Koding Tht Kelas Rabu Maret 2019.docx

Nama : Fitriani Golongan : A Absen : 31 NO.

TINDAKAN

LEAD TERM

KODE ICD 9 CM 27.0

1

Insisi drenase abses wajah/ submandibula/ angina ludovici

Drainage – ludwig’s angina

2

Insisi palatum

Incision - plate

27.1

3

Biopsi palatum durum

Biopsy – plate (bony)

27.21

4

Biopsi uvula/ palatum mole

Biopsy - uvula

27.22

5 6

Eksisi lesi palatum durum Eksisi luas lesi palatum durum

7

Hecting laserasi palatum

Excision –plate(bony) Resection-> alveolar process and palate Palatorrhaphy

8

Implan palatum

Insertion->Palatal Implant

27.61 27.64

9

Insisi uvula

Incision->Uvula

27.71

10

Eksisi uvula

Excision->Uvula

27.72

11

Insisi drenase abses tonsil/peritonsil/parafaring/retrofaring

Incision  tonsil

28.0

12

Biopsi tonsil dan adenoid

Biopsy  tonsil Biopsy  adenoid Biopsy  tonsil Biopsy  adenoid Tonsillectomy

13

Biopsi tonsil dan adenoid

14

Tonsilektomi

15

Tonsilektomi dengan adenoidektomi

27.31 27.32

28.11 28.11 28.2

16

Eksisi tonsil lingual

Tonsillectomy  with adenoidectomy Excision  tonsil  lingual

17 18

Eksisi tag tonsil Eksisi tonsil lingual

Excision  tonsil  tag Excision  tonsil  lingual

19

Adenoidektomi

20

Kontrol perdarahan pasca tonsilektomi dan adenoidektomi

28.91

28.3 28.4 28.5

28.5

21

Ekstraksi benda asing tonsil/adenoid dengan insisi

Adenoidectomy (without tonsillectomy) Control  hemorrhage  adonids (postoperative) Control  hemorrhage  tonsils (postoperative) Incision – tonsil

22

Eksisi lesi di tonsil dan adenoid

Excision – tonsil

28.92

23

Faringotomi

Pharyngotomy

29.0

24

Biopsi nasofaring/orofaring/hipofaring

Biopsy – nasopharinx

29.12

25

Eksisi kista brakial

Excision – branchial cleft cyst or vestige Myotomy -> cricopharyngeal

29.2

26

Miotomi krikofaring

28.6

28.7

29.31

27

Divertikulektomi faring

28

Faringektomi

Diverticulectomy -> Pharyngeal (by cricopharyngeal myotomy) Pharyngectomy (Partial)

29

Eksisi lesi di faring

Excision -> pharynx

29.39

30

Nasofaringektomi

Excision -> nasopharynx

29.3

31

Ekstirpasi angiofibroma nasofaring

Excision - pharynx

29.39

32

Faringoplasti

Suture - pharynx

29.51

33

Hecting laserasi faring

pharyngoplasty

29.4

34

Penutupan fistel celah brakial

closure - branchial

29.52

35

Penutupan fistel faring

closure - pharynx

36

Ekstraksi benda asing faring

Extraction > Removal – Foreign Body – Pharynx (Intraluminal)

29.53 98.13

37

Biopsi kelenjar tiroid

Biopsy - Thyroid Gland Nec

06.11

38

Biopsi kelenjar paratiroid

Biopsy – Parathyroid Gland

06.13

39

Lobectomy tiroid unilateral

Lobectomy – Thyroid Unilateral

06.2

40

Hemitiroidektomi

Hemithyroidectomy

06.2

41

Eksisi lesi tiroid (kista tiroid)

Excision-lesion-thyroid

06.31

42

Tiroidektomi parsial

43

Near total tiroidektomi

Thyroidectomy-partial or subtotal NEC Tiroidectomy-NEC

06.39 06.39

44

Tiroidektomi total

45

29.32 29.33

06.4

Eksisi tiroid lingual

hyroidectomy-complete or total Thyroidectomy - lingual

46

Eksisi duktus tiroglosus

Excition – duct - thyroglossa

06.6

47

Paratiroidektomi total

Parathyroidectomy - complete

06.81

48

Ligasi pembuluh darah tiroid

06.92

49

Hecting kelenjar tiroid

Ligation – thyroid vessel (arteri) (vein) Suture – Thyroid Gland

50

Rhinotomi lateral

Rhnotomy

21.1

51

Maksilektomi medial

Maksilektomy

22.31

52

Frontal sinusotomi (onkologi)

Sinusotomi - Frontal

22.41

53

Etmoidektomi eksternal (onkologi)

Ethmoidectomy

22.63

54

Sfenoidektomi eksternal (onkologi)

Sphenoidectomy

22.64

55

Pendekatan sublabial

56 57

Midfasial degloving Glosektomi parsial/ hemiglosektomi

Sinusectomy – maxillary – with Caldwel-Luc approach Sinusectomy – maxillary Glossectomy - partial

06.6

06.93

22.61 22.62 25.2

58

Glosektomi total

Glossectomy (total)

25.3

59 60

Glosektomi radikal Sialendoskopi Diagnostik

25.4

61

Sialolithektomi

62 63

Ekstirpasi kelenjar sublingual/ submandibula/ parotis parsial Parotidektomi parsial

Glossectomy - radical Procedure – diagnostic – salivary gland Excision – lesion – salivary gland or duct NEC Extirpation – see also excision – salivary gland -- partial Parotidectomy => Partial

64

Parotidektomi superfisial

Parotidectomy => Partial

65

Ekstirpasi kelenjar sublingual/ submandibula/ parotis total

Extirpation -> see also Excisition -> salivary gland -> complete Parotidectomy -> complete

66

Parotidektomi total

67

Sialendoskopi Diagnostik dan Dilatasi

68

Sialendoskopi Diagnostik dan Terapeutik

69

Radiofrekuensi Dasar Lidah

70

Eksplorasi Abses Multiple

71

Dilation -> salivary duct Operation -> slivary gland or duct Operation -> oral cavity

26.19 26.29 26.31 26.31 26.31 26.32 26.32 26.91 26.99 27.99

Marsupialisasi kista laring

Drainage -> abscess  Parapharyngeal  Peritonsilar  Retropharyngeal  Tonsil,tonsilar Marsupialization -> larynx

28.0 30.01

72

Eksisi lesi laring (papiloma, nodul)

Excision -> lesion -> larynx

30.09

73 74

Hemilaringektomi Epiglotiktomi

Hemilaryngektomy Epiglotidectomy

30.1

75

Kordektomi

Cardectomy, vocal

30.21 30.22

76

Laringektomi parsial

Laryngectomy -> partial

30.29

77 78

Laringektomi total Laringektomi radikal

Laryngectomy - complete Laryngectomy - radical

30.3

79

Injeksi laring

Injection - larynx

30.4 31.0

80

Trakeostomi temporer

Tracheostomy

31.1

81

Trakeostomi dengan penyulit

Tracheostomy -Temporary

31.1

82

Trakeostomi permanen

Tracheostomy - permanent

31.29

83

Trakeoskopi melalui stoma trakea

84

Trakeoskopi melalui stoma trakea

85

Laringoskopi/trakeoskopi

Tracheoscopy – throught tracheostomy (stoma) Tracheoscopy – throught tracheostomy (stoma) Laryngoscopy

86

Laringoskopi/trakeoskopi

Laryngoscopy

31.61

87 88

Biopsi laring dengan endoskopi Biopsi trakea dengan endoskopi

Biopsy – larynx - closed Biopsy – trachea – closed

31.43

31.41 31.41 31.61

31.44

89

Biopsi terbuka laring atau trakea

31.45

Eksisi lesi trakea

Biopsy, -larynx/-trachea, -open Excision, -lesion, --trachea

90 91 92

Laringofisure Hecting laserasi laring

Laryngofissure Suture, -larynx

30.29

93

Hecting laserasi laring

suture of laceration of laryn

94

Penutupan fistel laring

clouser of fistula of larynx

95

Revisi laringostomi/ repair stoma

revision of laryngostomy

31.63

96

Reparasi fraktur laring

repair of laryngeal of other

31.64

97

Eksisi neoplasma laring dengan laser

Repair-larynx

31.69

98 99

Penutupan fistel trakea Penutupan stoma trakeostomi dengan repair trakea

Closure-fistula-trachea Closure-tracheostomy

31.72

100

Revisi trakeostomi

Revision-tracheoctomy

31.74

101

Rekonstruksi trakea dan konstruksi laring

102

Lisis penyempitan trakea/laring

103

Penggantian stent laring/trakea

104

Pemasangan T-Tube/ganti T stent

105 106

Injeksi obat terapetik ke trakea Fistulasasi trakeoesofagus

31.5 31.61 31.61 31.62

31.72

107

Bronkoskopi melalui stoma

108

Bronkoskopi fiber optik

LT : Tracheoplasty -with artificial larynx LT : Lysis -adhesions --trachea LT : Replacement -Laryngeal stent LT : Replacement -stent --trachea Injection-trachea Fistulizationtracheoesophageal Bronchoscopy- through tracheostomy Bronchoscopy-fiberoptic

109

Bronkoskopi

Bronchoscopy

33.22 33.23

110

Biopsi bronkus dengan endoskopi

Bronchoscopy-with biopsy

33.24

111

Ligasi arteri karotis eksterna

21.06

112

Biopsi eksisi kelenjar limfe leher simpel

Ligation-artery-external carotid Excision-lymph structure

113

Biopsi insisi kelenjar limfe leher simpel

114

Eksisi kelenjar limfe regional

115

Diseksi leher selektif

116

Diseksi leher radikal unilateral

Excision – lymph, lymphatic - node(simple) Excision -lymph,lymphatic regional Excision – node – lymphatic dirainage area (inchuding skin, subcutaneous tissue, and fat) Dissection – neck radical – unilatral

31.75

31.92 31.93

31.93 31.94 31.95 33.21

40.29 40.29 40.3

40.3 40.41

117

Diseksi leher radikal modifikasi

118

Diseksi leher radikal bilateral

119

Esofagotomi 1/3 proksimal

120

Insisi web esofagus

Dissection-see also excisionneck,radical modifikasi(unilteral) Dissection-see also excitionneck,radical bilteral Esophgotomy

40.42 40.42 42.0

121

Esofagostomi

Incision-contesophagus.esophageal NECweb Esophagostomy

122

Esofagostomi servikal

Esophagostomy – cervical

42.10 42.11

123

Esofagoskopi

Esophagoscopy

42.23

124

Biopsi esofagus per endoskopi

Biopsy – Esophagus – closed(endoscopic)

42.24

125

Biopsi esofagus per endoskopi

Biopsy – Esophagus – closed(endoscopic) Biopsy – Esophagus – closed(endoscopic) Excision – Diverticulus Esophagus Excision – Esophagus(Local) Endoscopic

42.02

42.24

126

Biopsi esofagus per endoskopi

127

Eksisi divertikulum esofagus

128

Tindakan esofagus kompleks (eksisi, varises)

129

Reseksi esofagus

Reesection - esophagus

42.41

130

Reparasi fistel esofagus

Repair – esophagus - fistula

42.84

131

Reparasi striktur esofagus

Repair – esophagus - stricture

42.85

132 133

Dilatasi esofagus Dilatasi esofagus

Dilatation - esophagus Dilatation of esophagus

K22.8

42.24 42.40

42.33

134

Dilatasi esofagus

Dilatation of esophagus

42.92 42.92

135

Mandibulektomi parsial

Partial mandibulectomy

76.31

136

Maksilektomi parsial

Partial ostectomy of other facial bone

137

Maksilektomi total

Hemimaxillectomy

76.39

138

Maksilektomi radikal

Hemimaxillectomy

76.39

139 140

Mandibulektomi total Reduksi terbuka fraktur malar dan zigoma

Mandibulectomy -Total Reduction - Malar - Open

76.42 76.72

141

Reduksi terbuka fraktur maksila

Reduction – fracture – maxilla – open

76.74

76.39

142

Reduksi terbuka fraktur mandibula

143

Eksisi kulit luas

144

Esofageal manometri

145

Intubasi dengan Flexible Bronkoskopi

146 147

Pembersihan kanul trakeostomi Cuci trakea dan bronkus

148

Penggantian NGT

149

Penggantian kanul trakeostomi

150

Pengangkatan kanul trakeostomi

151

Ekstraksi benda asing esofagus

Reduction – fracture – mandible – open Excision – skin – radical (wide) Manometry – esophageal Insertion –Tube - Endotracheal Toilette - Tracheostomy Lavage –Bronchus NEC – Trachea NEC Replacement - Nasogastric Replacement-tubetracheostomy Removal-tube- tracheostomy Removalesophafus(intraluminal) Removal-larynx(intraluminal)

76.76 86.4 89.32 96.04 96.55 96.56 97.01 97.23 97.37 98.02

152

Ekstraksi benda asing laring

153

Ekstraksi benda asing trakea

154

Ekstraksi benda asing bronkus

155

Biopsi sinonasal app gingivobuccal

156

Biopsi Lidah

Removal – foreign body – trachea (instraluminal) Removal – foreign body – bronkus (instraluminal) Excision – lesion – nasal sinus – with Caldwell-Luc approach Biopsy – tongue

157

Hecting laserasi lidah

Suture - tongue

158

Frenektomi lingual

Frenectomy - lingual

159

Insisi drenase kelenjar liur

160

Biopsi kelenjar liur

161

Marsupialisasi kista kelenjar liur

162

Hecting laserasi kelenjar liur

163

Probing saluran liur

Incision – salivary gland or duct Biopsy – salivary gland or duct - open Marsupialization – ranula,salivary gland Suture (laceration) – salivary gland Probing – salivary duct

164 165

Insisi drenase abses wajah, submandibula, angina ludovici Biopsi bibir

Drainage –Facial region Biopsy -> lip

27.23

166

Biopsi mulut/ basis lidah

Biopsy-> mouth

27.24

167

Biopsi eksisi rongga mulut

Procedure->oral cavity

27.29

168

Frenektomi labial

Frenectomy-> labial

169

Hecting laserasi bibir

Suture (laceration)  Lip

27.41 27.51

170

Hecting laserasi mulut

171

Penutupan fistel mulut

Suture (laceration)  Mouth Closure  Fistula  Mouth

27.52 27.53

98.14 98.15 98.15 22.61 25.01 25.51 25.92 26.0 26.12 26.21 26.41 26.91 27.0

172

Ekstraksi benda asing mulut

Removal  Foreign body  Mouth (intraluminal)

98.01

1. Seorang pasien mendatangi poli THT dengan keluhan hidung sering tersumbat,ingus kental , terasa sakit di wajah bagian sekitar mata dan gejala tersebut semakin terasa saat menundukkan kepala. Dari gejaala yang di paparkan, apa diagnosa yang tepat untuk penyakit tersebut? a. Sinusitis b. Salesma c. Flu d. Rninitis allergic e. influenza