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List Item Special CMG Tipe Special koefisien utk Kode KODE
NO
CMG top up INA-CBG dasar ICD 10/ICD 9 CM
Diagnosis I211 Acute transmural myocardial infarction of inferior wall (I-4-10,Q-5-30) Severity 3
Special I212 Acute transmural myocardial infarction of other sites (I-4-10,Q-5-30) Severity 3
1 0,25 Rawat
Streptokinase Drug
Inap I213 Acute transmural myocardial infarction of unspecified site (I-4-10,Q-5-30) Severity 3
I214 Acute subendocardial myocardial infarction (I-4-10,Q-5-30) Severity 3
I219 Acute myocardial infarction, unspecified (I-4-10,Q-5-30) Severity 3
I233 Rupture cardiac wall without haemopericardium as current complication following acute myocardial infarction (I-4-10,Q-5-30) Severity 3
Diagnosis
Special
Deferiprone 0,5 Rawat D460 Refractory anaemia without sideroblasts, so stated (D-4-13,Q-5-33) Severity 2
Drug
2 Inap
Diagnosis
Special
0,5 Rawat D461 Refractory anaemia with sideroblasts (D-4-13,Q-5-33) Severity 2
Deferoksamin Drug
3 Inap
Diagnosis
Special
Deferasirox 0,5 Rawat D462 Refractory anaemia with excess of blasts (D-4-13,Q-5-33) Severity 2
Drug
4 Inap
D463 Refractory anaemia with excess of blasts with transformation (D-4-13,Q-5-33) Severity 2
D464 Refractory anaemia, unspecified (D-4-13,Q-5-33) Severity 2
D500 Iron deficiency anaemia secondary to blood loss (chronic) (D-4-13,Q-5-33) Severity 2
D501 Sideropenic dysphagia (D-4-13,Q-5-33) Severity 2
D508 Other iron deficiency anaemias (D-4-13,Q-5-33) Severity 2
D509 Iron deficiency anaemia, unspecified (D-4-13,Q-5-33) Severity 2
D510 Vitamin b12 defic anaemia due to intrinsic factor deficiency (D-4-13,Q-5-44) Severity 2
D511 Vit b12 def anaem select vit b12 malabsorp with proteinuria (D-4-13,Q-5-44) Severity 2
D512 Transcobalamin ii deficiency (D-4-13,Q-5-44) Severity 2
D513 Other dietary vitamin b12 deficiency anaemia (D-4-13,Q-5-44) Severity 2
D518 Other vitamin b12 deficiency anaemias (D-4-13,Q-5-44) Severity 2
D519 Vitamin b12 deficiency anaemia, unspecified (D-4-13,Q-5-44) Severity 2
D520 Dietary folate deficiency anaemia (D-4-13,Q-5-44) Severity 2
D521 Drug-induced folate deficiency anaemia (D-4-13,Q-5-44) Severity 2
D528 Other folate deficiency anaemias (D-4-13,Q-5-44) Severity 2
D529 Folate deficiency anaemia, unspecified (D-4-13,Q-5-44) Severity 2
D530 Protein deficiency anaemia (D-4-13,Q-5-44) Severity 2
D531 Other megaloblastic anaemias, not elsewhere classified (D-4-13,Q-5-44) Severity 2
D532 Scorbutic anaemia (D-4-13,Q-5-44) Severity 2
D538 Other specified nutritional anaemias (D-4-13,Q-5-44) Severity 2
D539 Nutritional anaemia, unspecified (D-4-13,Q-5-33) Severity 1
D550 Anaemia due to glucose-6-phosphate dehydrogenase deficiency (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D551 Anaemia due to other disorders of glutathione metabolism (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D552 Anaemia due to disorders of glycolytic enzymes (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D553 Anaemia due to disorders of nucleotide metabolism (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D558 Other anaemias due to enzyme disorders (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D559 Anaemia due to enzyme disorder, unspecified (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D560 Alpha thalassaemia (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D561 Beta thalassaemia (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D562 Delta-beta thalassaemia (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D563 Thalassaemia trait (D-4-13,Q-5-44) Severity 1
D564 Hereditary persistence of fetal haemoglobin [hpfh] (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D568 Other thalassaemias (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D569 Thalassaemia, unspecified (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D571 Sickle-cell anaemia without crisis (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D572 Double heterozygous sickling disorders (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D573 Sickle-cell trait (D-4-13,Q-5-44) Severity 1
D578 Other sickle-cell disorders (D-4-13,Q-5-44) Severity 1
D580 Hereditary spherocytosis (D-4-13,Q-5-44) Severity 1
D581 Hereditary elliptocytosis (D-4-13,Q-5-44) Severity 1
D582 Other haemoglobinopathies (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 1
D588 Other specified hereditary haemolytic anaemias (P-8-14,D-4-13,P-9-14,Q-5-44) Severity 2
D589 Hereditary haemolytic anaemia, unspecified (D-4-13,Q-5-44) Severity 2
D590 Drug-induced autoimmune haemolytic anaemia (D-4-13,Q-5-44) Severity 2
D591 Other autoimmune haemolytic anaemias (D-4-13,Q-5-44) Severity 2
D592 Drug-induced nonautoimmune haemolytic anaemia (D-4-13,Q-5-44) Severity 2
D593 Haemolytic-uraemic syndrome (D-4-13,Q-5-44) Severity 2
D594 Other nonautoimmune haemolytic anaemias (D-4-13,Q-5-44) Severity 2
D595 Paroxysmal nocturnal haemoglobinuria [marchiafava-micheli] (D-4-13,Q-5-44) Severity 2
D596 Haemoglobinuria due to haemolysis from other external causes (D-4-13,Q-5-44) Severity 2
D598 Other acquired haemolytic anaemias (D-4-13,Q-5-44) Severity 2
D599 Acquired haemolytic anaemia, unspecified (D-4-13,Q-5-44) Severity 2
D600 Chronic acquired pure red cell aplasia (P-8-14,D-4-13,P-9-14,Q-5-33) Severity 2
D601 Transient acquired pure red cell aplasia (D-4-13,Q-5-33) Severity 3
D608 Other acquired pure red cell aplasias (D-4-13,Q-5-33) Severity 3
D609 Acquired pure red cell aplasia, unspecified (D-4-13,Q-5-33) Severity 3
D610 Constitutional aplastic anaemia (P-8-14,D-4-13,P-9-14,Q-5-33) Severity 2
D611 Drug-induced aplastic anaemia (D-4-13,Q-5-33) Severity 3
D612 Aplastic anaemia due to other external agents (D-4-13,Q-5-33) Severity 3
D613 Idiopathic aplastic anaemia (D-4-13,Q-5-33) Severity 3
D618 Other specified aplastic anaemias (D-4-13,Q-5-33) Severity 3
D619 Aplastic anaemia, unspecified (D-4-13,Q-5-33) Severity 3
D62 Acute posthaemorrhagic anaemia (D-4-13,Q-5-33) Severity 2
D640 Hereditary sideroblastic anaemia (D-4-13,Q-5-33) Severity 2
D641 Secondary sideroblastic anaemia due to disease (D-4-13,Q-5-33) Severity 2
D642 Secondary sideroblastic anaemia due to drugs and toxins (D-4-13,Q-5-33) Severity 2
D643 Other sideroblastic anaemias (D-4-13,Q-5-33) Severity 2
D644 Congenital dyserythropoietic anaemia (D-4-13,Q-5-33) Severity 2
D648 Other specified anaemias (D-4-13,Q-5-33) Severity 2
D649 Anaemia, unspecified (D-4-13,Q-5-33) Severity 2
D740 Congenital methaemoglobinaemia (D-4-13,Q-5-44) Severity 2
D748 Other methaemoglobinaemias (D-4-13,Q-5-44) Severity 2
D749 Methaemoglobinaemia, unspecified (D-4-13,Q-5-44) Severity 2
P569 Hydrops fetalis due to other and unspec haemolytic disease (D-4-13,P-8-17,P-9-17,Q-5-41) Severity 3
P570 Kernicterus due to isoimmunization (D-4-13,P-8-17,P-9-17,Q-5-42) Severity 3
P578 Other specified kernicterus (D-4-13,P-8-17,P-9-17,Q-5-41) Severity 3
P579 Kernicterus, unspecified (D-4-13,P-8-17,P-9-17,Q-5-41) Severity 3
P612 Anaemia of prematurity (D-4-13,P-8-17,P-9-17,Q-5-42) Severity 3
P613 Congenital anaemia from fetal blood loss (D-4-13,P-8-17,P-9-17,Q-5-42) Severity 2
P614 Other congenital anaemias, not elsewhere classified (D-4-13,P-8-17,P-9-17,Q-5-42) Severity 2
R71 Abnormality of red blood cells (D-4-13,Q-5-44) Severity 1
T803 ABO incompatibility reaction (D-4-13,Q-5-41) Severity 2
T804 Rh incompatibility reaction (D-4-13,Q-5-41) Severity 2
T808 Other complications following infusion transfusion & therap inject (D-4-13,Q-5-41) Severity 3
T809 Unspecified complication following infusion transfusion and therapeutic inject (D-4-13,Q-5-41) Severity 3
8891 Magnetic resonance imaging of brain and brain stem Class III
8892 Magnetic resonance imaging of chest and myocardium for evaluation of Class III
Special Prosedur Rawat
3 MRI 1,5 8893 Magnetic resonance imaging of spinal canal Class III
Investigation Jalan
8894 Magnetic resonance imaging of musculoskeletal Class III
8895 Magnetic resonance imaging of pelvis, prostate, and bladder Class III
8896 Other intraoperative magnetic resonance imaging Class III
8897 Magnetic resonance imaging of other and unspecified sites Class III
8705 Contrast dacryocystogram Class III