NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.

1 Pasang IUD 69.7 5 5 0

2 Ektraksi IUD 97.71 5 5 0
3 Pasang Implant 99.23 5 5 0
4 Aff Implan 10 5 0
5 Kolposkopi 70.21 20 15 0
6 Kardiotokograf 75.34 20 5 0
7 Papsmear 70.29 20 15 0
8 IVA 70.29
9 Biopsi 70.24 20 15 0
10 Hidrotubasi 20 15 0
11 Inseminasi 69.92 20 15 0
12 Swim up sperma + inseminasi 99.96 + 69.92 20 15 0
13 Histeroskopi Office 68.12 20 45 0
14 Kriosurgery 67.33 20 15 0
15 Irigasi/vaginal toilet 70.91 20 5 0
16 Mikrokuret 69.09 20 15 0
17 Punksi cavum Douglas 70 20 15 0
18 Pasang + laminaria 69.93 20 5 0
19 Debridement Luka Operasi 54.3 20 15 0
20 Podoflin 5 5 0
21 Pasang pesarium 96.18 20 5 0
22 Swab vagina 70.29 5 5 0
23 Ektripasi polip 71.9 20 15 0
24 Pasang/angkat tampon 75.8 5 5 0
25 Suntik KB/Obat/vaksin 99.24 5 0 0
26 - Dasar 99.24 20 15 0
27 - Lanjut (Konsultasi tingkat IV oleh expert) 99.24 25 45 0
NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.2

28 - Khusus (Intervensi) 99.24 25 90 15

29 Induksi / akselerasi persalinan 73.4 20 5 0
30 Partus pervaginam tanpa penyulit 73.59 20 5 0
31 Partus pervaginam dengan penyulit (EV-EF dll) 73.59 20 45 0
32 Manual plasenta post partum 75.4 20 5 0
33 Manual plasenta rujukan 75.4 20 45 0
34 Jahitan ruptur perineum grade 3 - 4 post partum, robekan serviks 75.62 20 45 15
35 Persalinan dengan embryotomi 73.8 20 45 0
36 Kuretase pascapersalinan 69.02 20 45 15
37 Kuretase abortus 69.02 20 45 15
38 Sectio caesaria tanpa penyulit 74 20 45 15
39 Section dengan penyulit (perlekatan berat, histeroraf). 74 20 45 45
40 Section caesaria + histerektomi obstetri 74.0 + 74.99 20 45 45
41 Operasi obstetri Khusus (plasenta akreta) 68.9 20 45 45
Kecil
42 Sistoskopi LEETZ 57.32 20 45 0
43 Kista Bartholin/kista Gartner 71.2 20 45 0
44 Konisasi 67.2 20 45 0
45 Ekstraksi IUD dengan anestesi 97.71 20 45 15
46 Polip serviks 69.99 20 45 15
47 Kauterisasi kondiloma akuminata 71.9 20 45 15
48 Penjahitan laserasi ringan 75.6 20 45 15
49 Drainase abses 71.9 20 45 15
50 Shirodkar 67.53 20 45 15
51 Kolpotomi pada abses cavum Douglas 70.12 20 45 15
Sedang
52 Ekstirpasi 71.9 20 45 15
53 Mioma geburt 68.29 20 45 15
54 Robekan serviks/forniks 75.51 20 45 15
55 Hematoma / ruptur 75.9 20 45 15
56 Histeroraf 69.99 20 45 15
NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.2

Besar
57 Kolporaf anterior 70.29 20 45 15
58 Kolporaf posterior 70.29 20 45 15
Khusus
59 Repair fstula 71.72 20 45 45
60 Vaginoplasti 70.79 20 45 45
61 Rekonstruksi vagina 70.62 20 45 45
62 Histerektomi pervaginam + kolpoperineoplasti 68.5 + 70.79 20 45 45
63 Purandare 71.9 20 45 45
64 Penyulit + 50% 20 45 45
TINDAKAN GINEKOLOGI
Kecil
65 Tubektomi 66.5 20 45 15
66 Kemoterapi 99.25 20 45 0
Sedang
67 Kehamilan ektopik 74.3 20 45 15
68 Miomektomi 68.29 20 45 15
69 Kistektomi 71.9 20 45 15
70 Salpingo-ooforektomi 65 20 45 15
71 Pemasangan Implan Tableport 20 45 15
72 Laparotomi Diagnostik 71.9 20 45 15
73 Ligasi Arteri Hipogastrica / Uterina 38.86 20 45 15
74 Ekstirpasi Giant Condiloma 71.9 20 45 15
75 Penyulit + 50% 20 45 15
Besar
76 Histerektomi 68.4 20 45 45
77 Miomektomi 68.29 20 45 45
78 Reseksi adenomiosis 69.1 20 45 45
79 Infeksi panggul/PUS dengan perlekatan. 54.11 20 45 45
80 Adhesiolisis perlekatan berat pelvik. 65.8 20 45 45
81 Repair tuba (tubaplasti) 66.7 20 45 45
NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.2

82 Transposisi Ovarium 65.79 20 45 45

83 Penyulit + 50 % 20 45 45
Khusus
84 Histerektomi radikal 68.6 25 90 45
85 Staging Laparatomi 54.11 25 90 45
86 Trachelectomy Radical Servix 69.99 25 90 45
87 Eksenterasi (Anterior Posterior) 71.9 25 90 45
88 Vulvektomi radikal 71.5 25 90 45
89 Debulking Kanker Ovarium Lanjut 25 90 45
90 Ultra Radikal Histerektomi 68.6 25 90 45
91 Operasi Frozen Pelvic 71.9 25 90 45
92 Relaparatomi High-risk complication 54.12 25 90 45
93 Penyulit + 50% 25 90 45
LAPAROSKOPI/ HISTEROSKOPI
Kecil
94 Tubektomi 66.2 20 45 15
95 Second Look 66.2 20 45 15
96 Histeroskopi diagnostik 68.12 20 45 15
97 Laparoskopi diagnostik 54.21 20 45 15
Sedang
98 Kistektomi 71.9 20 90 45
99 Ooforektomi/salpingektomi 65.5 / 66.4 20 90 45
100 Salpingoooforektomi 65.6 20 90 45
101 Eksplorasi ektraksi IUD translokasi. 97.71 20 90 45
102 Adhesiolisis Perlekatan Ringan 65.81 20 90 45
103 Penyulit + 50% 20 90 45
104 Transposisi Ovarium 65.99 20 90 45
105 Ovareksi 65.9 20 90 45
Besar
106 Histerektomi 68.41 25 90 45
107 Miomektomi 68.29 25 90 45
NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.2

108 Adhesiolisis Perlekatan berat 65.81 25 90 45

109 Reseksi endometriosis 68.23 25 90 45
110 Reseksi adenomiosis 68.29 25 90 45
111 Histeroskopi operatif 68.12 25 90 45
112 Rekanalisasi tuba 66.7 25 90 45
113 Laparaskopi histerektomi radikal 68.61 25 90 45
114 Laparaskopi Histerektomi / Kistektomi / Adesiolisis Berat 68.61 / 71.9 / 25 90 45
115 Penyulit + 50% 25 90 45
Khusus
116 Onkologi 25 90 45
117 Penyulit + 50 % 25 90 45
NO NAMA TINDAKAN ICD IX-CM F1 F2.1 F2.2 F3 F4

Neurootologi
1 Audiologi Nada Murni 95.41 20 15 0 0 2
2 Timpanometri 95.41 20 15 0 0 2
3 BERA NO 95.41 20 45 0 0 5
4 E.N.G Komputer 95.24 20 45 0 0 35
5 Test Sisi/ Decay 95.46 20 15 0 0 5
6 Audiometri Tutur 95.41 20 15 0 0 5
7 Vibrasi 95.42 20 15 0 0 5
8 Fasialis N VIII 89.13 20 15 0 0 10
9 Posturograf NO 95.46 20 15 0 0 15
10 Tes Keseimbangan dengan Frezels 95.46 20 15 0 0 15
11 Audiometri Tes gliserol 95.41 20 15 0 0 15
12 Terapi Reposisi Otolot 95.46 20 15 0 0 25
13 OAE NO 95.46 20 15 0 0 5
14 Tes Keseimbangan Sederhana 95.46 20 5 0 5
Otologi
15 Irigasi Liang Telinga 96.52 5 5 0 0 5
16 Ekstrasi Benda Asing Telinga 98.11 5 5 0 0 5
17 Insisi Abses 18.09 5 5 0 0 5
18 Biopsi (Biopsi Otologi) 18.12 20 15 0 0 5
19 Ekstraksi jaringan granulasi 98.11 5 15 0 0 5
20 Parasintesis 20.09 5 15 0 0 5
21 Otomikroskopi Diagnostik 18.1 5 15 0 0 5
22 Ear toilet 96.52 5 15 0 0 5
23 Ambil bahan kultur 18.19 5 15 0 0 5
24 Pasang gromet 20.01 5 15 0 0 5
25 Patch Test Diagnostik 5 15 0 0 5
26 Patch Paper Therapi 5 15 0 0 5
27 Benda Asing dg Penyulit 98.11 5 15 0 0 5
28 Kaustik Jar Granulasi 18.29 5 15 0 0 5
29 Serumen dg Penyulit 96.52 15 15 0 0 5
F2.2 F3 F4 TOTAL RVU JASA
SKOR
0 0 5 15 5000 75,000
0 0 5 15 5000 75,000
0 0 5 15 5000 75,000
0 0 5 20 5000 100,000
0 0 5 40 5000 200,000
0 0 5 30 5000 150,000
0 0 5 40 5000 200,000
Gratis
0 0 5 40 5000 200,000
0 0 5 40 5000 200,000
0 0 5 40 5000 200,000
0 0 5 40 5000 200,000
0 0 35 100 5000 500,000
0 0 10 45 5000 225,000
0 0 5 30 5000 150,000
0 0 5 40 5000 200,000
0 0 5 40 5000 200,000
0 0 5 30 5000 150,000
0 0 5 40 5000 200,000
0 0 5 15 5000 75,000
0 0 5 30 5000 150,000
0 0 5 15 5000 75,000
0 0 5 40 5000 200,000
0 0 5 15 5000 75,000
0 0 1 6 5000 30,000
0 0 5 40 5000 200,000
0 0 5 75 5000 375,000
F2.2 F3 F4 TOTAL RVU JASA
SKOR
15 15 10 155 5000 775,000
0 0 5 30 5000 150,000
0 0 60 85 10000 850,000
0 0 60 125 10000 1,250,000
0 0 5 30 5000 150,000
0 0 5 70 5000 350,000
15 5 15 100 5000 500,000
0 0 35 100 10000 1,000,000
15 5 15 100 10000 1,000,000
15 0 5 85 10000 850,000
15 5 5 90 20000 1,800,000
45 5 15 130 20000 2,600,000
45 15 25 150 20000 3,000,000
45 15 40 165 20000 3,300,000

0 0 10 75 10000 750,000
0 0 10 75 10000 750,000
0 0 10 75 10000 750,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000
15 5 5 90 10000 900,000

15 5 15 100 10000 1,000,000

15 5 15 100 10000 1,000,000
15 5 15 100 10000 1,000,000
15 5 15 100 10000 1,000,000
15 5 15 100 10000 1,000,000
F2.2 F3 F4 TOTAL RVU JASA
SKOR

15 5 5 90 20000 1,800,000
15 5 5 90 20000 1,800,000

45 5 15 130 20000 2,600,000

45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000

15 5 5 90 10000 900,000
0 0 5 70 5000 350,000

15 5 15 100 20000 2,000,000

15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000
15 5 15 100 20000 2,000,000

45 5 15 130 20000 2,600,000

45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000
F2.2 F3 F4 TOTAL RVU JASA
SKOR
45 5 15 130 20000 2,600,000
45 5 15 130 20000 2,600,000

45 15 50 225 20000 4,500,000

45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000

15 5 5 90 20000 1,800,000
15 5 5 90 20000 1,800,000
15 5 5 90 20000 1,800,000
15 5 5 90 20000 1,800,000

45 5 15 175 20000 3,500,000

45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000
45 5 15 175 20000 3,500,000

45 15 50 225 20000 4,500,000

45 15 50 225 20000 4,500,000
F2.2 F3 F4 TOTAL RVU JASA
SKOR
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000
45 15 50 225 20000 4,500,000

45 45 50 255 20000 5,100,000

45 45 50 255 20000 5,100,000
TOTAL RVU JASA
SKOR

37 5000 185,000
37 5000 185,000
70 5000 350,000
100 5000 500,000
40 5000 200,000
40 5000 200,000
40 5000 200,000
45 5000 225,000
50 5000 250,000
50 5000 250,000
50 5000 250,000
60 5000 300,000
40 5000 200,000
30 5000 150,000

15 10000 150,000
15 10000 150,000
15 5000 75,000
40 5000 200,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
25 5000 125,000
35 5000 175,000