TOP UP UNTUK SPECIAL PROSEDUR

NO

List Item Special CMG

Tipe Special
CMG

koefisien utk
top up

Kode

KODE

INA-CBG dasar

ICD 10/ICD 9 CM
0713 Biopsy of pituitary gland, transfrontal approach Class I
0715 Biopsy of pituitary gland, unspecified approach Class I
0717 Biopsy of pineal gland Class I
0751 Exploration of pineal field Class I
0752 Incision of pineal gland Class I
0753 Partial excision of pineal gland Class I

Tumor pineal
Endoskopy

Special
Procedure

0,5

Prosedur Rawat
Inap

0754 Total excision of pineal gland Class I

0759 Other operations on pineal gland Class I
0761 Partial excision of pituitary gland, transfrontal approach Class I
0762 Partial excision of pituitary gland, transsphenoidal approach Class I
0763 Partial excision of pituitary gland, unspecified approach Class I
0764 Total excision of pituitary gland, transfrontal approach Class I
0765 Total excision of pituitary gland, transsphenoidal approach Class I
0768 Total excision of pituitary gland, other specified approach Class I
0769 Total excision of pituitary gland, unspecified approach Class I
0771 Exploration of pituitary fossa Class I
0772 Incision of pituitary gland Class I
0779 Other operations on hypophysis Class I
8151 Total hip replacement Class I

Hip Replacement / knee

replacement

Special
Procedure

0,5

Prosedur Rawat
Inap

8152 Partial hip replacement Class I

8153 Revision of hip replacement, NEC Class I
8154 Total knee replacement Class I
8155 Revision of knee replacement, NEC Class I
8156 Total ankle replacement Class I
8162 Fusion or refusion of 2-3 vertebrae Class I
8163 Fusion or refusion of 4-8 vertebrae Class I
8164 Fusion or refusion of 9 or more vertebrae Class I
8426 Foot reattachment Class I
8427 Lower leg or ankle reattachment Class I
8428 Thigh reattachment Class I
3541 Enlargement of existing atrial septal defect Class II

PCI

Special
Procedure

Prosedur Rawat
Inap

3596 Percutaneous valvuloplasty Class II

3604 Intracoronary artery thrombolytic infusion Class II
3605 Multiple vessel (percutaneous) transluminal coronary angioplasty (pt Class II
3606 Insertion of non-drug -eluting coronary artery stent(s) Class II
3607 Insertion of drug-eluting coronary artery stent(s) Class II
3609 Other specified removal of coronary artery obstruction Class II
3726 Catheter based invasive electrophysiologic testing Class II
3727 Cardiac mapping Class II
3734 Excision or destruction of lesion or tissue of heart, other approach Class
111 Incision of cornea Class II

Keratoplasty

Special
Procedure

Prosedur Rawat
Inap

1151 Suture of corneal laceration Class II

1152 Repair of postoperative wound dehiscence of cornea Class II
1153 Repair of corneal laceration or wound with conjunctival flap Class II
1159 Other repair of cornea Class II
1160 Corneal transplant, not otherwise specified Class II
1161 Lamellar keratoplasty with autograft Class II
1162 Other lamellar keratoplasty Class II
1163 Penetrating keratoplasty with autograft Class II
1164 Other penetrating keratoplasty Class II
1169 Other corneal transplant Class II
1171 Keratomeleusis Class II
1172 Keratophakia Class II
1173 Keratoprosthesis Class II
1174 Thermokeratoplasty Class II
1175 Radial keratotomy Class II
1176 Epikeratophakia Class II
1179 Other reconstructive surgery on cornea Class II
1192 Removal of artificial implant from cornea Class II
1199 Other operations on cornea Class II
1200 Removal of intraocular foreign body from anterior segment of eye, no Class II
1201 Removal of intraocular foreign body from anterior segment of eye wit Class II
1202 Removal of intraocular foreign body from anterior segment of eye wit Class II
1211 Iridotomy with transfixion Class II
1212 Other iridotomy Class II
1213 Excision of prolapsed iris Class II
1214 Other iridectomy Class II
1221 Diagnostic aspiration of anterior chamber of eye Class II
1222 Biopsy of iris Class II
1229 Other diagnostic procedures on iris, ciliary body, sclera, and anter Class II
1231 Lysis of goniosynechiae Class II
1232 Lysis of other anterior synechiae Class II
1233 Lysis of posterior synechiae Class II
1234 Lysis of corneovitreal adhesions Class II
1235 Coreoplasty Class II
1239 Other iridoplasty Class II
1240 Removal of lesion of anterior segment of eye, not otherwise specifie Class II
1241 Destruction of lesion of iris, nonexcisional Class II
1242 Excision of lesion of iris Class II

1243 Destruction of lesion of ciliary body, nonexcisional Class II

1244 Excision of lesion of ciliary body Class II
1251 Goniopuncture without goniotomy Class II
1252 Goniotomy without goniopuncture Class II
1253 Goniotomy with goniopuncture Class II
1254 Trabeculotomy ab externo Class II
1255 Cyclodialysis Class II
1259 Other facilitation of intraocular circulation Class II
1261 Trephination of sclera with iridectomy Class II
1262 Thermocauterization of sclera with iridectomy Class II
1263 Iridencleisis and iridotasis Class II
1264 Trabeculectomy ab externo Class II
1265 Other scleral fistulization with iridectomy Class II
1266 Postoperative revision of scleral fistulization procedure Class II
1269 Other scleral fistulizing procedure Class II
1271 Cyclodiathermy Class II
1272 Cyclocryotherapy Class II
1273 Cyclophotocoagulation Class II
1274 Diminution of ciliary body, not otherwise specified Class II
1279 Other glaucoma procedures Class II
1281 Suture of laceration of sclera Class II
1282 Repair of scleral fistula Class II
1283 Revision of operative wound of anterior segment, not elsewhere class Class II
1285 Repair of scleral staphyloma with graft Class II
1286 Other repair of scleral staphyloma Class II
1291 Therapeutic evacuation of anterior chamber Class II
1292 Injection into anterior chamber Class II
1293 Removal or destruction of epithelial downgrowth from anterior chambe Class II
1297 Other operations on iris Class II
1298 Other operations on ciliary body Class II
1299 Other operations on anterior chamber Class II
1300 Removal of foreign body from lens, not otherwise specified Class II
1301 Removal of foreign body from lens with use of magnet Class II
1302 Removal of foreign body from lens without use of magnet Class II
1311 Intracapsular extraction of lens by temporal inferior route Class II
1319 Other intracapsular extraction of lens Class II
132 Extracapsular extraction of lens by linear extraction technique Class II
133 Extracapsular extraction of lens by simple aspiration (and irrigatio Class II
1341 Phacoemulsification and aspiration of cataract Class II
1342 Mechanical phacofragmentation and aspiration of cataract by posterio Class II
1343 Mechanical phacofragmentation and other aspiration of cataract Class II
1351 Extracapsular extraction of lens by temporal inferior route Class II
1359 Other extracapsular extraction of lens Class II
1364 Discission of secondary membrane (after cataract) Class II
1365 Excision of secondary membrane (after cataract) Class II
1366 Mechanical fragmentation of secondary membrane (after cataract) Class II
1369 Other cataract extraction Class II
1370 Insertion of pseudophakos, not otherwise specified Class II
1371 Insertion of intraocular lens prosthesis at time of cataract extract Class II
1372 Secondary insertion of intraocular lens prosthesis Class II
138 Removal of implanted lens Class II
139 Other operations on lens Class II
1400 Removal of foreign body from posterior segment of eye, not otherwise Class II
1401 Removal of foreign body from posterior segment of eye with use of ma Class II
1402 Removal of foreign body from posterior segment of eye without use of Class II
1421 Destruction of chorioretinal lesion by diathermy Class II
1422 Destruction of chorioretinal lesion by cryotherapy Class II
1426 Destruction of chorioretinal lesion by radiation therapy Class II
1427 Destruction of chorioretinal lesion by implantation of radiation sou Class II
1429 Other destruction of chorioretinal lesion Class II
1431 Repair of retinal tear by diathermy Class II
1432 Repair of retinal tear by cryotherapy Class II
1433 Repair of retinal tear by xenon arc photocoagulation Class II
1434 Repair of retinal tear by laser photocoagulation Class II
1435 Repair of retinal tear by photocoagulation of unspecified type Class II
1439 Other repair of retinal tear Class II
1441 Scleral buckling with implant Class II
1449 Other scleral buckling Class II
1451 Repair of retinal detachment with diathermy Class II
1452 Repair of retinal detachment with cryotherapy Class II
1453 Repair of retinal detachment with xenon arc photocoagulation Class II
1454 Repair of retinal detachment with laser photocoagulation Class II
1455 Repair of retinal detachment with photocoagulation of unspecified ty Class II
1459 Other repair of retinal detachment Class II
1471 Removal of vitreous, anterior approach Class II
1472 Other removal of vitreous Class II
1473 Mechanical vitrectomy by anterior approach Class II
1474 Other mechanical vitrectomy Class II
1475 Injection of vitreous substitute Class II
1479 Other operations on vitreous Class II
149 Other operations on retina, choroid, and posterior chamber Class II
161 Removal of penetrating foreign body from eye, not otherwise specifie Class II
1623 Biopsy of eyeball and orbit Class II
1629 Other diagnostic procedures on orbit and eyeball Class II
500 Hepatotomy Class II
5

Pancreatectomy

Special
Procedure

Prosedur Rawat
Inap

5021 Marsupialization of lesion of liver Class II

5022 Partial hepatectomy Class I
5029 Other destruction of lesion of liver Class II
503 Lobectomy of liver Class I

504 Total hepatectomy Class I

5061 Closure of laceration of liver Class II
5069 Other repair of liver Class II
5092 Extracorporeal hepatic assistance Class I
5182 Pancreatic sphincterotomy Class II
5183 Pancreatic sphincteroplasty Class II
5201 Drainage of pancreatic cyst by catheter Class II
5209 Other pancreatotomy Class II
5222 Other excision or destruction of lesion or tissue of pancreas or pancreatic duct Class II
523 Marsupialization of pancreatic cyst Class II
524 Internal drainage of pancreatic cyst Class II
5251 Proximal pancreatectomy Class I
5252 Distal pancreatectomy Class I
5253 Radical subtotal pancreatectomy Class I
5259 Other partial pancreatectomy Class I
526 Total pancreatectomy Class I
527 Radical pancreaticoduodenectomy Class I
5280 Pancreatic transplant, not otherwise specified Class I
5281 Reimplantation of pancreatic tissue Class I
5282 Homotransplant of pancreas Class I
5283 Heterotransplant of pancreas Class I
5292 Cannulation of pancreatic duct Class II
5295 Other repair of pancreas Class I
5296 Anastomosis of pancreas Class I
5299 Other operations on pancreas Class II
3500 Closed heart valvotomy, unspecified valve Class I

7
8

Special
Procedure

Prosedur Rawat
Inap

Renal Transplantation

Special
Procedure

Diagnosis Rawat
Inap

Stereotactic Surgery &

Radiotheraphy

Special
Procedure

Diagnosis Rawat
Inap

Repair of septal defect

of heart with

3501 Closed heart valvotomy, aortic valve Class I

3502 Closed heart valvotomy, mitral valve Class I
3503 Closed heart valvotomy, pulmonary valve Class I
3504 Closed heart valvotomy, tricuspid valve Class I
3531 Operations on papillary muscle Class I
3532 Operations on chordae tendineae Class I
3533 Annuloplasty Class I
3534 Infundibulectomy Class I
3535 Operations on trabeculae carneae cordis Class I
3539 Operations on other structures adjacent to valves of heart Class I
3542 Creation of septal defect in heart Class I
3550 Repair of unspecified septal defect of heart with prosthesis Class I
3551 Repair of atrial septal defect with prosthesis, open technique Class I
3552 Repair of atrial septal defect with prosthesis, closed technique Class I
3553 Repair of ventricular septal defect with prosthesis, open technique Class I
3560 Repair of unspecified septal defect of heart with tissue graft Class I
3561 Repair of atrial septal defect with tissue graft Class I
3562 Repair of ventricular septal defect with tissue graft Class I
3570 Other and unspecified repair of unspecified septal defect of heart Class I
3571 Other and unspecified repair of atrial septal defect Class I
3572 Other and unspecified repair of ventricular septal defect Class I
3595 Revision of corrective procedure on heart Class I
3598 Other operations on septa of heart Class I
3599 Other operations on valves of heart Class I
3603 Open chest coronary artery angioplasty Class I
362 Heart revascularization by arterial implant Class I
3631 Open chest transmyocardial revascularization Class I
3632 Other transmyocardial revascularization Class I
3639 Other heart revascularization Class I
363 Other heart revascularization Class I
3691 Repair of aneurysm of coronary vessel Class I
3699 Other operations on vessels of heart Class I
3710 Incision of heart, not otherwise specified Class I
3711 Cardiotomy Class I
3712 Pericardiotomy Class I
3724 Biopsy of pericardium Class I
3731 Pericardiectomy Class I
3732 Excision of aneurysm of heart Class I
3733 Excision or destruction of other lesion or tissue of heart, open approach Class I
3735 Partial ventriculectomy Class I
374 Repair of heart and pericardium Class I
3761 Implant of pulsation balloon Class I
3791 Open chest cardiac massage Class I
3799 Other operations on heart and pericardium Class I
3964 Intraoperative cardiac pacemaker Class I
3966 Percutaneous cardiopulmonary bypass Class I
5569 Other kidney transplantation Class I
Z510 Radiotherapy session (C-4-12,Q-5-42) Severity 1
3195 Tracheoesophageal fistulization Class II

Torakotomi

Special
Procedure

Prosedur Rawat
Inap

3209 Other local excision or destruction of lesion or tissue of bronchus Class II

3221 Plication of emphysematous bleb Class II
3229 Other local excision or destruction of lesion or tissue of lung Class II
329 Other excision of lung Class II
330 Incision of bronchus Class II
331 Incision of lung Class II
3325 Open biopsy of bronchus Class II
3328 Open biopsy of lung Class II
3329 Other diagnostic procedures on lung or bronchus Class II
3339 Other surgical collapse of lung Class II
3393 Puncture of lung Class II

3399 Other operations on lung Class II

3402 Exploratory thoracotomy Class II
3403 Reopening of recent thoracotomy site Class II
341 Incision of mediastinum Class II
3421 Transpleural thoracoscopy Class II
3422 Mediastinoscopy Class II
3426 Open mediastinum biopsy Class II
3427 Biopsy of diaphragm Class II
3428 Other diagnostic procedures on chest wall, pleura, and diaphragm Class II
3429 Other diagnostic procedures on mediastinum Class II
343 Excision or destruction of lesion or tissue of mediastinum Class II
3459 Other excision of pleura Class II
346 Scarification of pleura Class II
3473 Closure of other fistula of thorax Class II
3479 Other repair of chest wall Class II
3481 Excision of lesion or tissue of diaphragm Class II
3482 Suture of laceration of diaphragm Class II
3483 Closure of fistula of diaphragm Class II
3484 Other repair of diaphragm Class II
3485 Implantation of diaphragmatic pacemaker Class II
3489 Other operations on diaphragm Class II
3493 Repair of pleura Class II
3499 Other operations on thorax Class II
4061 Cannulation of thoracic duct Class II
4062 Fistulization of thoracic duct Class II
4063 Closure of fistula of thoracic duct Class II
4064 Ligation of thoracic duct Class II
4069 Other operations on thoracic duct Class II
537 Repair of diaphragmatic hernia, abdominal approach Class II
5380 Repair of diaphragmatic hernia with thoracic approach, not otherwise specified Class II
5381 Plication of the diaphragm Class II
5382 Repair of parasternal hernia Class II
7701 Sequestrectomy of scapula, clavicle, and thorax (ribs and sternum) Class II
7711 Other incision of bone without division, scapula, clavicle, and thorax (ribs and sternum) Class II
7721 Wedge osteotomy of scapula, clavicle, and thorax (ribs and sternum) Class II
7731 Other division of scapula, clavicle, and thorax (ribs and sternum) Class II
7761 Local excision of lesion or tissue of scapula, clavicle, and thorax (ribs and sternum) Class II
7771 Excision of bone for graft, scapula, clavicle, and thorax (ribs and sternum) Class II
7781 Other partial ostectomy of scapula, clavicle, and thorax (ribs and sternum) Class II
7791 Total ostectomy of scapula, clavicle, and thorax (ribs and sternum) Class II
7801 Bone graft of scapula, clavicle, and thorax (ribs and sternum) Class II
7811 Application of external fixation device, scapula, clavicle, and thorax (ribs and sternum) Class II
7841 Other repair or plastic operations on scapula, clavicle, and thorax (ribs and sternum) Class II
7851 Internal fixation of bone without fracture reduction on scapula, clavicle, and thorax (ribs and sternum)
Class II
7861 Removal of implanted device from scapula, clavicle, and thorax (ribs and sternum) Class II
7871 Osteoclasis of scapula, clavicle, and thorax (ribs and sternum) Class II
7881 Diagnostic procedures on scapula, clavicle, and thorax (ribs and sternum) Class II
7891 Insertion of bone growth stimulator into scapula, clavicle, and thorax (ribs and sternum) Class II
3173 Closure of other fistula of trachea Class II

10

Lobektomi / bilobektomi

Special
Procedure

Prosedur Rawat
Inap

3175 Reconstruction of trachea and construction of artificial larynx Class II

3179 Other repair and plastic operations on trachea Class II
321 Other excision of bronchus Class II
3222 Lung volume reduction surgery Class II
323 Segmental resection of lung Class I
3241 Thoracoscopic lobectomy of lung Class I
3249 Other lobectomy of lung Class I
324 Lobectomy of lung Class I
325 Pneumonectomy Class I
326 Radical dissection of thoracic structures Class I
3334 Thoracoplasty Class I
3341 Suture of laceration of bronchus Class II
3342 Closure of bronchial fistula Class II
3343 Closure of laceration of lung Class I
3348 Other repair and plastic operations on bronchus Class II
3349 Other repair and plastic operations on lung Class I
3392 Ligation of bronchus Class II
3398 Other operations on bronchus Class II
3451 Decortication of lung Class I
3474 Repair of pectus deformity Class II
9397 Decompression chamber Class I
J90 Pleural effusion, not elsewhere classified (J-4-20,Q-5-38) Severity 3

11

Air plumbage

Special
Procedure

Diagnosa Rawat
Inap

J91 Pleural effusion in conditions classified elsewhere (J-4-20,Q-5-38) Severity 3

J930 Spontaneous tension pneumothorax (J-4-20,Q-5-38) Severity 3
J931 Other spontaneous pneumothorax (J-4-20,Q-5-38) Severity 2
J938 Other pneumothorax (J-4-20,Q-5-38) Severity 2
J939 Pneumothorax, unspecified (J-4-20,Q-5-38) Severity 2
J940 Chylous effusion (J-4-20,Q-5-38) Severity 3
J942 Haemothorax (J-4-20,Q-5-38) Severity 3
J982 Interstitial emphysema (J-4-20,Q-5-44) Severity 2
P251 Pneumothorax originating in the perinatal period (J-4-20,P-8-08,P-9-17,Q-5-42) Severity 3
P252 Pneumomediastinum originating in the perinatal period (J-4-20,P-8-08,P-9-17,Q-5-42) Severity 3
P253 Pneumopericardium originating in the perinatal period (J-4-20,P-8-08,P-9-17,Q-5-42) Severity 3
P258 Oth conds rel interstit emphysema orig in perinatal period (J-4-20,P-8-08,P-9-17,Q-5-42) Severity 3
S270 Traumatic pneumothorax (J-4-20,Q-5-41) Severity 2
S2700 Traumatic pneumothorax, without open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
S2701 Traumatic pneumothorax, with open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
S271 Traumatic haemothorax (J-4-20,Q-5-41) Severity 2

S2710 Traumatic haemothorax, without open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
S2711 Traumatic haemothorax, with open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
S272 Traumatic haemopneumothorax (J-4-20,Q-5-41) Severity 2
S2720 Traumatic haemopneumothorax, without open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
S2721 Traumatic haemopneumothorax, with open wound into thoracic cavity (J-4-20,Q-5-41) Severity 2
T797 Traumatic subcutaneous emphysema (J-4-20,Q-5-42) Severity 2
0716 Biopsy of thymus Class II

12

Timektomi

Special
Procedure

Prosedur Rawat
Inap

0780 Thymectomy, not otherwise specified Class II

0781 Partial excision of thymus Class II
0782 Total excision of thymus Class II
0791 Exploration of thymus field Class II
0792 Incision of thymus Class II
0793 Repair of thymus Class II
0794 Transplantation of thymus Class II
0799 Other and unspecified operations on thymus Class II
400 Incision of lymphatic structures Class II
4011 Biopsy of lymphatic structure Class II
4019 Other diagnostic procedures on lymphatic structures Class II
4021 Excision of deep cervical lymph node Class II
4022 Excision of internal mammary lymph node Class II
4023 Excision of axillary lymph node Class II
4024 Excision of inguinal lymph node Class II
4029 Simple excision of other lymphatic structure Class II
403 Regional lymph node excision Class II
4050 Radical excision of lymph nodes, not otherwise specified Class II
4051 Radical excision of axillary lymph nodes Class II
4052 Radical excision of periaortic lymph nodes Class II
4053 Radical excision of iliac lymph nodes Class II
4054 Radical groin dissection Class II
4059 Radical excision of other lymph nodes Class II
409 Other operations on lymphatic structures Class II
111 Incision of cornea Class II

13

Vitrectomy

Special
Procedure

Prosedur Rawat
Ina

1151 Suture of corneal laceration Class II

1152 Repair of postoperative wound dehiscence of cornea Class II
1153 Repair of corneal laceration or wound with conjunctival flap Class II
1159 Other repair of cornea Class II
1160 Corneal transplant, not otherwise specified Class II
1161 Lamellar keratoplasty with autograft Class II
1162 Other lamellar keratoplasty Class II
1163 Penetrating keratoplasty with autograft Class II
1164 Other penetrating keratoplasty Class II
1169 Other corneal transplant Class II
1171 Keratomeleusis Class II
1172 Keratophakia Class II
1173 Keratoprosthesis Class II
1174 Thermokeratoplasty Class II
1175 Radial keratotomy Class II
1176 Epikeratophakia Class II
1179 Other reconstructive surgery on cornea Class II
1192 Removal of artificial implant from cornea Class II
1199 Other operations on cornea Class II
1200 Removal of intraocular foreign body from anterior segment of eye, no Class II
1201 Removal of intraocular foreign body from anterior segment of eye wit Class II
1202 Removal of intraocular foreign body from anterior segment of eye wit Class II
1211 Iridotomy with transfixion Class II
1212 Other iridotomy Class II
1213 Excision of prolapsed iris Class II
1214 Other iridectomy Class II
1221 Diagnostic aspiration of anterior chamber of eye Class II
1222 Biopsy of iris Class II
1229 Other diagnostic procedures on iris, ciliary body, sclera, and anter Class II
1231 Lysis of goniosynechiae Class II
1232 Lysis of other anterior synechiae Class II
1233 Lysis of posterior synechiae Class II
1234 Lysis of corneovitreal adhesions Class II
1235 Coreoplasty Class II
1239 Other iridoplasty Class II
1240 Removal of lesion of anterior segment of eye, not otherwise specifie Class II
1241 Destruction of lesion of iris, nonexcisional Class II
1242 Excision of lesion of iris Class II
1243 Destruction of lesion of ciliary body, nonexcisional Class II
1244 Excision of lesion of ciliary body Class II
1251 Goniopuncture without goniotomy Class II
1252 Goniotomy without goniopuncture Class II
1253 Goniotomy with goniopuncture Class II
1254 Trabeculotomy ab externo Class II
1255 Cyclodialysis Class II
1259 Other facilitation of intraocular circulation Class II
1261 Trephination of sclera with iridectomy Class II
1262 Thermocauterization of sclera with iridectomy Class II
1263 Iridencleisis and iridotasis Class II
1264 Trabeculectomy ab externo Class II
1265 Other scleral fistulization with iridectomy Class II
1266 Postoperative revision of scleral fistulization procedure Class II
1269 Other scleral fistulizing procedure Class II
1271 Cyclodiathermy Class II
1272 Cyclocryotherapy Class II
1273 Cyclophotocoagulation Class II

1274 Diminution of ciliary body, not otherwise specified Class II

1279 Other glaucoma procedures Class II
1281 Suture of laceration of sclera Class II
1282 Repair of scleral fistula Class II
1283 Revision of operative wound of anterior segment, not elsewhere class Class II
1285 Repair of scleral staphyloma with graft Class II
1286 Other repair of scleral staphyloma Class II
1291 Therapeutic evacuation of anterior chamber Class II
1292 Injection into anterior chamber Class II
1293 Removal or destruction of epithelial downgrowth from anterior chambe Class II
1297 Other operations on iris Class II
1298 Other operations on ciliary body Class II
1299 Other operations on anterior chamber Class II
1300 Removal of foreign body from lens, not otherwise specified Class II
1301 Removal of foreign body from lens with use of magnet Class II
1302 Removal of foreign body from lens without use of magnet Class II
1311 Intracapsular extraction of lens by temporal inferior route Class II
1319 Other intracapsular extraction of lens Class II
132 Extracapsular extraction of lens by linear extraction technique Class II
133 Extracapsular extraction of lens by simple aspiration (and irrigatio Class II
1341 Phacoemulsification and aspiration of cataract Class II
1342 Mechanical phacofragmentation and aspiration of cataract by posterio Class II
1343 Mechanical phacofragmentation and other aspiration of cataract Class II
1351 Extracapsular extraction of lens by temporal inferior route Class II
1359 Other extracapsular extraction of lens Class II
1364 Discission of secondary membrane (after cataract) Class II
1365 Excision of secondary membrane (after cataract) Class II
1366 Mechanical fragmentation of secondary membrane (after cataract) Class II
1369 Other cataract extraction Class II
1370 Insertion of pseudophakos, not otherwise specified Class II
1371 Insertion of intraocular lens prosthesis at time of cataract extract Class II
1372 Secondary insertion of intraocular lens prosthesis Class II
138 Removal of implanted lens Class II
139 Other operations on lens Class II
1400 Removal of foreign body from posterior segment of eye, not otherwise Class II
1401 Removal of foreign body from posterior segment of eye with use of ma Class II
1402 Removal of foreign body from posterior segment of eye without use of Class II
1421 Destruction of chorioretinal lesion by diathermy Class II
1422 Destruction of chorioretinal lesion by cryotherapy Class II
1426 Destruction of chorioretinal lesion by radiation therapy Class II
1427 Destruction of chorioretinal lesion by implantation of radiation sou Class II
1429 Other destruction of chorioretinal lesion Class II
1431 Repair of retinal tear by diathermy Class II
1432 Repair of retinal tear by cryotherapy Class II
1433 Repair of retinal tear by xenon arc photocoagulation Class II
1434 Repair of retinal tear by laser photocoagulation Class II
1435 Repair of retinal tear by photocoagulation of unspecified type Class II
1439 Other repair of retinal tear Class II
1441 Scleral buckling with implant Class II
1449 Other scleral buckling Class II
1451 Repair of retinal detachment with diathermy Class II
1452 Repair of retinal detachment with cryotherapy Class II
1453 Repair of retinal detachment with xenon arc photocoagulation Class II
1454 Repair of retinal detachment with laser photocoagulation Class II
1455 Repair of retinal detachment with photocoagulation of unspecified ty Class II
1459 Other repair of retinal detachment Class II
1471 Removal of vitreous, anterior approach Class II
1472 Other removal of vitreous Class II
1473 Mechanical vitrectomy by anterior approach Class II
1474 Other mechanical vitrectomy Class II
1475 Injection of vitreous substitute Class II
1479 Other operations on vitreous Class II
149 Other operations on retina, choroid, and posterior chamber Class II
161 Removal of penetrating foreign body from eye, not otherwise specifie Class II
1623 Biopsy of eyeball and orbit Class II
1629 Other diagnostic procedures on orbit and eyeball Class II
1311 Intracapsular extraction of lens by temporal inferior route Class II

14

Phacoemulsification

Special
Procedure

Prosedur Rawat
Jalan

1319 Other intracapsular extraction of lens Class II

132 Extracapsular extraction of lens by linear extraction technique Class II
133 Extracapsular extraction of lens by simple aspiration (and irrigatio Class II
1341 Phacoemulsification and aspiration of cataract Class II
1342 Mechanical phacofragmentation and aspiration of cataract by posterio Class II
1343 Mechanical phacofragmentation and other aspiration of cataract Class II
1351 Extracapsular extraction of lens by temporal inferior route Class II
1359 Other extracapsular extraction of lens Class II
1364 Discission of secondary membrane (after cataract) Class II
1365 Excision of secondary membrane (after cataract) Class II
1369 Other cataract extraction Class II
1370 Insertion of pseudophakos, not otherwise specified Class II
1371 Insertion of intraocular lens prosthesis at time of cataract extract Class II
1372 Secondary insertion of intraocular lens prosthesis Class II
3141 Tracheoscopy through artificial stoma Class III

15

Microlaringoscopy

Special
Procedure

Prosedur Rawat
Jalan

3142 Laryngoscopy and other tracheoscopy Class III

3144 Closed (endoscopic) biopsy of trachea Class III
3193 Replacement of laryngeal or tracheal stent Class III
3201 Endoscopic excision or destruction of lesion or tissue of bronchus Class III
3228 Endoscopic excision or destruction of lesion or tissue of lung Class III
3321 Bronchoscopy through artificial stoma Class III

3322 Fiber-optic bronchoscopy Class III

3323 Other bronchoscopy Class III
3324 Closed (endoscopic) biopsy of bronchus Class III
3327 Endoscopic biopsy of lung (closed) Class III
3391 Bronchial dilation Class III
5110 Endoscopic retrograde cholangiopancreatography (ERCP) Class III

16

Cholangiograph

Special
Procedure

Prosedur Rawat
Jalan

5111 Endoscopic retrograde cholangiography (ERC) Class III

5114 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi Class III
5115 Pressure measurement of sphincter of Oddi Class III
5164 Endoscopic excision or destruction of lesion of biliary ducts or sphincter of Oddi Class III
5184 Endoscopic dilation of ampulla and biliary duct Class III
5185 Endoscopic sphincterotomy and papillotomy Class III
5186 Endoscopic insertion of nasobiliary drainage tube Class III
5187 Endoscopic insertion of stent (tube) into bile duct Class III
5188 Endoscopic removal of stone(s) from biliary tract Class III
5213 Endoscopic retrograde pancreatography (ERP) Class III
5214 Closed [endoscopic] biopsy of pancreatic duct Class III
5221 Endoscopic excision or destruction of lesion or tissue of pancreatic Class III
5293 Endoscopic insertion of stent (tube) into pancreatic duct Class III
5294 Endoscopic removal of stone(s) from pancreatic duct Class III
5297 Endoscopic insertion of nasopancreatic drainage tube Class III
5298 Endoscopic dilation of pancreatic duct Class III
9705 Replacement of stent (tube) in biliary or pancreatic duct Class III

TOP UP UNTUK SPECIAL PROSTHESIS

NO

List Item Special CMG

Subdural grid electrode

Tipe Special
CMG

Special
Prosthesis

koefisien
utk top up

0,5

Kode

KODE

INA-CBG dasar

ICD 10/ICD 9 CM

Prosedur Rawat Inap

0112 Open biopsy of cerebral meninges Class I

0113 Closed (percutaneous) (needle) biopsy of brain Class II
0114 Open biopsy of brain Class I
0118 Other diagnostic procedures on brain and cerebral meninges Class II
0121 Incision and drainage of cranial sinus Class II
0122 Removal of intracranial neurostimulator Class II
0123 Reopening of craniotomy site Class II
0124 Other craniotomy Class II
0125 Other craniectomy Class II
0131 Incision of cerebral meninges Class II
0132 Lobotomy and tractotomy Class I
0139 Other incision of brain Class II
0141 Operations on thalamus Class I
0142 Operations on globus pallidus Class I
0151 Excision of lesion or tissue of cerebral meninges Class I
0152 Hemispherectomy Class I
0153 Lobectomy of brain Class I
0159 Other excision or destruction of lesion or tissue of brain Class I
016 Excision of lesion of skull Class II
0201 Opening of cranial suture Class II
0202 Elevation of skull fracture fragments Class II
0203 Formation of cranial bone flap Class I
0204 Bone graft to skull Class II
0205 Insertion of skull plate Class I
0206 Other cranial osteoplasty Class I
0207 Removal of skull plate Class II
0211 Simple suture of dura mater of brain Class I
0212 Other repair of cerebral meninges Class I
0214 Choroid plexectomy Class I
022 Ventriculostomy Class II
0291 Lysis of cortical adhesions Class I
0292 Repair of brain Class I
0293 Implantation of intracranial neurostimulator Class II
0299 Other operations on skull, brain, and cerebral meninges Class II
0401 Excision of acoustic neuroma Class II
0441 Decompression of trigeminal nerve root Class II
3554 Repair of endocardial cushion defect with prosthesis Class I
3563 Repair of endocardial cushion defect with tissue graft Class I
3573 Other and unspecified repair of endocardial cushion defect Class I

Cote graft

Special
Prosthesis

0,5

Prosedur Rawat Inap

3581 Total repair of tetralogy of fallot Class I

3582 Total repair of total anomalous pulmonary venous connection Class I
3583 Total repair of truncus arteriosus Class I
3584 Total correction of transposition of great vessels, not elsewhere classified Class I
3591 Interatrial transposition of venous return Class I
3592 Creation of conduit between right ventricle and pulmonary artery Class I
3593 Creation of conduit between left ventricle and aorta Class I
3594 Creation of conduit between atrium and pulmonary artery Class I
0115 Biopsy of skull Class II

TMJ Prothesis

Special
Prosthesis

Prosedur Rawat Inap

0119 Other diagnostic procedures on skull Class II

0353 Repair of vertebral fracture Class II
7601 Sequestrectomy of facial bone Class II
7609 Other incision of facial bone Class II
7611 Biopsy of facial bone Class II
7619 Other diagnostic procedures on facial bones and joints Class II

762 Local excision or destruction of lesion of facial bone Class II

7631 Partial mandibulectomy Class II
7642 Other total mandibulectomy Class II
765 Temporomandibular arthroplasty Class II
7669 Other facial bone repair Class II
7670 Reduction of facial fracture, not otherwise specified Class II
7672 Open reduction of malar and zygomatic fracture Class II
7674 Open reduction of maxillary fracture Class II
7676 Open reduction of mandibular fracture Class II
7677 Open reduction of alveolar fracture Class II
7679 Other open reduction of facial fracture Class II
7691 Bone graft to facial bone Class II
7692 Insertion of synthetic implant in facial bone Class II
7694 Open reduction of temporomandibular dislocation Class II
7697 Removal of internal fixation device from facial bone Class II
7699 Other operations on facial bones and joints Class II
3802 Incision of other vessels of head and neck Class II

Liquid Embolic (for AVM)

Special
Prosthesis

Prosedur Rawat Inap

3812 Endarterectomy of other vessels of head and neck Class II

3832 Resection of other vessels of head and neck with anastomosis Class II
3842 Resection of vessel with replacement, other vessels of head and neck Class II
3852 Ligation and stripping of varicose veins, other vessels of head an Class II
3862 Other excision of vessels, other vessels of head and neck Class II
3882 Other surgical occlusion of vessels, other vessels of head and neck Class II
3972 Endovascular repair or occlusion of head and neck vessels Class II
3974 Endovascular removal of obstruction from head and neck vessel
8151 Total hip replacement Class I

Hip Implant/ knee implant

Special
Prosthesis

Prosedur Rawat Inap

8152 Partial hip replacement Class I

8153 Revision of hip replacement, NEC Class I
8154 Total knee replacement Class I
8155 Revision of knee replacement, NEC Class I
8156 Total ankle replacement Class I
8162 Fusion or refusion of 2-3 vertebrae Class I
8163 Fusion or refusion of 4-8 vertebrae Class I
8164 Fusion or refusion of 9 or more vertebrae Class I
8426 Foot reattachment Class I
8427 Lower leg or ankle reattachment Class I
8428 Thigh reattachment Class I

TOP UP SPECIAL DRUGS

NO

List Item
Special CMG

Tipe
koefisien
Special utk top
CMG
up

Kode

KODE

INA-CBG
dasar

ICD 10/ICD 9 CM
I210 Acute transmural myocardial infarction of anterior wall (I-4-10,Q-5-30) Severity 3

Streptokinase

Deferiprone
2

Deferoksamin

Deferasirox
4

I211 Acute transmural myocardial infarction of inferior wall (I-4-10,Q-5-30) Severity 3

I212 Acute transmural myocardial infarction of other sites (I-4-10,Q-5-30) Severity 3
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

Special
Drug

0,25

Diagnosis
Rawat
Inap

Special
Drug

0,5

Diagnosis
Rawat
Inap

D460 Refractory anaemia without sideroblasts, so stated (D-4-13,Q-5-33) Severity 2

Special
Drug

0,5

Diagnosis
Rawat
Inap

D461 Refractory anaemia with sideroblasts (D-4-13,Q-5-33) Severity 2

Special
Drug

0,5

Diagnosis
Rawat
Inap

D462 Refractory anaemia with excess of blasts (D-4-13,Q-5-33) Severity 2

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
P560 Hydrops fetalis due to isoimmunization (D-4-13,P-8-17,P-9-17,Q-5-41) Severity 3
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
A021 Salmonella septicaemia (A-4-10,Q-5-42) Severity 3

Human
Albumin

Special
Drug

0,5

A207 Septicaemic plague (A-4-10,Q-5-35) Severity 3

A227 Anthrax septicaemia (A-4-10,Q-5-35) Severity 3
A391 Waterhouse-friderichsen syndrome (A-4-10,Q-5-35) Severity 3
A392 Acute meningococcaemia (A-4-10,Q-5-35) Severity 3
A393 Chronic meningococcaemia (A-4-10,Q-5-35) Severity 3
A394 Meningococcaemia, unspecified (A-4-10,Q-5-35) Severity 3
A398 Other meningococcal infections (A-4-10,Q-5-35) Severity 3
A399 Meningococcal infection, unspecified (A-4-10,Q-5-35) Severity 3
A400 Septicaemia due to streptococcus, group a (A-4-10,Q-5-35) Severity 3
A401 Septicaemia due to streptococcus, group b (A-4-10,Q-5-35) Severity 3
A402 Septicaemia due to streptococcus, group d (A-4-10,Q-5-35) Severity 3
A403 Septicaemia due to streptococcus pneumoniae (A-4-10,Q-5-35) Severity 3
A408 Other streptococcal septicaemia (A-4-10,Q-5-35) Severity 3
A409 Streptococcal septicaemia, unspecified (A-4-10,Q-5-35) Severity 3
A410 Septicaemia due to staphylococcus aureus (A-4-10,Q-5-35) Severity 3
A411 Septicaemia due to other specified staphylococcus (A-4-10,Q-5-35) Severity 3
A412 Septicaemia due to unspecified staphylococcus (A-4-10,Q-5-35) Severity 3
A413 Septicaemia due to haemophilus influenzae (A-4-10,Q-5-35) Severity 3
A414 Septicaemia due to anaerobes (A-4-10,Q-5-35) Severity 3
A415 Septicaemia due to other gram-negative organisms (A-4-10,Q-5-35) Severity 3
A418 Other specified septicaemia (A-4-10,Q-5-35) Severity 3
A419 Septicaemia, unspecified (A-4-10,Q-5-35) Severity 3
A427 Actinomycotic septicaemia (A-4-10,Q-5-35) Severity 3
B377 Candidal septicaemia (A-4-10,Q-5-35) Severity 3
R571 Hypovolaemic shock (A-4-10,Q-5-37) Severity 3

Diagnosis
Rawat
Inap

TOP UP SPECIAL PENUNJANG

NO

List Item Special

CMG

Tipe Special CMG

koefisien utk top

up

Kode

KODE

INA-CBG dasar

ICD 10/ICD 9 CM
8741 Computerized axial tomography of thorax Class III

Other CT Scan

Special
Investigation

1,5

Prosedur Rawat
Jalan

8771 Computerized axial tomography of kidney Class III

8801 Computerized axial tomography of abdomen Class III
8838 Other computerized axial tomography Class III
8898 Bone mineral density studies Class III
9201 Thyroid scan and radioisotope function studies Class III

Nuclear Medicine

Special
Investigation

1,5

Prosedur Rawat
Jalan

9202 Liver scan and radioisotope function study Class III

9203 Renal scan and radioisotope function study Class III
9204 Gastrointestinal scan and radioisotope function study Class III
9205 Cardiovascular and hematopoietic scan and radioisotope function study Class III
9209 Other radioisotope function studies Class III
9211 Cerebral scan Class III
9212 Scan of other sites of head Class III
9213 Parathyroid scan Class III
9214 Bone scan Class III
9215 Pulmonary scan Class III
9216 Scan of lymphatic system Class III
9218 Total body scan Class III
9219 Scan of other site Class III
8891 Magnetic resonance imaging of brain and brain stem Class III

MRI

Special
Investigation

1,5

Prosedur Rawat
Jalan

8892 Magnetic resonance imaging of chest and myocardium for evaluation of Class III
8893 Magnetic resonance imaging of spinal canal Class III
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

8714 Contrast radiogram of orbit Class III

Diagnostic and
Imaging of Eye

Special
Investigation

1,5

Prosedur Rawat
Jalan

8882 Ocular thermography Class III

9511 Fundus photography Class III
9512 Fluorescein angiography or angioscopy of eye Class III
9513 Ultrasound study of eye Class III
9514 X-ray study of eye Class III
9516 P32 and other tracer studies of eye Class III
9521 Electroretinogram (ERG) Class III
9522 Electro-oculogram (EOG) Class III
9524 Electronystagmogram (ENG) Class III
9525 Electromyogram of eye (EMG) Class III
9526 Tonography, provocative tests, and other glaucoma testing Class III