CHAPTER XVIII

Symptoms, signs and abnormal clinical

and laboratory findings, not elsewhere
classified
(R00–R99)

KODIFIKASI PENYAKIT & TINDAKAN KPT III

(General Coding)
pendahuluan

• Bab XVIII meliputi symptoms, signs, hasil abnormal

dari klinik atau prosedur investigasi lainnya, dan
kondisi tidak jelas dimana tidak ada diagnosa yg
diklasifikasikan dicatat.

• Umumnya, kategori di Bab XVIII meliputi suatu

penetapan kondisi yg kurang baik dan gejala tanpa
menetapkan diagnosis akhir.
• Pada kenyataannya seluruh katagori pada Bab XVIII
dapat menunjuk 'not otherwise specified', 'unknown
etiology' or 'transient'.
• Indek Alpabet digunakan untuk menentukan kode
symptoms & signs
• Subcategories sisa, no .8, umumnya digunakan untuk
kondisi symptom lain yang relevan yang tidak
diklasifikasikan ditempat lain
DESKRIPSI (Lanjutan-1)

• Kondisi dan tanda, gejala atau simtoma yang

termasuk di dalam Bab R ini:

a) kasus-kasus yang diagnosisnya tidak

dapat ditegakkan walau semua fakta
yang ada sudah diinvestigasi.

b) tanda, gejala dan simtoma, yang hadir

pada saat pertemuan initial, yang terbukti
hanya sepintas tanpa dapat dikenal
causanya. 4
DESKRIPSI (Lanjutan-2)

c) diagnosis kerja yang pasiennya tidak

datang kembali untuk investigasi atau
asuhan lebih lanjut.

d) kasus-kasus dirujuk ke tempat lain

untuk investigasi atau terapi sebelum
diagnosisnya dapat ditegakkan.

e) kasus-kasus yang karena alasan tertentu

kepastian diagnosisnya belum diperoleh.

5
DESKRIPSI (Lanjutan-3)

f) simtoma tertentu, yang informasi

tambahannya tersedia dan menduduki
masalah berkekhususan penting dalam
asuhan medis.
Excludes: temuan abnormal kasus antenatal
skrining bumil (O28.-)
kondisi-kondisi tertentu yang
berasal mula pada periode
perinatal (P00-P96)

6
DESKRIPSI (Lanjutan-4)

• Rentang kategori dari R00 – R99

• Ada 90 dari 100 yang tersedia sudah teralokasikan

• Tidak memilki kode berasterisk

• R10 Abnormal and pelvic pain di subdivisi sesuai site

sakit yang timbul.
Contoh: Rasa saki terlokasi di abdomen atas.

7
DESKRIPSI (Lanjutan-5)

• Ada 2 (dua) exclusion di bawah judul Bab

• Exclusion apapun di blok atau kategori di sini

disediakan dan kategori atau subkategori yang
termasuk exclusion senantiasa dispesifikasi-kan.

• Pada indeks afabetik ICD-jilid 2 harus digunakan

untuk menjelaskan (klarifikasi) tanda dan simtoma
mana yang harus diambil dari Bab XVIII dan
mana yang termauk Bab-bab lain.
8
 DESKRIPSI (Lanjutan-6)

• Grup R40 – R46 dikreasi untuk mengklasifikasikan

simtoma yang berhubungan dengan persepsi
cognitif, status emotional dan perilaku

• Grup R47 – R49, untuk simtoma terkait kondisi

gangguan speech (wicara) dan suara.

9
DESKRIPSI (Lanjutan-7)

• R70 – R94 meliputi berbagai temuan-temuan

abnormal.
Kode ini digunakan manakala tidak ada
diagnosis yang berhasil ditegakkan dan
seseorang (pasien) difollow-up dari hasil
pemeriksaan yang menunjukkan adanya temuan
yang abnormal.

10
 DESKRIPSI (Lanjutan-8)

• R95 – R99 Ill-defined dan sebab kematian

yang tidak diketahui, sesuai yang ditandakan
judul, untuk digunakan bagi kode mortalitas.

Mereka hanya digunakan apabila tidak ada

kode spesifik yang bisa tepat digunakan.

11
TUJUAN

• Mengenal berbagai istilah simtoma penyakit dan

mampu menentukan kode istilah simtoma penyakit,
hasil temuan abnormal yang tidak disertai diagnoses.
• Memahami peraturan yang memperbolehkan istilah
simtoma penyakit digunakan sebagai diagnosis
kondisi utama.
• Mamahami istilah simtoma yang tidak berlaku bagi
kode kondisi perinatal/neonatal.

12
Palpitation,Tachycardia dan
Bradycardia

• Palpitation: perasaan gugup, berdebar-debar detak

jantung, yang disadari pasien.

• Tachycardia: laju aksi detak jantung yang melebihi

batas normal.

• Bradyardia: lambatnya detak/kerja jantung, yang

termanifestasi pada nadi ( < 60x/menit)

13
Dyspnoea, Hiccough, Halithosis
& Asphyxia
• Dyspnoea: orthopnoea, shortness of breath.
(bernapas lega bila badan tegak,
bernapas pendek-pendek)
• Hiccough: sedakan, ketegukan, kecegukan.

• Halithosis (halitosis): napas berbau, mulut berbau

busuk.

• Asphyxia: suffocation, mati lemas, kekurangan

napas.
14
Fasciculation, Ataxia, Meningismus

• Fasciculation: twitching, kedutan, kejangan

• Ataxia: kehilangan perasaan keseimbanga

(gerak)
• Meningismus: meningism, kondisi iritasi akut
meninges akibat infeksi, umumnya spesifik dengan
demam dan sering pada pneumonias.

• Somnolence: drowsiness, perasaan mengantuk

Stupor: semikoma
15
Dysarthria, Anarthria, Dysphasia &
Aphasia

• Dysarthria: kekurang sempurnanya articulation

(pengucapan) kata.
• Anarthria: defective articulation in speaking.

• Dysphasia: kesulitan, kekurangmampuan berbicara

dan pengertian bahasa (kerusakan sentral)
• Aphasia: kekurang sempurnanya kapasitas
penggunaan kata untuk padanan atau ide (ini adalah
gangguan organik pada otak)

16
Anosmia, Parosmia & Parageusia

• Anosmia: Kekurangan sensasi pembauan.

Gangguan bisa: afferent, kurangya konduktivitas
pada saraf olfactus; bisa sentral (penyakit
cerebral); organik (penyakit selaput hidung);
periferal (gangguan saraf olfactus)

• Parosmia: Pervision (deviasi) of the sense of

smell (bau).

• Paraqeusia: Pervision of the sens of taste. 17

Terdiri 11 Blok :
R00–R09 Gejala dan Tanda yg menyertai sistem peredaran dan
pernapasan
R10–R19 Gejala dan Tanda yg menyertai sistem pencernaan dan
abdomen
R20–R23 Gejala dan Tanda yg menyertai jaringan kulit dan
subcutaneous
R25–R29 Gejala dan Tanda yg menyertai sistem saraf dan
musculoskeletal
R30–R39 Gejala dan Tanda yg menyertai sistem urinaria
R40–R46 Gejala dan Tanda yg menyertai kesadaran, persepsi
keadaan emosinal dan tingkah laku
R47–R49 Gejala dan Tanda yg menyertai kemapuan berbicara
dan suara
Terdiri 11 Blok :..........................

R50–R69 Gejala dan tanda hal umum

R70–R79 Temuan abnormal dari pemeriksaan darah tanpa
diagnosa
R80–R82 Temuan abnormal dari pemeriksaan urin tanpa
diagnosa
R83–R89 Temuan abnormal dari pemeriksaan zat cair, zat kimia
dan jaringan lain dari tubuh, tanpa diagnosa
R90–R94 Temuan abnormal pada gamabaran diagnostic&
didalam fungsi penelitian, tanpa diagnosa
R95–R99 Kondisi/sakit yg tidak jelas dan penyebabnya tidak
diketahui penyebab kematian
1. R00–R09 Gejala dan Tanda yg menyertai
sistem peredaran dan pernapasan

R00 Abnormalities of heart beat

• R00.0 Tachycardia, unspecified
Rapid heart beat
• R00.1 Bradycardia, unspecified
Slow heart beat
Use additional external cause code (Chapter XX), if desired, to identify drug, if
drug-induced.
• R00.2 Palpitations (debaran jantung)
R01 Cardiac murmurs (bunyi) and other cardiac sounds
R02 Gangrene, not elsewhere classified

R03 Abnormal blood-pressure reading, without diagnosis

R05 Cough
Excludes: cough with haemorrhage (R04.2), psychogenic cough (F45.3)

R06 Abnormalities of breathing

Excludes: .....
R06.0 Dyspnoea / Orthopnoea / Shortness of breath
Excludes: transient tachypnoea of newborn (P22.1)
R06.1 Stridor
Excludes: congenital laryngeal stridor (P28.8), laryngismus (stridulus) (J38.5)
R06.2 Wheezing (bunyi denging)
R06.3 Periodic breathing / Cheyne-Stokes breathing
R06.4 Hyperventilation
Excludes: psychogenic hyperventilation (F45.3)
R06.5 Mouth breathing / Snoring (dengkur)
Excludes: dry mouth NOS (R68.2)
R06.6 Hiccough (Cegukan)
Excludes: psychogenic hiccough (F45.3)
R06.7 Sneezing
R07 Pain in throat and chest
R09 Other symptoms and signs involving the
circulatory and respiratory systems
Excludes:........
R09.0 Asphyxia (sesak dada)
Excludes: asphyxia (due to): birth (P21.-), carbon monoxide (T58),
foreign body in respiratory tract (T17.-), intrauterine
(P20.-), traumatic (T71)
R09.1 Pleurisy
Excludes: pleurisy with effusion (J90)
R09.2 Respiratory arrest
Cardiorespiratory failure
R09.3 Abnormal sputum
2. R10–R19 Gejala dan Tanda yg menyertai
sistem pencernaan dan abdomen
Excludes:.......
R10 Abdominal and pelvic pain
R11 Nausea (mual) and vomiting, Excludes: ........
R12 Heartburn (rasa panas dlm perut), Excludes: ...........
R13 Dysphagia
R14 Flatulence (gas dlm perut) & related conditions Excludes:......
R15 Faecal incontinence Excludes:......
R16 Hepatomegaly and splenomegaly, not elsewhere classified
R17 Unspecified jaundice (kuning) Excludes:.......
R18 Ascites
R19 Other symptoms and signs involving the digestive system and abdomen
R19.0 Intra-abdominal and pelvic swelling, mass and lump
R19.1 Abnormal bowel sounds
R19.2 Visible peristalsis
R19.3 Abdominal rigidity
R19.4 Change in bowel habit
R19.5 Other faecal abnormalities
R19.6 Halitosis
3. R20–R23 Gejala dan Tanda yg menyertai
jaringan kulit dan subcutaneous
R20 Disturbances of skin sensation Excludes:
R21 Rash (ruam)and other nonspecific skin eruption
R22 Localized swelling (bengkak), mass and lump of skin and
subcutaneous tissue
R23 Other skin changes
R23.0 Cyanosis
R23.1 Pallor (Pucat)
R23.2 Flushing (kemerah2 an)
R23.3 Spontaneous ecchymoses
R23.4 Changes in skin texture
R23.8 Other and unspecified skin changes
4. R25–R29 Gejala dan Tanda yg menyertai
sistem saraf &musculoskeletal
R25 Abnormal involuntary movements, Excludes:.....
R25.0 Abnormal head movements
R25.1 Tremor, unspecified
R25.2 Cramp and spasm
R25.3 Fasciculation
R25.8 Other and unspecified abnormal involuntary movements
R26 Abnormalities of gait and mobility, Excludes:........
R26.0 Ataxic gait
R26.1 Paralytic gait
R27 Other lack (kekurangan) of coordination
R27.0 Ataxia, unspecified
R29 Other symptoms and signs involving the nervous and musculoskeletal systems
R29.0 Tetany
R29.1 Meningismus
R29.2 Abnormal reflex
R29.3 Abnormal posture
R29.4 Clicking hip
5. R30–R39 Gejala dan Tanda yg menyertai
sistem urinaria
R30 Pain associated with micturition, Excludes: psychogenic pain (F45.3)
R30.0 Dysuria
R30.1 Vesical tenesmus
R30.9 Painful micturition, unspecified
R31 Unspecified haematuria , Excludes: recurrent or persistent haematuria (N02.)
R32 Unspecified urinary incontinence
R33 Retention of urine
R34 Anuria and oliguria
R35 Polyuria
R36 Urethral discharge
R39 Other symptoms and signs involving the urinary system
R39.0 Extravasation of urine
R39.1 Other difficulties with micturition
R39.2 Extrarenal uraemia
6. R40–R46 Gejala dan Tanda yg menyertai
kesadaran, persepsi keadaan
emosinal dan tingkah laku

Excludes: those constituting part of a pattern of mental disorder (F00–F99)

R40 Somnolence, stupor and coma, Excludes:....
R41 Other symptoms and signs involving cognitive functions and awareness
Excludes: dissociative [conversion] disorders (F44.-)
R41.0 Disorientation, unspecified
R41.1 Anterograde amnesia
R41.2 Retrograde amnesia
R42 Dizziness and giddiness
R43 Disturbances of smell and taste
R43.0 Anosmia
R43.1 Parosmia
R43.2 Parageusia
R44 Other symptoms and signs involving general sensations and perceptions
R44.0 Auditory hallucinations
R44.1 Visual hallucinations
R44.2 Other hallucinations
R44.3 Hallucinations, unspecified
R44.8 Other and unspecified symptoms and signs involving general sensations

R45 Symptoms and signs involving emotional state

R45.0 Nervousness
R45.1 Restlessness and agitation (pergolakan/hasutan)
R45.2 Unhappiness
R45.3 Demoralization (kemerostan ) and apathy (kelesuan)
R45.4 Irritability and anger
R45.5 Hostility (permusuhan)
R45.6 Physical violence (kekerasan fisik)
R45.7 State of emotional shock and stress, unspecified
R45.8 Other symptoms and signs involving emotional state
Suicidal ideation (tendencies)
Excludes: suicidal ideation constituting part of a mental disorder (F00-F99)
R46 Symptoms and signs involving appearance and behaviour
R46.0 Very low level of personal hygiene
R46.1 Bizarre personal appearance
R46.2 Strange and inexplicable (tdk dpt dipahami) behaviour
R46.3 Overactivity
R46.4 Slowness and poor responsiveness
Excludes: stupor (R40.1)
R46.5 Suspiciousness and marked evasiveness
R46.6 Undue concern and preoccupation with stressful events
R46.7 Verbosity and circumstantial detail obscuring reason for contact
R46.8 Other symptoms and signs involving appearance and behaviour
.
7. R47–R49 Gejala dan Tanda yg
menyertai kemapuan berbicara & suara
R47 Speech disturbances, not elsewhere classified Excludes:.....
R47.0 Dysphasia and aphasia
R47.1 Dysarthria and anarthria
R47.8 Other and unspecified speech disturbances
R48 Dyslexia and other symbolic dysfunctions, not elsewhere classified
R48.0 Dyslexia and alexia
R48.1 Agnosia
R48.2 Apraxia
R48.8 Other and unspecified symbolic dysfunctions
R49 Voice disturbances
R49.0 Dysphonia
R49.1 Aphonia
R49.2 Hypernasality and hyponasality
R49.8 Other and unspecified voice disturbances
Change in voice NOS
8. R50-R69 Gejala dan Tanda Umum
R50 Fever of unknown origin
R50.0 Fever with chills / Fever with rigors
R50.1 Persistent fever
R51 Headache
R52 Pain, not elsewhere classified, liat includes & excludes....
R53 Malaise and fatigue
R54 Senility (keadaan lemah krn umur)
R55 Syncope and collapse
R56 Convulsions, not elsewhere classified
R57 Shock, not elsewhere classified, liat excludes:.....
R57.0 Cardiogenic shock
R57.1 Hypovolaemic shock
R57.8 Other shock
Endotoxic shock
R57.9 Shock, unspecified
 8. R50-R69 Gejala dan Tanda Umum......................

R58 Haemorrhage, not elsewhere classified

R59 Enlarged lymph nodes liat includes & excludes....
R60 Oedema, not elsewhere classified liat excludes....
R61 Hyperhidrosis
R62 Lack of expected normal physiological development liat excludes....
R63 Symptoms and signs concerning food and fluid intake
R63.0 Anorexia
R63.1 Polydipsia
R63.2 Polyphagia
R64 Cachexia Excludes:......
R68 Other general symptoms and signs
R68.0 Hypothermia, not associated with low environmental temperature
R68.1 Nonspecific symptoms peculiar to infancy
R68.2 Dry mouth, unspecified
R68.3 Clubbing of fingers
R69 Unknown and unspecified causes of morbidity
9. R70–R79 Temuan abnormal dari
pemeriksaan darah tanpa diagnosa
R70 Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity
R71 Abnormality of red blood cells
R72 Abnormality of white blood cells, not elsewhere classified
Abnormal leukocyte differential NOS
R73 Elevated blood glucose level, Excludes:.....
R74 Abnormal serum enzyme levels
R75 Laboratory evidence of human immunodeficiency virus [HIV]
R76 Other abnormal immunological findings in serum
R77 Other abnormalities of plasma proteins
R78 Findings of drugs and other substances, not normally found in blood
R79 Other abnormal findings of blood chemistry
10. R80–R82 Temuan abnormal dari
pemeriksaan urin tanpa diagnosa
Excludes: .....
R80 Isolated proteinuria
R81 Glycosuria, Excludes: renal glycosuria (E74.8)
R82 Other abnormal findings in urine, Excludes: haematuria (R31)
R82.0 Chyluria, Excludes: filarial chyluria (B74.-)
R82.1 Myoglobinuria
R82.2 Biliuria
R82.3 Haemoglobinuria Excludes:.....
R82.4 Acetonuria/ Ketonuria
R82.5 Elevated urine levels of drugs, medicaments and biological substances
R82.6 Abnormal urine levels of substances chiefly nonmedicinal as to source
R82.7 Abnormal findings on microbiological examination of urine
Positive culture findings
R82.8 Abnormal findings on cytological and histological examination of urine
R82.9 Other and unspecified abnormal findings in urine
11. R83–R89 Temuan abnormal dari pemeriksaan zat cair,
zat kimia dan jaringan lain dari tubuh, tanpa diagnosa

Excludes: .....
Penggunaan 4-karakter subdivisi digunakan untuk katagori R83–R89:
.0 Abnormal level of enzymes
.1 Abnormal level of hormones
.2 Abnormal level of other drugs, medicaments and biological substances
.3 Abnormal level of substances chiefly nonmedicinal as to source
.4 Abnormal immunological findings
.5 Abnormal microbiological findings
Positive culture findings
.6 Abnormal cytological findings
Abnormal Papanicolaou smear
.7 Abnormal histological findings
.8 Other abnormal findings
Abnormal chromosomal findings
.9 Unspecified abnormal finding
 11. R83–R89........

R83 Abnormal findings in cerebrospinal fluid

R84 Abnormal findings in specimens from respiratory organs
and thorax
R85 Abnormal findings in specimens from digestive organs
and abdominal cavity
R86 Abnormal findings in specimens from male genital organs
R87 Abnormal findings in specimens from female genital
organs
R89 Abnormal findings in specimens from other organs,
systems and tissues
12. R90–R94 Temuan abnormal pada gamabaran
diagnostic & didalam fungsi penyelidikan, tanpa diagnosa

Perhatikan Includes & excludes....

R90 Abnormal findings on diagnostic imaging of
central nervous system
R91 Abnormal findings on diagnostic imaging of lung
R92 Abnormal findings on diagnostic imaging of
breast
R93 Abnormal findings on diagnostic imaging of
other body structures
R94 Abnormal results of function studies
13. R95–R99 Kondisi/sakit yg tidak jelas dan
penyebabnya tidak diketahui penyebab kematian

Excludes: fetal death of unspecified cause (P95),Obstetric death NOS (O95)

R95 Sudden infant death syndrome
R96 Other sudden death, cause unknown
Excludes: sudden:cardiac death, so described (I46.1), infant death syndrome (R95)
R96.0 Instantaneous death
R96.1 Death occurring less than 24 hours from onset of symptoms, not otherwise
explained
Death known not to be violent or instantaneous for which no cause can be discovered
Death without sign of disease
R98 Unattended death/kematian tanpa perawatan
Death in circumstances where the body of the deceased was found and no
cause could be discovered
Found dead
R99 Other ill-defined and unspecified causes of mortality
Death NOS
Unknown cause of mortality
latihan
1. Pyrexia tdk diketahui penyebabnya
2. False-positive Wassermann reaction for syphilis
3. Hyperglycaemia
4. Scaling of skin of the hands
5. Petechiae
6. Hallucinations (visual)
7. Anorexia
8. SOL (Space- Occupying Lesion )
9. Hasil Pap smear abnormal
10. Sakit abdomen akut
11. Hasil tes laboratorium kadar gula darahnya meninggi
12. DOA (death on arrival)
13. Palpitasi
14. Muntah-muntah karena mabuk laut
Praktik Penyelesaian Soal Bab XVIII

Diskusi Soal 1
1. Pyrexia of unknown origin
(469; 510) Pyrexia (of unknown origin) R50.9
- atmosperic T67.0
- during labor NEC O75.2
- heat T67.0
- newborn, environmentally-induced P81
- peristent R50.1
- puerperal O86.4
Apakah istilah ini ada yang memenuhi kondisi kasus Anda?

40
Diskusi Soal 1 (Lanjutan)

[871; 841]
R50 Fever of unknown origin
Excludes: fever of unknown origen (during)(in):
- labour (O75.2)
- newborn (P81.9)
puerperal pyrexia NOS (O86.4)
Bila tidak ada penjelasan lain pada kasus di atas, maka:
R50.9 Fever, unspecified
Hyperpyrexia NOS; pyrexia NOS
Excludes: malignant hyperthermia due to
anaesthesia (T88.3)
Pastikan juga kasus Anda bukan termasuk excludes ini!
MC: R50.9 41
Diskusi Soal 2

2. False-positive Wassermann reaction for

syphilis
(221; 240)
False – see also condition
- positive serological test for syphilis
(Wassermann reaction) R76.2
[881; 851]
R76 Other abnormal immunological findings in
serum
R76.2 False-positive Wasserman reaction
MC: R76.2
42
Diskusi Soal 3

3. Hyperglycaemia
(274; 298) Hyperglycemia, hyperglycemic R73.9
[880; 850] R73 Elevated blood glucose level
Excludes: ...
R73.9 Hyperglycemia, unspecified

Karena pada kasus ini tidak disertai penjelasan lain,

maka kita terima bahwa hyperglycemianya
unspeficied.

MC: R73.9

43
Diskusi soal no 4

• Scaling of skin of the hands MC: R23.4

Diskusi Soal 5

5. Petechiae
(437; 475) Petechia, petechiae R23.3
- fetus or newborn P54.5
Pastikan bahwa kasus ini bukan bayi atau neonatal
[863; 833]
R23 Other skin changes
R23.3 Spontaneous ecchymoses
Petechiae
Excludes: ecchymoses in fetus and newborn
purpura (D69.-)
MC: R23.3
45
Diskusi Soal 6

6. Hallucination ( visual)
(252; 274) Hallucination R44.3
- auditory R44.0
- gustatory R44.2
- offactory R44.2
- specified NEC R44.2
- tactile R44.2
- visual R44.1
[868; 838] R44.3 Hallucination, unspecified.
Karena tidak disertai keterangan lain:
MC: R44.1
46
Diskusi Soal 7

7. Anorexia MC : R63.0

47
Diskusi Soal 8

8. SOL
Tidak dapat ditelusuri melalui lead-term Space atau
Occupying ataupun Lesion
Harus ditelusuri melalui:
Abnormal findings on diagnostic imaging of
central nervous system
(11-12; 11-12) - CNS NEC R90.8
[ 887; 857] R90.0 intracranial SOL
Pastikan melalui dokter bahwa gangguan ada di dalam
cranium.
MD: SOL R90.0
48
Diskusi Soal 9
9. Hasil Pap smear abnormal
(12; 12)
Abnormal
- finding
- - specimen - see Abnormal
specimen

(13; 13)
- specimen
- - cervix uteri R87.-
49
Diskusi Soal 9 (Lanjutan)

• [886; 856 → 855]

R87 Abnormal findings in specimens from
female genital organs
[885; 855] The following fourth-character sub-
divisions are for the use with catagories
R83 – R89
Kita pilih: .6 Abnormal cytological finding
Abnormal Papanicolaou smear
MD: R87.6

Berapa kode Pap smear pada pemeriksaan Rutin gyn.?

(426; 463) Z01.4 50
Diskusi Soal 10

10. Sakit abdomen akut

Pain, abdominal, acute.
(423; 460) Pain(s) R52.9
- abdominal R10.4
- - lower, severe atau upper
Tidak muncul akut
[ 859; 829]
R 10 Abdominal and pelvic pain
Excludes: dorsalgia (M54.-)
flatulence and ... (R14)
renal colik (N23)
51
Diskusi Soal 10 (Lanjutan)

• R10.0 Acute abdomen

Severe abdominal pain (general,
localized with abdominal rigidity).
Karena pada diagnosis dituliskan akut →
dan pastikan melalui analisis kualitatif rekam
medis, kondisi bukan karena renal, dorsalgia atau
flatulence, maka pilih Acute abdomen.

MD: R10.0

52
Diskusi Soal 11

11. Hasil tes laboratorium kadar gula

darahnya meninggi
(12; 12) Abnormal
- glucose tolerance (test) R73.0
(274; 298) Hyperglycemia, hyperglycemic
R73.9
[880; 850] R73 Elevated blood glucose level
Excludes: ...
Pada kasus di atas karena tidak ada keterangan rinci
→ MD: R73.9
53
Diskusi Soal 12

12. DOA (death of arrival)

(131; 143) Di bawah Dead tidak ditemukan.
(132; 144) Death
- cause unknown R99
- instantaneous R96.0
- known not to be violent or instanenous,
cause unknown R96.1
- sudden (cause unknown) R96.0
- unattended (cause unknown) R98
- without sign of disease R96.1
MD/ COD ? → Pastikan oleh dokternya! 54
Diskusi Soal 12 (Lanjutan)

• [890; 860]
Ill-defined and unknown causes of mortality
(R95-R99)
Excludes: fetal death of unspecified cause (P95)
obstetrical death NOS (O95)
R95 SIDS
R96 Other sudden death, cause unknown
R98 Unattended death
R99 Other ill-defined and unspecified causes of
mortality

55
Diskusi Soal 13

13. Palpitasi
(425;462) Palpitation (heart) R00.2
- psychogenic F45.3
[854; 824] R00.2 Palpitation
Awareness of heart beat.

Pastikan bahwa tidak ada dekumentasi

tentang specified arrhythmias (I47-I49)

MD: R00.2
56
 Diskusi Soal 14

14. Muntah-muntah akibat mabuk laut

Pada kasus ini ada gejala muntah-muntah (vomiting)
akibat mabuk laut (sea-sickness)

(563; 612) Vomiting (see also Hyperemesis)

R11
[860; 829] R11 Nausea and vomitng
Excludes: .... Tidak ada usuran
dengan seasikness.
(491; 533) Seasickness T75.3

57
Diskusi Soal 14 (Lanjutan)

[ 990; 956]
T75.3 Motion sickness
Airsickness
Seasickness
Travel sickness

MD: Mabuk laut T75.3

disertai gejala muntah-muntah R11

58
Jawaban

1. Pyrexia of unknown origin No. R50.9

2. False-positive Wassermann reaction for syphilis No. R76.2
3. Hyperglycaemia No. R73.9
4. Scaling of skin of the hands No. R23.4
5. Petechiae No. R23.3
6. Hallucinations (visual) No. R44.1
7. Anorexia No. R63.0
8. Intracranial space-occupying lesion No. R90.0
9. Abnormal Glucose Tolerance Test No. R73.0
10. Pasien 25 tahun masuk untuk pemeriksaan malaise dan fatigue. No. R53
11. Obs.Febris No. R50.9
12. Obs.sakit kepala sebelah No. R51