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Litugas Kodefikasi Terkait Cedera, Keracunan, Dan Faktor Eksternal

The document discusses three case examples to demonstrate coding injuries, poisoning, and external factors using ICD-10 and ICD-11. The first case describes a tibia and shaft fracture from football and is coded as S82.20 W09.30 in ICD-10 and NC92.2&XK8G&XJ44E&XJ92H&XA44U1&XA66B3 and PA60&XE617&XE9WC in ICD-11. The second case involves a 9% third degree burn to the hands and is coded as T23.3 T31.0 in ICD-10 and ND95.3&X

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Rida Firda Soleha
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96 views

Litugas Kodefikasi Terkait Cedera, Keracunan, Dan Faktor Eksternal

The document discusses three case examples to demonstrate coding injuries, poisoning, and external factors using ICD-10 and ICD-11. The first case describes a tibia and shaft fracture from football and is coded as S82.20 W09.30 in ICD-10 and NC92.2&XK8G&XJ44E&XJ92H&XA44U1&XA66B3 and PA60&XE617&XE9WC in ICD-11. The second case involves a 9% third degree burn to the hands and is coded as T23.3 T31.0 in ICD-10 and ND95.3&X

Uploaded by

Rida Firda Soleha
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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liTUGAS

KODEFIKASI TERKAIT CEDERA, KERACUNAN, DAN FAKTOR


EKSTERNAL

Oleh:

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN TASIKMALAYA

JURUSAN REKAM MEDIS DAN INFORMASI KESEHATAN

PROGRAM STUDI REKAM MEDIS DAN INFORMASI KESEHATAN

2021
1. Tery bermain sepakbola di langan kampung. Lalu dia terkilir dan mengalami fractur tibia
kiri dan shaft.
a. ICD-10
1) Pengertian
playing football on the village field. Then dislocated and fractured the left tibia
and shaft
2) Terminology medis
playing (k) = bermain
football (k) = sepakbola
on (k) = di
the village (k) = kampung
field. (k) = lapangan
Then (k) = lalu
dislocated (k) = terkilir
and (k) = dan
fractured (k) = fraktur/patah tulang
the left (k) = kiri
tibia (wr) = tibia
and (k) = dan
shaft. (WR) = shaft
3) Arti terminology Medis
Bermain sepakbola dilapangan kampung, lalu terkilir dan mengalami fraktur kiri
tibia dan shaft
4) Lead term :
Fracture dan slipping
5) ICD 10 v3
Alphabetical index : fracture – tibia (shaft)(with fibula) S82.2 (hal 290)
external cause : Slipping (accidental)(on same level)(with fall) W01 (hal 707)
6) ICD-10 v1
Tabular list = S82.20 fracturer of shaft of tibia (hal 828)
External cause = W01 Fall on same level from slipping, tripping, stumbling
(hal 927)
7) Keterangan : pilih 0 yakni tertutup karena tidak disebutkan
8) Kesimpulan :
Jadi diagnosis playing football on the village field. Then dislocated and fractured
the left tibia and shaft akurat terbaca pada ICD-10 dengan kode S82.20 W09.30
9) Cross check
Telah sesuai
b. ICD-11
Tery bermain sepakbola di langan kampung. Lalu dia terkilir dan mengalami fractur
tibia kiri dan shaft. Fraktur tersebut meluas ke sendi dan seluruh bagian artikular
terlepas dari bagian utama tulang 
NC92.2 Fracture of shaft of tibia

 Laterality
XK8G Left 
 Fracture open or closed
XJ44E Closed fracture 
 Joint involvement in fracture
XJ92H Fracture extends into joint and the entire articular part is detached
from the main part of the bone 
 Specific anatomy
XA44U1 Tibia 
XA66B3 Tibial shaft 
Kode akhir : NC92.2&XK8G&XJ44E&XJ92H&XA44U1&XA66B3

PA60 Unintentional fall on the same level or from less than 1 metre
 Activity when injured
XE617 Leisure or play 
 Place of occurrence
XE9WC Outdoor sporting grounds 
Kode akhir : PA60&XE617&XE9WC

2. Terbakar derajat 3 pada tangan sebesar 9% pada body surface area.


a. ICD-10
1) Pengertian
Burn of third degree on hands by 9% on body surface area
2) Terminology medis
burns (k) = luka bakar
of (k)= pada
third (ket)= ketiga
Degree (k) = derajat
on (k) = pada
hands (Wr) = tangan
by (k) = sebesar
9% (k) = 9%
on (k) = pada
body (k) = tubuh
surface (k) = permukaan
area (k) = luas
3) Arti terminology Medis
Luka bakar derajat 3 pada tangan sebesar 9% pada body surface area
4) Lead term: burn
5) ICD 10 v3
Alphabetical index :
Burn -hand T23- (hal 86)
Burn -unspecified site with extend of body surface involved specified-less than
10 percent T31.0 (hal 87)
6) ICD-10 v1
T23.3 Burn of third degree of wrist and hand (hal 849)
T31.0 Burn involving less than 10% of body surface (hal 852)
7) Tanda baca
8) Kesimpulan
Jadi diagnosis Luka bakar derajat 3 pada tangan sebesar 9% pada body surface
area akurat terbaca pada ICD10 dengan kode T23.3 T31.0
9) Cross check
Sudah sesuai
b. ICD-11
Terbakar derajat 3 pada tangan sebesar 9% pada body surface area akibat kebakaran
di hotel
ND95.3 Burn of wrist or hand, full thickness burn
 Extent of burn by body surface
XJ7TR Burns involving 5-9% of body surface 
XE0S0 Exposure to uncontrolled fire
 Aspects of place of injury occurrence 
XE6X4 Boarding house or hotel
Kode akhir XJ7TR& XE0S0& XE6X4 
3. David dislokasi pada jari-jari saat jatuh dari tempat tidur dirumah saat sedang tidur
malam.
a. ICD-10
1) Pengertian
dislocation of the fingers when falling out of bed at home while sleeping at night
2) Terminology medis
dislocation of (k) = dislokasi pada
the fingers (WR) = jari-jari
when falling out of bed at home while sleeping at night (k) = ketika jatuh dari
tempat tidur dirumah saat sedang tidur malam
3) Arti terminology Medis
dislokasi pada jari-jari saat jatuh dari tempat tidur dirumah saat sedang tidur
malam
4) Lead term
Dislocation dan fall
5) ICD 10 v3
Alphabetical index : dislocation-finger S63.1 (hal 217)
external cause : fall -from off—bed W06 (hal 687)
6) ICD-10 v1
Tabulary list
S63.1 dislocation of finger (hal 822)
W06.04 fall involving bed (hal 927)
7) Tanda baca
8) Kesimpulan
Jadi diagnosis dislocation of the fingers when falling out of bed at home while
sleeping at night akurat terbaca pada ICD 10 dengan kode S63.1 W06.04
9) Cross check
Sudah sesuai
b. ICD-11
 NC54.2Z Dislocation of finger, unspecified
PA60 & XE266 Unintentional fall on the same level or from less than 1 metre-home

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