No Keterangan ICD 10 Diagnosis ICD 9 Tindakan Plafon

1 DDH Q65.0 Congenital dislocation of hip, 77.39bSalter Osteotomy( Other division of bone, other)
unilateral 77.3 Ganz osteotomy (other division of bone )
93.53 Pemasangan hemispica ( application of other cast )
88.32 Arthrogam ( Contrast Arthrogram )
2 Skoliosis Q76.3 Congenital Scoliosis 81.64 Fusion of 9 or more vertebra
78.0 Bone graft
84.51 Insertion of interbody spinal fusion device
03.09 Other exploration and decompression of spinal canal
3 CTEV Q66.0 Congenital talipes equinovarus (1)Soft tissue procedure ( ATL & PMR)
83.11 Achillotenotomy
83.84 Release of clubfoot
80.47 Division of joint capsule, ligament or cartilage
83.85 Other change in muscle or tendon length
(2)Bony procedures
81.12 Triple arthrodesis
4 Blount M92.5 Juvenile ostepchondrosis of HTO & stapler epifisis :
disease tibia and fibula 78.77 Osteoclasis of tibia and fibula
79.37 ORIF of tibia
78.2 Limb shortening procedures : Open epiphysiodesis

5 Cerebral G80.9 Cerebral Palsy (1)Single – event milti-level surgery (SEMLS):

Palsy 83.85 Psoas lengthening ( other change in muscle or
tendon length
83.12 adductor tenotomy of hip
83.75 Rectus femoris transfer ( tendon transfer and
transplantation)
83.86 Hamstring transfer
83.75 Tibialis transfer (tendon transfer and
transplantation)
83.85 Achilles tendon lengthening
77.38 Clacaneal lengthening
 (2) Hip reconstruction surgery :
81.40 Acetabuloplasty
77.2 Femoral varization (wedge osteotomy )
78.79 Derotation osteotomy (osteoclasis )

6 Osteogenesis Q78.0 Osteogenesis imperfecta Shiskebab femur :

imperfecta 78.70 Osteclasis unspecified site
79.35 Open reduction of fracture with internal fixation of
femur

Shiskebab tibia :
78.77 Osteoclasis tibia and fibula
79.37 Open reduction of fracture with internal fixation of
tibia,fibulla
7 Sindaktili Q70 Syndactily 86.85 Correction of syndactily
86.61 Full Thickness skin graft to hand
8 Polidactili Q69 Polydactily 86.26 Ligation of dermal appendage
86.61 Full thickness skin graft to hand
9 Torticolis M43.6 Torticolis Release torticollis :
83.8 Other plastic operation on muscle, tendon, and fascia
93.27 Stretching of muscle or tendon
10 Slipped M93.02 Chronic slipped upper femoral 80.4 Division of joint capsule , ligament or cartilage
Capital epiphysis 77.2 Femoral varization (wedge osteotomy)
Femoral 79.35 Open reduction of fracture with internal fixation of
Epifisis femur
11 ORIF S52.4 Fracture of radius and ulna 79.33 Open reduction of fracture with internal fixation of
antebrachii radius, ulna
12 ORIF manus S62.0 Fracture of hand 79.34 Open reduction of fracture with internal fixation of
carpal,metacarpal
13 ORIF hip and S72.3 fracture of femur 79.35 Open reduction of fracture with internal fixation of
femur femur
14 ORIF patella S82.0 Fracture of patella 79.36 Open reduction of fracture with internal fixation of
patella
15 ORIF cruris S82.2 Fracture of cruris 79.37 Open reduction of fracture with internal fixation of
tibia, fibulla
16 ORIF pedis S92.3 Fracture of pedis 79.38 Open reduction of fracture with internal fixation of
tarsal, metatarsal
17 Aff implant S42.3 Fracture of humerus 78.62 Removal of implanted devices from bone (humerus)
humerus
18 Aff implant S52.4 Fracture od radius and ulna 78.63 Removal of implanted devices from bone (radius,
antebranchii ulna)
19 Aff implant S62.0 Fracture of hand 78.64 Removal of implanted devices from bone (carpal,
manus metacarpal)
20 Aff implant S82.0 Fracture of patella 78.65 Removal of implanted devices from bone
hip dan
femur
21 Aff implant S82.0 fracture of patella 78.66 Removal of implanted devices from bone (patella)
patella
22 Aff implant S82.2 Fracture of cruris 78.67 Removal of implanted devices from bone (tibia
cruris fibullar)
23 Aff implant S92.3 Fracture of pedis 78.68 Removal of implanted devices from bone (tarsal,
pedis metatarsal)
24 Aff implant S32 Fracture of vertebra 78.69 Removal of implanted devices from bone (other,
spine vertebra, pelvis)
25 Debridement S82.2 Fracture of cruris 79.6 Debridement of open fracture site
patah tulang
terbuka
26 Debridement M00.85 Arthritis due to bacteria, hip 80.4 Division of joint capsule, ligament or cartilage
sendi ec 80.7 Synovectomy
coxitis/
septic
arthritis
27 Closed S52.4 Fracture of radius and ulna 79.0 Closed reduction of fracture eithout internal fixation
reduction
28 Eksternal S82.2 Fracture of cruris 78.1 Application of external fixator device
fiksasi
29 Sham M25.60 Stiffness of unspecified joint 93.26 Manual rupture of joint adhesion
reduction
(joint
stffness)
30 French S42.30 Unspecified fracture of shaft 78.72 Osteoclasis humerus
osteotomy humerus 79.35 ORIF of femur
(Malunion
distal
humerus)
31 Varus de- S42.30 Unspecified fracture of shaft 78.72 Osteoclasis humerus
rotational humerus 79.35 ORIF of femur
osteotomy
(Malunion
proximal
humerus
32 Bone graft M89.9 Other disorder of bone 78.0 Bone graft
33 Pemasangan S82.2 Fracture of cruris 79.00 Closed reduction without internal fixation
gips 93.53 Application of other cast
34 Atrodesis
- Ankle 81.11 Ankle fusion

- Hip 81.21 Arthrodesis of hip

- Knee 81.22 Athrodesis of knee

- Shoulder 81.23 Arthrodesis of shoulder

- elbow 81.24 Arthrodesis of elbow

Aff implant S82.0 fracture of patella 78.66 Removal of implanted devices from bone (patella)
patella
ICD 9 for Procedures in Paediatrics Division