilateral;M750 - Adhesive
capsulitis of shoulder capsulitis of shoulder

44 December December 0503R0011222V002047 RJTL E144 G632 - Diabetic 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai E144 G632 - Diabetic 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
21, 2022 21, 2022 polyneuropathy;H040 - work-up polyneuropathy;H040 - 16.21
Dacryoadenitis Dacryoadenitis
45 December December 0503R0011222V002095 RJTL Z098 M512 - Other specified 0480 - Peripheral nerve injection, G-3-11-0 321,400 Koding prosedur tidak sesuai Z098 M512 - Other specified 9929 Q-5-44-0 183,500 137,900 Bersedia Mengembalikan
22, 2022 22, 2022 intervertebral disc not otherwise specified intervertebral disc
displacement;G560 - displacement;G560 -
Carpal tunnel Carpal tunnel
syndrome;M750 - Adhesive syndrome;M750 - Adhesive
capsulitis of shoulder;I10 - capsulitis of shoulder;I10 -
Essential (primary) Essential (primary)
hypertension hypertension

46 December December 0503R0011222V002204 RJTL Z098 P071 - Other low birth 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 P071 - Other low birth 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
23, 2022 23, 2022 weight;H351 - Retinopathy work-up weight;H351 - Retinopathy 16.21
of prematurity;P599 - of prematurity;P599 -
Neonatal jaundice, Neonatal jaundice,
unspecified;P375 - unspecified;P375 -
Neonatal candidiasis;P229 Neonatal candidiasis;P229
- Respiratory distress of - Respiratory distress of
newborn, unspecified newborn, unspecified

47 December December 0503R0011222V002388 RJTL Z098 M653 - Trigger finger 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
26, 2022 26, 2022 substance into tendon
48 December December 0503R0011222V002498 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
27, 2022 27, 2022 bilateral;M531 - substance into joint or ligament bilateral;M531 -
Cervicobrachial Cervicobrachial
syndrome;M478 - Other syndrome;M478 - Other
spondylosis spondylosis

49 December December 0503R0011222V002505 RJTL Z098 G560 - Carpal tunnel 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 G560 - Carpal tunnel 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
27, 2022 27, 2022 syndrome;M179 - substance into tendon syndrome;M179 -
narthrosis, narthrosis,
unspecified;M653 - Trigger unspecified;M653 - Trigger
finger finger

50 December December 0503R0011222V002535 RJTL Z098 M171 - Other primary 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M171 - Other primary 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
28, 2022 28, 2022 narthrosis substance into joint or ligament narthrosis

51 December December 0503R0011222V002561 RJTL M653 M478 - Other spondylosis 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai M653 M478 - Other spondylosis 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
28, 2022 28, 2022 substance into tendon
52 December December 0503R0011222V002629 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
29, 2022 29, 2022 bilateral;G632 - Diabetic substance into joint or ligament bilateral;G632 - Diabetic
polyneuropathy;E114 - polyneuropathy;E114 -
Non-insulin-dependent Non-insulin-dependent
diabetes mellitus with diabetes mellitus with
neurological neurological
complications;I633 - complications;I633 -
Cerebral infarction due to Cerebral infarction due to
thrombosis of cerebral thrombosis of cerebral
arteries;I10 - Essential arteries;I10 - Essential
(primary) hypertension (primary) hypertension
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

53 December December 0503R0011222V002715 RJTL Z098 H351 - Retinopathy of 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H351 - Retinopathy of 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
29, 2022 29, 2022 prematurity;L97 - Ulcer of work-up prematurity;L97 - Ulcer of 16.21
lower limb, not elsewhere lower limb, not elsewhere
classified classified

54 December December 0503R0011222V002861 RJTL Z098 P071 - Other low birth 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 P071 - Other low birth 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
30, 2022 30, 2022 weight;H351 - Retinopathy work-up weight;H351 - Retinopathy 16.21
of prematurity of prematurity

55 November November 0503R0011122V000211 RITL Kelas 1 R560 9039 - Other microscopic
2, 2022 4, 2022 examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-I 3,577,900 Cek diagnosa utama yang A499 9039 - Other microscopic
spesifik. examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-14-I 2,964,700 613,200 pasien dengan kejang,
demam sejak 1 hari sebelum
masuk rs. Demam tinggi,
keluhan lain tidak ada. Tidak
ada penunjang untuk
bacterial infection. Leukosit
9400

56 December December 0503R0011222V000080 RITL Kelas 2 R560 E46 - Unspecified protein-
1, 2022 8, 2022 energy malnutrition;A90 -
Dengue fever [classical
dengue];J209 - Acute
bronchitis, unspecified
9039 - Other microscopic
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-II 3,918,400 Cek diagnosa utama yang A90 J209 9039 - Other microscopic
spesifik, penunjang malnutrisi examination of specimen from
tidak ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,832,700 2,085,700 Pasien masuk dengan
demam hari ke-2 + Kejang
>15 menit, Kejang demam
kompleks merupakan
masalah emergency saat
pasien datang dan paling
banyak menghabiskan
resource. Penunjang
Mlanutrisi terlampir. (E46
ganti ke E44.0)

57 December December 0503R0011222V000090 RITL Kelas 2 R560 R11 - Nausea and 9039 - Other microscopic
2, 2022 7, 2022 vomiting;E46 - Unspecified examination of specimen from
protein-energy ear, nose, throat, and
malnutrition;J304 - Allergic larynx;9059 - Other microscopic
rhinitis, unspecified examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-I 3,066,800 Cek diagnosa utama yang R11 J304 9039 - Other microscopic
spesifik, penunjang malnutrisi examination of specimen from
tidak ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
K-4-17-I 1,707,700 1,359,100 pasien masuk dengan
keluhan kejang, demam
sampai suhu 40.4 derajat
celcius. Tidak smua
bronchitis akut berkaitan
dengan kejang demam. Bukti
Penunjang mlanutrisi
terlampir, (E46 ganti ke
E44.1)

58 December December 0503R0011222V000420 RITL Kelas 3 R560 R11 - Nausea and 9039 - Other microscopic G-4-22-I 2,555,600 Cek diagnosa utama yang A099 9039 - Other microscopic K-4-17-I 1,423,100 1,132,500 Kejang demam kompleks
6, 2022 9, 2022 vomiting;A099 - examination of specimen from spesifik examination of specimen from merupakan masalah
Gastroenteritis and colitis ear, nose, throat, and ear, nose, throat, and emergency saat pasien
of unspecified origin larynx;9059 - Other microscopic larynx;9059 - Other microscopic datang dan paling banyak
examination of blood;9918 - examination of blood;9918 - menghabiskan resource.
Injection or infusion of Injection or infusion of Mendapat terapi kejang
electrolytes;9921 - Injection of electrolytes;9921 - Injection of Fenitoin dan Asam Valproat.
antibiotic antibiotic

59 December December 0503R0011222V000848 RITL Kelas 3 R560 B360 - Pityriasis 9039 - Other microscopic G-4-22-II 3,265,300 Cek diagnosa utama yang A90 B360 9039 - Other microscopic A-4-13-I 1,527,300 1,738,000 Bersedia Mengembalikan
11, 2022 18, 2022 versicolor;A90 - Dengue examination of specimen from spesifik examination of specimen from
fever [classical ear, nose, throat, and ear, nose, throat, and
dengue];K590 - larynx;9059 - Other microscopic larynx;9059 - Other microscopic
Constipation examination of blood;9918 - examination of blood;9918 -
Injection or infusion of Injection or infusion of
electrolytes;9921 - Injection of electrolytes;9921 - Injection of
antibiotic antibiotic

60 December December 0503R0011222V002465 RITL Kelas 3 R560 A91 - Dengue 9039 - Other microscopic
26, 2022 31, 2022 haemorrhagic fever examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-III 3,815,400 Cek diagnosa utama yang A91 9039 - Other microscopic
spesifik examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,527,300 2,288,100 Pasien datang dengan
keluhan emergency, kejang
berulang, Suhu 39-40.
mendapat terapi Pct,
Fenitoin, Diawal belum jelas
DBD sehingga diberikan
Antibiotik.
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

61 December December 0503R0011222V000532 RITL Kelas 3 J180 R560 - Febrile convulsions 8744 - Routine chest x-ray, so
6, 2022 10, 2022 described;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9394 - Respiratory
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic
J-4-16-II 4,739,300 DS R56.0 bagian dari DU J180 8744 - Routine chest x-ray, so J-4-16-I 3,372,600 1,366,700 Bersedia Mengembalikan
described;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9394 - Respiratory
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic

62 December December 0503R0011222V002468 RITL Kelas 3 A099 R560 - Febrile convulsions 9039 - Other microscopic
26, 2022 30, 2022 examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
K-4-17-II 1,946,400 DS R56.0 bagian dari DU A099 9039 - Other microscopic K-4-17-I 1,423,100 523,300 Bersedia Mengembalikan
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic

63 November December 0503R0011122V002899 RITL Kelas 3 B059 B370 - Candidal stomatitis 9039 - Other microscopic A-4-13-II 2,300,800 koding stomatitis yang sesuai B059 9039 - Other microscopic A-4-13-I 1,527,300 773,500 Bersedia Mengembalikan
28, 2022 2, 2022 examination of specimen from K12.0 examination of specimen from
ear, nose, throat, and ear, nose, throat, and
larynx;9059 - Other microscopic larynx;9059 - Other microscopic
examination of blood;9918 - examination of blood;9918 -
Injection or infusion of Injection or infusion of
electrolytes electrolytes

64 November December 0503R0011122V003034 RITL Kelas 3 K30 B370 - Candidal 8744 - Routine chest x-ray, so K-4-18-II 1,787,000 koding stomatitis yang sesuai K30 E86 - Volume 8744 - Routine chest x-ray, so K-4-18-I 1,257,500 529,500 Bersedia Mengembalikan
29, 2022 2, 2022 stomatitis;E86 - Volume described;8952 - K12.0 depletion;I119 - described;8952 -
depletion;I119 - Electrocardiogram;9039 - Other Hypertensive heart disease Electrocardiogram;9039 - Other
Hypertensive heart disease microscopic examination of without (congestive) heart microscopic examination of
without (congestive) heart specimen from ear, nose, throat, failure specimen from ear, nose, throat,
failure and larynx;9059 - Other and larynx;9059 - Other
microscopic examination of microscopic examination of
blood;9918 - Injection or infusion blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of of electrolytes;9921 - Injection of
antibiotic antibiotic

65 December December 0503R0011222V000251 RITL Kelas 3 K30 B370 - Candidal 8744 - Routine chest x-ray, so K-4-18-II 1,787,000 koding stomatitis yang sesuai K30 R11 - Nausea and 8744 - Routine chest x-ray, so K-4-18-I 1,257,500 529,500 Bersedia Mengembalikan
4, 2022 19, 2022 stomatitis;R11 - Nausea described;8952 - K12.0 vomiting;I119 - described;8952 -
and vomiting;I119 - Electrocardiogram;9039 - Other Hypertensive heart disease Electrocardiogram;9039 - Other
Hypertensive heart disease microscopic examination of without (congestive) heart microscopic examination of
without (congestive) heart specimen from ear, nose, throat, failure specimen from ear, nose, throat,
failure and larynx;9059 - Other and larynx;9059 - Other
microscopic examination of microscopic examination of
blood;9918 - Injection or infusion blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of of electrolytes;9921 - Injection of
antibiotic antibiotic

66 December December 0503R0011222V000080 RITL Kelas 2 R560 E46 - Unspecified protein-
1, 2022 8, 2022 energy malnutrition;A90 -
Dengue fever [classical
dengue];J209 - Acute
bronchitis, unspecified
9039 - Other microscopic
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-II 3,918,400 Koding diagnosa spesifik dan A90 J209 9039 - Other microscopic
Bukti penunjang malnutrisi tidak examination of specimen from
ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,832,700 2,085,700 pasien masuk dengan
demam hari ke 2, kejang >15
menit. Sehingga ditegakkan
diagnosis kejang demam
komplek karena masalah
emergency yang harus
ditangani.
 TGL TANGGAL
NO NO SEP JENPEL KLS RWT DU DS
DATANG PULANG
67 December December 0503R0011222V000178 RITL Kelas 3 N390 E41 - Nutritional
2, 2022 13, 2022 marasmus;E86 - Volume
depletion
68 December December 0503R0011222V001592 RITL Kelas 3 A90 E41 - Nutritional marasmus 9039 - Other microscopic
17, 2022 21, 2022
69 November November 0503R0011122V001849 RJTL R05 A162 - Tuberculosis of
18, 2022 18, 2022 lung, without mention of skin lesion or defect;8744 -
bacteriological or
histological
confirmation;Z030 -
Observation for suspected
tuberculosis
70 November November 0503R0011122V002206 RJTL Z030 A162 - Tuberculosis of
22, 2022 22, 2022 lung, without mention of
bacteriological or
histological confirmation
71 November November 0503R0011122V002213 RJTL Z098 J219 - Acute bronchiolitis, 8602 - Injection or tattooing of L-3-12-0
22, 2022 22, 2022 unspecified;Z030 -
Observation for suspected Routine chest x-ray, so described
tuberculosis;R05 -
Cough;A162 - Tuberculosis
of lung, without mention of
bacteriological or
histological confirmation
72 November November 0503R0011122V002291 RJTL Z098 Z030 - Observation for
23, 2022 23, 2022 suspected
tuberculosis;A162 -
Tuberculosis of lung,
without mention of
bacteriological or
histological
confirmation;R05 - Cough
73 November November 0503R0011122V002354 RJTL Z030 A162 - Tuberculosis of
23, 2022 23, 2022 lung, without mention of
bacteriological or
histological confirmation
PROSEDUR
5794 - Insertion of indwelling
urinary catheter;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes
8602 - Injection or tattooing of L-3-12-0
Routine chest x-ray, so described
8602 - Injection or tattooing of L-3-12-0
skin lesion or defect;8744 -
Routine chest x-ray, so described
skin lesion or defect;8744 -
8602 - Injection or tattooing of
skin lesion or defect
8602 - Injection or tattooing of L-3-12-0
skin lesion or defect;8744 -
Routine chest x-ray, so described
BY
INACBG Keterangan
VERIFIKASI REVISI
N-4-12-III 4,871,600 Bukti penunjang malnutrisi N390
A-4-13-III 2,760,900 Bukti penunjang malnutrisi A90
207,200 Skrining tidak masuk dalam R05
penjaminan. FKTP juga bisa
pemeriksaan untuk TB
207,200 Skrining tidak masuk dalam Z030
penjaminan. FKTP juga bisa
pemeriksaan untuk TB
207,200 Skrining tidak masuk dalam 0 0
penjaminan. FKTP juga bisa
pemeriksaan untuk TB
L-3-12-0 207,200 Skrining tidak masuk dalam 0 0
penjaminan. FKTP juga bisa
pemeriksaan untuk TB
207,200 Skrining tidak masuk dalam 0 0
penjaminan. FKTP juga bisa
pemeriksaan untuk TB
DU INACBG BY VERIFIKASI
DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
REVISI KOREKSI
5794 - Insertion of indwelling N-4-12-I 2,181,200 2,690,400 Bukti terlampir
urinary catheter;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic
9039 - Other microscopic A-4-13-I 1,527,300 1,233,600 Bukti terlampir
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes
A162 - Tuberculosis of Q-5-44-0 183,500 23,700 bersedia Mengembalikan
lung, without mention of
bacteriological or
histological
confirmation;Z030 -
Observation for suspected
tuberculosis
A162 - Tuberculosis of Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
lung, without mention of
bacteriological or
histological confirmation
0 0 - 207,200 Bersedia Mengembalikan
0 0 - 207,200 Bersedia Mengembalikan
0 0 - 207,200 Bersedia Mengembalikan
30,520,500
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

1 12/6/2022 12/6/2022
0503R0011222V000481 RJTL 0 Z098 E115 - Non-insulin-
dependent diabetes
mellitus with peripheral
circulatory complications
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - dependent diabetes
Application of other wound mellitus with peripheral
dressing;9659 - Other irrigation of circulatory complications
wound

2 12/14/2022 12/14/2022 0503R0011222V001292 RJTL Z098 E115 - Non-insulin-
dependent diabetes
mellitus with peripheral
circulatory complications
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - dependent diabetes
Application of other wound mellitus with peripheral
dressing;9659 - Other irrigation of circulatory complications
wound

3 12/6/2022 12/6/2022
0503R0011222V000476 RJTL
Z098 D539 - Nutritional anaemia, 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 D539 - Nutritional anaemia, 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
unspecified;E119 - Non- wound, infection, or burn;9059 - unspecified;E119 - Non-
insulin-dependent diabetes Other microscopic examination of insulin-dependent diabetes
mellitus without blood;9357 - Application of other mellitus without
complications;I139 - wound dressing;9659 - Other complications;I139 -
Hypertensive heart and irrigation of wound;9789 - Hypertensive heart and
renal disease, Removal of other therapeutic renal disease,
unspecified;I739 - device unspecified;I739 -
Peripheral vascular Peripheral vascular
disease, unspecified;S984 - disease, unspecified;S984
Traumatic amputation of - Traumatic amputation of
foot, level unspecified;Z488 foot, level unspecified;Z488
- Other specified surgical - Other specified surgical
follow-up care follow-up care

4 12/20/2022 12/20/2022 0503R0011222V001891 RJTL Z488 S980 - Traumatic 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 S980 - Traumatic 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
amputation of foot at ankle wound, infection, or burn;9357 - amputation of foot at ankle
level Application of other wound level
dressing;9659 - Other irrigation of
wound;9789 - Removal of other
therapeutic device

5 12/6/2022 12/6/2022
0503R0011222V000496 RJTL
Z488 N40 - Hyperplasia of 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 N40 - Hyperplasia of 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
prostate wound, infection, or burn;9357 - prostate
Application of other wound
dressing;9659 - Other irrigation of
wound

6 12/7/2022 12/7/2022
0503R0011222V000587 RJTL
Z488 K409 - Unilateral or
unspecified inguinal hernia,
without obstruction or
gangrene
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 K409 - Unilateral or 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - unspecified inguinal hernia,
Application of other wound without obstruction or
dressing;9659 - Other irrigation of gangrene
wound

7 12/30/2022 12/30/2022 0503R0011222V002851 RJTL Z488 K358 - Acute appendicitis, 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 K358 - Acute appendicitis, 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
other and unspecified wound, infection, or burn;9357 - other and unspecified
Application of other wound
dressing;9659 - Other irrigation of
wound;9789 - Removal of other
therapeutic device

8 12/6/2022 12/6/2022
0503R0011222V000460 RJTL
Z098 T814 - Infection following a 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 T814 - Infection following a 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
procedure, not elsewhere wound, infection, or burn;9357 - procedure, not elsewhere
classified Application of other wound classified
dressing;9659 - Other irrigation of
wound
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

9 12/6/2022 12/6/2022
0503R0011222V000480 RJTL
Z098 E115 - Non-insulin- 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z098 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
dependent diabetes wound, infection, or burn;9357 - dependent diabetes
mellitus with peripheral Application of other wound mellitus with peripheral
circulatory complications dressing;9659 - Other irrigation of circulatory complications
wound

10 12/5/2022 12/5/2022 0503R0011222V000293 RJTL Z488 E115 - Non-insulin-
dependent diabetes
mellitus with peripheral
circulatory complications
8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 E115 - Non-insulin- 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
wound, infection, or burn;9357 - dependent diabetes
Application of other wound mellitus with peripheral
dressing;9659 - Other irrigation of circulatory complications
wound

11 12/7/2022 12/7/2022 0503R0011222V000579 RJTL Z488 C509 - Malignant neoplasm 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 C509 - Malignant 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
of breast, unspecified wound, infection, or burn;9357 - neoplasm of breast,
Application of other wound unspecified
dressing;9659 - Other irrigation of
wound

12 12/9/2022 12/9/2022 0503R0011222V000714 RJTL Z488 D24 - Benign neoplasm of 8622 - Excisional debridement of L-3-11-0 342,400 Cek Tindakan GV coding 93.57 Z488 D24 - Benign neoplasm of 9357 Z-3-27-0 186,200 156,200 Bersedia Mengembalikan
breast wound, infection, or burn;9357 - breast
Application of other wound
dressing;9659 - Other irrigation of
wound

13 12/7/2022 12/7/2022 0503R0011222V000569 RJTL Z358 O210 - Mild hyperemesis 8878 - Diagnostic ultrasound of Z-3-25-0 300,000 USG dilakukan 2x dalam Z358 O210 - Mild hyperemesis Q-5-44-0 183,500 116,500 Bersedia Mengembalikan
gravidarum gravid uterus sebulan tidak sesuai dgn PMK gravidarum
dan dilakukan post ranap

14 12/12/2022 12/12/2022 0503R0011222V000933 RJTL Z488 H445 - Degenerated 8911 - Tonometry;9501 - Limited H-3-12-0 213,700 Fragmentasi dari rawat inap tgl Z488 H445 - Degenerated Q-5-44-0 183,500 30,200 Bersedia Mengembalikan
conditions of globe;H259 - eye examination 8/12/2022, sesuai dgn PMK 26 conditions of globe;H259 -
Senile cataract, fragmentasi < 7 hari Senile cataract,
unspecified;H402 - Primary unspecified;H402 - Primary
angle-closure glaucoma angle-closure glaucoma

15 12/22/2022 12/22/2022 0503R0011222V002136 RJTL Z358 O159 - Eclampsia, 8878 - Diagnostic ultrasound of Z-3-25-0 300,000 USG dilakukan 2x dalam Z358 O159 - Eclampsia, Q-5-44-0 183,500 116,500 Bersedia Mengembalikan
unspecified as to time gravid uterus sebulan tidak sesuai dgn PMK unspecified as to time
period;O441 - Placenta period;O441 - Placenta
praevia with haemorrhage praevia with haemorrhage

16 December December 0503R0011222V000062 RJTL A162 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
1, 2022 1, 2022 skin lesion or defect;8744 - penjaminan. FKTP juga bisa
Routine chest x-ray, so described pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

17 December December 0503R0011222V000096 RJTL Z098 G560 - Carpal tunnel 0480 - Peripheral nerve injection, G-3-11-0 321,400 Koding injeksi tidak sesuai Z098 G560 - Carpal tunnel 9929 Q-5-44-0 183,500 137,900 Bersedia Mengembalikan
2, 2022 2, 2022 syndrome not otherwise specified syndrome

18 December December 0503R0011222V000103 RJTL Z098 R11 - Nausea and 8602 - Injection or tattooing of L-3-12-0 207,200 Koding prosedur tidak sesuai Z098 R11 - Nausea and Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
2, 2022 2, 2022 vomiting;J180 - skin lesion or defect vomiting;J180 -
Bronchopneumonia, Bronchopneumonia,
unspecified unspecified

19 December December 0503R0011222V000292 RJTL Z098 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
5, 2022 5, 2022 lung, without mention of skin lesion or defect penjaminan. FKTP juga bisa
bacteriological or pemeriksaan untuk TB. TB
histological masuk dalam 144 dx yang
confirmation;J180 - harus selesai di FKTP
Bronchopneumonia,
unspecified;Z030 -
Observation for suspected
tuberculosis;J459 -
Asthma, unspecified
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

20 December December 0503R0011222V000304 RJTL M171 8192 - Injection of therapeutic M-3-11-0 409,800 Koding injeksi tidak sesuai M171 0 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
5, 2022 5, 2022 substance into joint or ligament

21 December December 0503R0011222V000461 RJTL Z098 R05 - Cough;J189 - 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam Z098 R05 - Cough;J189 - Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
6, 2022 6, 2022 Pneumonia, skin lesion or defect penjaminan. FKTP juga bisa Pneumonia,
unspecified;E46 - pemeriksaan untuk TB. TB unspecified;E46 -
Unspecified protein-energy masuk dalam 144 dx yang Unspecified protein-energy
malnutrition harus selesai di FKTP malnutrition

22 December December 0503R0011222V001063 RJTL Z098 M179 - narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M179 - narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
13, 2022 13, 2022 unspecified;I10 - Essential substance into joint or unspecified;I10 - Essential
(primary) hypertension;I64 - ligament;8827 - Skeletal x-ray of (primary) hypertension;I64
Stroke, not specified as thigh, knee, and lower leg - Stroke, not specified as
haemorrhage or infarction haemorrhage or infarction

23 December December 0503R0011222V001232 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 bilateral;G570 - Lesion of substance into joint or ligament bilateral;G570 - Lesion of
sciatic nerve sciatic nerve

24 December December 0503R0011222V001272 RJTL Z098 M512 - Other specified 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M512 - Other specified 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 intervertebral disc substance into joint or ligament intervertebral disc
displacement;M170 - displacement;M170 -
Primary narthrosis, bilateral Primary narthrosis, bilateral

25 December December 0503R0011222V001274 RJTL Z098 M653 - Trigger finger 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
14, 2022 14, 2022 substance into tendon
26 December December 0503R0011222V001335 RJTL M653 M750 - Adhesive capsulitis 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai M653 M750 - Adhesive capsulitis 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
15, 2022 15, 2022 of shoulder substance into tendon of shoulder
27 December December 0503R0011222V001756 RJTL Z098 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 207,200 Bersedia Mengembalikan
19, 2022 19, 2022 lung, without mention of skin lesion or defect;8744 - penjaminan. FKTP juga bisa
bacteriological or Routine chest x-ray, so described pemeriksaan untuk TB. TB
histological confirmation masuk dalam 144 dx yang
harus selesai di FKTP

28 December December 0503R0011222V001758 RJTL A162 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
19, 2022 19, 2022 skin lesion or defect;8744 - penjaminan. FKTP juga bisa
Routine chest x-ray, so described pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

29 December December 0503R0011222V001789 RJTL Z098 J180 - Bronchopneumonia, 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam Z098 J180 - Bronchopneumonia, Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
19, 2022 19, 2022 unspecified skin lesion or defect;9059 - Other penjaminan. FKTP juga bisa unspecified
microscopic examination of blood pemeriksaan untuk TB. TB
masuk dalam 144 dx yang
harus selesai di FKTP

30 December December 0503R0011222V001861 RJTL Z098 M513 - Other specified 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M513 - Other specified 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
20, 2022 20, 2022 intervertebral disc substance into tendon intervertebral disc
degeneration;M171 - Other degeneration;M171 - Other
primary narthrosis;M653 - primary narthrosis;M653 -
Trigger finger Trigger finger

31 December December 0503R0011222V001886 RJTL Z098 M653 - Trigger finger;I633 - 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger;I633 - 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
20, 2022 20, 2022 Cerebral infarction due to substance into tendon Cerebral infarction due to
thrombosis of cerebral thrombosis of cerebral
arteries;F019 - Vascular arteries;F019 - Vascular
dementia, unspecified dementia, unspecified
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

32 December December 0503R0011222V001980 RJTL Z098 G632 - Diabetic 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 G632 - Diabetic 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
21, 2022 21, 2022 polyneuropathy;E144 - substance into joint or ligament polyneuropathy;E144 -
Unspecified diabetes Unspecified diabetes
mellitus with neurological mellitus with neurological
complications;M170 - complications;M170 -
Primary narthrosis, Primary narthrosis,
bilateral;M750 - Adhesive bilateral;M750 - Adhesive
capsulitis of shoulder capsulitis of shoulder

33 December December 0503R0011222V002095 RJTL Z098 M512 - Other specified 0480 - Peripheral nerve injection, G-3-11-0 321,400 Koding prosedur tidak sesuai Z098 M512 - Other specified 9929 Q-5-44-0 183,500 137,900 Bersedia Mengembalikan
22, 2022 22, 2022 intervertebral disc not otherwise specified intervertebral disc
displacement;G560 - displacement;G560 -
Carpal tunnel Carpal tunnel
syndrome;M750 - Adhesive syndrome;M750 - Adhesive
capsulitis of shoulder;I10 - capsulitis of shoulder;I10 -
Essential (primary) Essential (primary)
hypertension hypertension

34 December December 0503R0011222V002388 RJTL Z098 M653 - Trigger finger 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M653 - Trigger finger 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
26, 2022 26, 2022 substance into tendon
35 December December 0503R0011222V002498 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
27, 2022 27, 2022 bilateral;M531 - substance into joint or ligament bilateral;M531 -
Cervicobrachial Cervicobrachial
syndrome;M478 - Other syndrome;M478 - Other
spondylosis spondylosis

36 December December 0503R0011222V002505 RJTL Z098 G560 - Carpal tunnel 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 G560 - Carpal tunnel 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
27, 2022 27, 2022 syndrome;M179 - substance into tendon syndrome;M179 -
narthrosis, narthrosis,
unspecified;M653 - Trigger unspecified;M653 - Trigger
finger finger

37 December December 0503R0011222V002535 RJTL Z098 M171 - Other primary 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M171 - Other primary 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
28, 2022 28, 2022 narthrosis substance into joint or ligament narthrosis

38 December December 0503R0011222V002561 RJTL M653 M478 - Other spondylosis 8397 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai M653 M478 - Other spondylosis 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
28, 2022 28, 2022 substance into tendon
39 December December 0503R0011222V002629 RJTL Z098 M170 - Primary narthrosis, 8192 - Injection of therapeutic M-3-11-0 409,800 Koding prosedur tidak sesuai Z098 M170 - Primary narthrosis, 9929 Q-5-44-0 183,500 226,300 Bersedia Mengembalikan
29, 2022 29, 2022 bilateral;G632 - Diabetic substance into joint or ligament bilateral;G632 - Diabetic
polyneuropathy;E114 - polyneuropathy;E114 -
Non-insulin-dependent Non-insulin-dependent
diabetes mellitus with diabetes mellitus with
neurological neurological
complications;I633 - complications;I633 -
Cerebral infarction due to Cerebral infarction due to
thrombosis of cerebral thrombosis of cerebral
arteries;I10 - Essential arteries;I10 - Essential
(primary) hypertension (primary) hypertension

40 December December 0503R0011222V000848 RITL Kelas 3 R560 B360 - Pityriasis 9039 - Other microscopic G-4-22-II 3,265,300 Cek diagnosa utama yang A90 B360 9039 - Other microscopic A-4-13-I 1,527,300 1,738,000 Bersedia Mengembalikan
11, 2022 18, 2022 versicolor;A90 - Dengue examination of specimen from spesifik examination of specimen from
fever [classical ear, nose, throat, and ear, nose, throat, and
dengue];K590 - larynx;9059 - Other microscopic larynx;9059 - Other microscopic
Constipation examination of blood;9918 - examination of blood;9918 -
Injection or infusion of Injection or infusion of
electrolytes;9921 - Injection of electrolytes;9921 - Injection of
antibiotic antibiotic
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

41 December December 0503R0011222V000532 RITL Kelas 3 J180 R560 - Febrile convulsions 8744 - Routine chest x-ray, so
6, 2022 10, 2022 described;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9394 - Respiratory
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic
J-4-16-II 4,739,300 DS R56.0 bagian dari DU J180 8744 - Routine chest x-ray, so J-4-16-I 3,372,600 1,366,700 Bersedia Mengembalikan
described;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9394 - Respiratory
medication administered by
nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or
infusion of electrolytes;9921 -
Injection of antibiotic

42 December December 0503R0011222V002468 RITL Kelas 3 A099 R560 - Febrile convulsions 9039 - Other microscopic
26, 2022 30, 2022 examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
K-4-17-II 1,946,400 DS R56.0 bagian dari DU A099 9039 - Other microscopic K-4-17-I 1,423,100 523,300 Bersedia Mengembalikan
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic

43 November December 0503R0011122V002899 RITL Kelas 3 B059 B370 - Candidal stomatitis 9039 - Other microscopic A-4-13-II 2,300,800 koding stomatitis yang sesuai B059 9039 - Other microscopic A-4-13-I 1,527,300 773,500 Bersedia Mengembalikan
28, 2022 2, 2022 examination of specimen from K12.0 examination of specimen from
ear, nose, throat, and ear, nose, throat, and
larynx;9059 - Other microscopic larynx;9059 - Other microscopic
examination of blood;9918 - examination of blood;9918 -
Injection or infusion of Injection or infusion of
electrolytes electrolytes

44 November December 0503R0011122V003034 RITL Kelas 3 K30 B370 - Candidal 8744 - Routine chest x-ray, so K-4-18-II 1,787,000 koding stomatitis yang sesuai K30 E86 - Volume 8744 - Routine chest x-ray, so K-4-18-I 1,257,500 529,500 Bersedia Mengembalikan
29, 2022 2, 2022 stomatitis;E86 - Volume described;8952 - K12.0 depletion;I119 - described;8952 -
depletion;I119 - Electrocardiogram;9039 - Other Hypertensive heart disease Electrocardiogram;9039 - Other
Hypertensive heart disease microscopic examination of without (congestive) heart microscopic examination of
without (congestive) heart specimen from ear, nose, throat, failure specimen from ear, nose, throat,
failure and larynx;9059 - Other and larynx;9059 - Other
microscopic examination of microscopic examination of
blood;9918 - Injection or infusion blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of of electrolytes;9921 - Injection of
antibiotic antibiotic

45 December December 0503R0011222V000251 RITL Kelas 3 K30 B370 - Candidal 8744 - Routine chest x-ray, so K-4-18-II 1,787,000 koding stomatitis yang sesuai K30 R11 - Nausea and 8744 - Routine chest x-ray, so K-4-18-I 1,257,500 529,500 Bersedia Mengembalikan
4, 2022 19, 2022 stomatitis;R11 - Nausea described;8952 - K12.0 vomiting;I119 - described;8952 -
and vomiting;I119 - Electrocardiogram;9039 - Other Hypertensive heart disease Electrocardiogram;9039 - Other
Hypertensive heart disease microscopic examination of without (congestive) heart microscopic examination of
without (congestive) heart specimen from ear, nose, throat, failure specimen from ear, nose, throat,
failure and larynx;9059 - Other and larynx;9059 - Other
microscopic examination of microscopic examination of
blood;9918 - Injection or infusion blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of of electrolytes;9921 - Injection of
antibiotic antibiotic

46 November November 0503R0011122V001849 RJTL R05 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam R05 A162 - Tuberculosis of Q-5-44-0 183,500 23,700 bersedia Mengembalikan
18, 2022 18, 2022 lung, without mention of skin lesion or defect;8744 - penjaminan. FKTP juga bisa lung, without mention of
bacteriological or Routine chest x-ray, so described pemeriksaan untuk TB bacteriological or
histological histological
confirmation;Z030 - confirmation;Z030 -
Observation for suspected Observation for suspected
tuberculosis tuberculosis

47 November November 0503R0011122V002206 RJTL Z030 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam Z030 A162 - Tuberculosis of Q-5-44-0 183,500 23,700 Bersedia Mengembalikan
22, 2022 22, 2022 lung, without mention of skin lesion or defect;8744 - penjaminan. FKTP juga bisa lung, without mention of
bacteriological or Routine chest x-ray, so described pemeriksaan untuk TB bacteriological or
histological confirmation histological confirmation
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

48 November November 0503R0011122V002213 RJTL Z098 J219 - Acute bronchiolitis, 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
22, 2022 22, 2022 unspecified;Z030 - skin lesion or defect;8744 - penjaminan. FKTP juga bisa
Observation for suspected Routine chest x-ray, so described pemeriksaan untuk TB
tuberculosis;R05 -
Cough;A162 - Tuberculosis
of lung, without mention of
bacteriological or
histological confirmation

49 November November 0503R0011122V002291 RJTL Z098 Z030 - Observation for 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
23, 2022 23, 2022 suspected skin lesion or defect penjaminan. FKTP juga bisa
tuberculosis;A162 - pemeriksaan untuk TB
Tuberculosis of lung,
without mention of
bacteriological or
histological
confirmation;R05 - Cough

50 November November 0503R0011122V002354 RJTL Z030 A162 - Tuberculosis of 8602 - Injection or tattooing of L-3-12-0 207,200 Skrining tidak masuk dalam 0 0 0 0 - 207,200 Bersedia Mengembalikan
23, 2022 23, 2022 lung, without mention of skin lesion or defect;8744 - penjaminan. FKTP juga bisa
bacteriological or Routine chest x-ray, so described pemeriksaan untuk TB
histological confirmation

12,837,300
 TGL TANGGAL
NO NO SEP JENPEL KLS RWT DU DS
DATANG PULANG
1 12/5/2022 12/8/2022 0503R0011222V000410 RITL Kelas 1 J441 J180 - Bronchopneumonia,
unspecified;I119 -
Hypertensive heart disease
without (congestive) heart
failure
2 12/20/2022 12/25/2022 0503R0011222V001941 RITL Kelas 3 J441 K30 - Dyspepsia;I159 -
Secondary hypertension,
unspecified;J180 -
Bronchopneumonia,
unspecified;R42 -
Dizziness and giddiness
3 December December 0503R0011222V000350 RJTL Z098 H358 - Other specified
5, 2022 5, 2022 retinal disorders;N309 -
Cystitis, unspecified
4 December December 0503R0011222V000369 RJTL Z098 H309 - Chorioretinal
5, 2022 5, 2022 inflammation, unspecified
5 December December 0503R0011222V000566 RJTL E143 H360 - Diabetic
7, 2022 7, 2022 retinopathy;H040 -
Dacryoadenitis
6 December December 0503R0011222V000568 RJTL Z098 H351 - Retinopathy of
7, 2022 7, 2022 prematurity
7 December December 0503R0011222V000689 RJTL Z098 E143 - Unspecified
9, 2022 9, 2022 diabetes mellitus with
ophthalmic
complications;H360 -
Diabetic retinopathy;H259 -
Senile cataract, unspecified
8 December December 0503R0011222V000690 RJTL Z098 H401 - Primary open-angle 9503 - Extended ophthalmologic H-3-12-0
9, 2022 9, 2022 glaucoma;H259 - Senile work-up
cataract, unspecified
9 December December 0503R0011222V000970 RJTL Z098 E143 - Unspecified
12, 2022 12, 2022 diabetes mellitus with
ophthalmic
complications;H259 -
Senile cataract,
unspecified;H360 - Diabetic
retinopathy
10 December December 0503R0011222V001181 RJTL Z098 H109 - Conjunctivitis, 9503 - Extended ophthalmologic H-3-12-0
14, 2022 14, 2022 unspecified;H401 - Primary work-up
open-angle glaucoma
11 December December 0503R0011222V001883 RJTL Z098 H309 - Chorioretinal
20, 2022 20, 2022 inflammation, unspecified
BY DU INACBG BY VERIFIKASI
PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
VERIFIKASI REVISI REVISI KOREKSI
8744 - Routine chest x-ray, so J-4-17-III 6,099,000 PPOK-Pneumonia. Diagnosa J440 I11.9 8744 - Routine chest x-ray, so J-4-17-I 3,881,000 2,218,000 Sesuai BA kesepakatan
described;8952 - Kombinasi kode dengan J44.0. described;8952 - 2019, Halaman 15 Aspek
Electrocardiogram;9039 - Other Penunjang spirometri untuk Electrocardiogram;9039 - Other Koding No.18, Kode ICD-10
microscopic examination of penegakan diagnosa PPOK? microscopic examination of sudah sesuai dengan
specimen from ear, nose, throat, specimen from ear, nose, throat, diagnosa di Resume Medis
and larynx;9059 - Other and larynx;9059 - Other (PPOK Exacerbasi Akut
microscopic examination of microscopic examination of J44.1 + BP J18.0)
blood;9918 - Injection or infusion blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of of electrolytes;9921 - Injection of
antibiotic antibiotic
8744 - Routine chest x-ray, so J-4-17-III 4,356,400 PPOK-Pneumonia. Diagnosa J440 K30 - Dyspepsia;I159 - 8744 - Routine chest x-ray, so J-4-17-I 2,772,100 1,584,300 Sesuai BA kesepakatan
described;9039 - Other Kombinasi kode dengan J44.0. Secondary hypertension, described;9039 - Other 2019, Halaman 15 Aspek
microscopic examination of Penunjang spirometri untuk unspecified;R42 - microscopic examination of Koding No.18, Kode ICD-10
specimen from ear, nose, throat, penegakan diagnosa PPOK? Dizziness and giddiness specimen from ear, nose, throat, sudah sesuai dengan
and larynx;9059 - Other and larynx;9059 - Other diagnosa di Resume Medis
microscopic examination of microscopic examination of (PPOK Exacerbasi Akut
blood;9394 - Respiratory blood;9394 - Respiratory J44.1 + BP J18.0)
medication administered by medication administered by
nebulizer;9396 - Other oxygen nebulizer;9396 - Other oxygen
enrichment;9918 - Injection or enrichment;9918 - Injection or
infusion of electrolytes;9921 - infusion of electrolytes;9921 -
Injection of antibiotic Injection of antibiotic
9503 - Extended ophthalmologic H-3-12-0 213,700 cek koding prosedur. Cek Z098 H358 - Other specified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up kesesuaian dengan PNPK. retinal disorders;N309 - 16.21
Koding 95.01 Cystitis, unspecified
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H309 - Chorioretinal 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up inflammation, unspecified 16.21
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai E143 H360 - Diabetic 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up retinopathy;H040 - 16.21
Dacryoadenitis
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H351 - Retinopathy of 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up prematurity 16.21
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 E143 - Unspecified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up diabetes mellitus with 16.21
ophthalmic
complications;H360 -
Diabetic retinopathy;H259 -
Senile cataract,
unspecified
213,700 Koding prosedur tidak sesuai Z098 H401 - Primary open-angle 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
glaucoma;H259 - Senile 16.21
cataract, unspecified
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 E143 - Unspecified 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up diabetes mellitus with 16.21
ophthalmic
complications;H259 -
Senile cataract,
unspecified;H360 -
Diabetic retinopathy
213,700 Koding prosedur tidak sesuai Z098 H109 - Conjunctivitis, 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
unspecified;H401 - Primary 16.21
open-angle glaucoma
9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H309 - Chorioretinal 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
work-up inflammation, unspecified 16.21
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

12 December December 0503R0011222V002047 RJTL E144 G632 - Diabetic 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai E144 G632 - Diabetic 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
21, 2022 21, 2022 polyneuropathy;H040 - work-up polyneuropathy;H040 - 16.21
Dacryoadenitis Dacryoadenitis
13 December December 0503R0011222V002204 RJTL Z098 P071 - Other low birth 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 P071 - Other low birth 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
23, 2022 23, 2022 weight;H351 - Retinopathy work-up weight;H351 - Retinopathy 16.21
of prematurity;P599 - of prematurity;P599 -
Neonatal jaundice, Neonatal jaundice,
unspecified;P375 - unspecified;P375 -
Neonatal candidiasis;P229 Neonatal candidiasis;P229
- Respiratory distress of - Respiratory distress of
newborn, unspecified newborn, unspecified

14 December December 0503R0011222V002715 RJTL Z098 H351 - Retinopathy of 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 H351 - Retinopathy of 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
29, 2022 29, 2022 prematurity;L97 - Ulcer of work-up prematurity;L97 - Ulcer of 16.21
lower limb, not elsewhere lower limb, not elsewhere
classified classified

15 December December 0503R0011222V002861 RJTL Z098 P071 - Other low birth 9503 - Extended ophthalmologic H-3-12-0 213,700 Koding prosedur tidak sesuai Z098 P071 - Other low birth 9501 Q-5-44-0 183,500 30,200 Rubah Kode Prosedur ke
30, 2022 30, 2022 weight;H351 - Retinopathy work-up weight;H351 - Retinopathy 16.21
of prematurity of prematurity

16 November November 0503R0011122V000211 RITL Kelas 1 R560 9039 - Other microscopic
2, 2022 4, 2022 examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-I 3,577,900 Cek diagnosa utama yang A499 9039 - Other microscopic
spesifik. examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-14-I 2,964,700 613,200 pasien dengan kejang,
demam sejak 1 hari sebelum
masuk rs. Demam tinggi,
keluhan lain tidak ada. Tidak
ada penunjang untuk
bacterial infection. Leukosit
9400

17 December December 0503R0011222V000080 RITL Kelas 2 R560 E46 - Unspecified protein-
1, 2022 8, 2022 energy malnutrition;A90 -
Dengue fever [classical
dengue];J209 - Acute
bronchitis, unspecified
9039 - Other microscopic
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-II 3,918,400 Cek diagnosa utama yang A90 J209 9039 - Other microscopic
spesifik, penunjang malnutrisi examination of specimen from
tidak ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,832,700 2,085,700 Pasien masuk dengan
demam hari ke-2 + Kejang
>15 menit, Kejang demam
kompleks merupakan
masalah emergency saat
pasien datang dan paling
banyak menghabiskan
resource. Penunjang
Mlanutrisi terlampir. (E46
ganti ke E44.0)

18 December December 0503R0011222V000090 RITL Kelas 2 R560 R11 - Nausea and 9039 - Other microscopic
2, 2022 7, 2022 vomiting;E46 - Unspecified examination of specimen from
protein-energy ear, nose, throat, and
malnutrition;J304 - Allergic larynx;9059 - Other microscopic
rhinitis, unspecified examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-I 3,066,800 Cek diagnosa utama yang R11 J304 9039 - Other microscopic
spesifik, penunjang malnutrisi examination of specimen from
tidak ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
K-4-17-I 1,707,700 1,359,100 pasien masuk dengan
keluhan kejang, demam
sampai suhu 40.4 derajat
celcius. Tidak smua
bronchitis akut berkaitan
dengan kejang demam. Bukti
Penunjang mlanutrisi
terlampir, (E46 ganti ke
E44.1)

19 December December 0503R0011222V000420 RITL Kelas 3 R560 R11 - Nausea and 9039 - Other microscopic G-4-22-I 2,555,600 Cek diagnosa utama yang A099 9039 - Other microscopic K-4-17-I 1,423,100 1,132,500 Kejang demam kompleks
6, 2022 9, 2022 vomiting;A099 - examination of specimen from spesifik examination of specimen from merupakan masalah
Gastroenteritis and colitis ear, nose, throat, and ear, nose, throat, and emergency saat pasien
of unspecified origin larynx;9059 - Other microscopic larynx;9059 - Other microscopic datang dan paling banyak
examination of blood;9918 - examination of blood;9918 - menghabiskan resource.
Injection or infusion of Injection or infusion of Mendapat terapi kejang
electrolytes;9921 - Injection of electrolytes;9921 - Injection of Fenitoin dan Asam Valproat.
antibiotic antibiotic
 TGL TANGGAL BY DU INACBG BY VERIFIKASI
NO NO SEP JENPEL KLS RWT DU DS PROSEDUR INACBG Keterangan DS REVISI PROSEDUR REVISI EFISIENSI TELAAH DARI RS
DATANG PULANG VERIFIKASI REVISI REVISI KOREKSI

20 December December 0503R0011222V002465 RITL Kelas 3 R560 A91 - Dengue 9039 - Other microscopic
26, 2022 31, 2022 haemorrhagic fever examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-III 3,815,400 Cek diagnosa utama yang A91 9039 - Other microscopic
spesifik examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,527,300 2,288,100 Pasien datang dengan
keluhan emergency, kejang
berulang, Suhu 39-40.
mendapat terapi Pct,
Fenitoin, Diawal belum jelas
DBD sehingga diberikan
Antibiotik.

21 December December 0503R0011222V000080 RITL Kelas 2 R560 E46 - Unspecified protein-
1, 2022 8, 2022 energy malnutrition;A90 -
Dengue fever [classical
dengue];J209 - Acute
bronchitis, unspecified
9039 - Other microscopic
examination of specimen from
ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
G-4-22-II 3,918,400 Koding diagnosa spesifik dan A90 J209 9039 - Other microscopic
Bukti penunjang malnutrisi tidak examination of specimen from
ada ear, nose, throat, and
larynx;9059 - Other microscopic
examination of blood;9394 -
Respiratory medication
administered by nebulizer;9396 -
Other oxygen enrichment;9918 -
Injection or infusion of
electrolytes;9921 - Injection of
antibiotic
A-4-13-I 1,832,700 2,085,700 pasien masuk dengan
demam hari ke 2, kejang >15
menit. Sehingga ditegakkan
diagnosis kejang demam
komplek karena masalah
emergency yang harus
ditangani.

22 December December 0503R0011222V000178 RITL Kelas 3 N390 E41 - Nutritional 5794 - Insertion of indwelling
2, 2022 13, 2022 marasmus;E86 - Volume urinary catheter;9039 - Other
depletion microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic
N-4-12-III 4,871,600 Bukti penunjang malnutrisi N390 5794 - Insertion of indwelling N-4-12-I 2,181,200 2,690,400 Bukti terlampir
urinary catheter;9039 - Other
microscopic examination of
specimen from ear, nose, throat,
and larynx;9059 - Other
microscopic examination of
blood;9918 - Injection or infusion
of electrolytes;9921 - Injection of
antibiotic

23 December December 0503R0011222V001592 RITL Kelas 3 A90 E41 - Nutritional marasmus 9039 - Other microscopic A-4-13-III 2,760,900 Bukti penunjang malnutrisi A90 9039 - Other microscopic A-4-13-I 1,527,300 1,233,600 Bukti terlampir
17, 2022 21, 2022 examination of specimen from examination of specimen from
ear, nose, throat, and ear, nose, throat, and
larynx;9059 - Other microscopic larynx;9059 - Other microscopic
examination of blood;9918 - examination of blood;9918 -
Injection or infusion of Injection or infusion of
electrolytes electrolytes

17,683,200