No.

Kode INA CBG

L-3-11-0

L-3-12-0

M-2-10-0

M-2-42-0

M-2-51-0

M-2-52-0

M-2-63-0

M-3-14-0

M-3-15-0

10

M-3-17-0

11

Q-5-12-0

12

U-2-11-0

Deskripsi Tindakan
Prosedur Besar Pada Kulit
- Insisi Abses Multipel Ektra Oral
Prosedur Kecil Pada Kulit
- Insisi abses intra oral
Prosedur Rekonstruksi Tulang Kranial dan
Wajah
- Fraktur Maksila / Mandibula (Splinting)

- Fraktur Dentoalveolar (IMF)

Prosedur Pemindahan Alat Implan
- Aff Arch Bar
Prosedur Besar Pada Jaringan Lunak
- Marsuapialisasi Ranula
- Eksisi Epulis
- Ekstirpasi Mucocele
Prosedur Kecil Pada Jaringan Lunak
- Debridement
- WT
- Insisional Biopsi
Prosedur Insisi, Biopsi dan Graft pada Tulang
- Vestibuloplasty + Graft + Obturator
- Marsupialisasi kasus kista tulang +
obturator
Prosedur Reduksi Fraktur Wajah Tertutup
- Splinting pada fraktur dentoalveolar 1
segmen
Prosedur aplikasi cast dan splint
Prosedur Pemasangan Alat Prostetik
- Obturator Surgical
Gigi
- Ekstraksi Gigi Simple
Prosedur Besar Lain pada Kepala dan Leher

ICD-9

Diagnosa

ICD-10

Tarif INACBG

682.9

Cellulitis and abscess of mouth

K12.2

480,625

682.9

Cellulitis and abscess of mouth

K12.2

363,545

Open :
76.72/76.76
Closed :
76.71/76.75

Fracture of Malar and Maxillary Bones S02.4

Fracture of Mandible
S02.6
Fractures of other skull and facial bonesS02.8

2,863,442

24.8

Fracture of Malar and Maxillary Bones S02.4

Fracture of Mandible
S02.6

208,246

Mucocele of Salivary Gland

Other specified disorder of gingiva
and edentulous alveolar ridge
Mucocele of Salivary Gland

K11.6

644,928

Open Wound in Facial Bone

Open Wound in Facial Bone
Benigna Neoplasma in Oral Cavity
Maligna Neoplasma in Oral Cavity

S01.90
S01.90
D10.30
C06.9

24.4
24.4
79.6
27.52
27.24

K06.8
K11.6
444,238

K09
24.91
24.4

Cyst of oral region, not elsewhere

classified
Fractures of other skull and facial
bones

1,792,371
S02.8

684,268

93.54

Fracture of Malar and Maxillary Bones S02.4

Fracture of Mandible
S02.6
Fractures of other skull and facial bonesS02.8

395,357

V52.3

Maligna Neoplasma of Palate

C05

395,172

23.0

Chronic apical periodontitis

Chronic periodontitis

K04.5
K05.3

293,578

93.54

- Fraktur Mandibula dengan LA

13

U-2-13-0

14

U-2-21-0

15

U2-22-0

Open : 802.3
Closed : 802.2

Fracture of Mandible

S02.6

3,842,945

26.29

Sialolithiasis

K11.5

437,782

23.19
24.4
93.54
93.57

Anomalies of tooth position

Unspecified Cyst of Jaw
Avulsion
Unspecified Disorder of Nasal and
Nasal Sinuses

K07.3
K09
S03.2
J34.9

1,071,744

23.19
24.6
24.5

Anomalies of tooth position

Embedded and impacted teeth
Other specified diseases of jaws

K07.3
K01
K10.8

553,647

24.4
27.41

Irritative hyperplasia of oral mucosa

Ankyloglosia

K13.6
Q38.1

451,427

24.4
27.52

Lipoma of other specific sites

Internal sutures of mouth, without
mention of complications

214.8
873.6

361,458

24.4

Radicular cyst

K04.8

456,531

23.71

Acute Apical Periodontitis of Pulpal

Origin

K04.4

432,079

Prosedur Diagnostik lain pada telinga,

hidung, mulut dan tenggorokan
- Profe Punksi pada kasus abses / kista
- Scrapping

27.24
27.29

27.29

K12.2
C0.0
C0.1
C0.2
C0.3
C0.4
C0.5
C0.6
B37.0
K12.2

444,679

- Kultur Pus + Tes sensitivitas

Cellulitis and abscess of mouth

Malignant neoplasms of lip
Malignant neoplasms of base of
tongue
Malignant neoplasms of tongue
Malignant neoplasms of gum
Malignant neoplasms of floor of the
mouth
Malignant neoplasms of palate
Malignant neoplasms of unspecified
places
Oral Candidosis

Prosedur Kelenjar Ludah

- Ekstraksi Batu Kelenjar
Prosedur Bedah pada THT dan Mulut
- Odontektomi kelas III
- Enukleasi Luas pada Kista Maksila
- Replantasi Gigi dan Splinting
- Penutupan OAF
Prosedur sedang pada telinga, hidung,
mulut dan tenggorokan
- Odontektomi kelas I-II
- Surgical Eksposure
- Alveolectomy
Prosedur Besar pada mulut dan lidah
- Eksisi Iritasi Fibroma
- Frenectomy

16

U-2-31-0

17

U-2-23-0

Prosedur kecil pada Mulut dan Lidah

- Ekstirpasi lipoma
- WT pada kasus vulnus app

18

U-3-10-0

19

U-3-11-0

Prosedur sedang lain pada telinga, hidung,

mulut dan tenggorokan
- Enukleasi kista radikuler 1 gigi
Prosedur kecil lain pada telinga, hidung,
mulut dan tenggorokan
- Open bur

20

U-3-13-0

Cellulitis and abscess of mouth

21

U-3-16-0

Prosedur Pada Gigi

- Ekstraksi gigi + Hecting
- Ekstraksi gigi dengan flap

22

Z-3-27-0

Perawatan Luka
- Pada Setiap pasien post op / trauma pada
kunjungan I

ss

23.19
23.19

Chronic apical periodontitis

Chronic periodontitis

K04.5
K05.3

403,236

V58.43

Fracture of Malar and Maxillary Bones S02.4

Fracture of Mandible
S02.6
Fractures of other skull and facial bonesS02.8

433,963