Recording ICD-10 diagnoses and ICD-9-CM procedures

Diagnoses use ICD-10 and procedures use ICD-9-CM, in line with SATUSEHAT terminology (SATUSEHAT is the Ministry of Health's national health data platform). Correct codes determine whether submissions to SATUSEHAT and BPJS claims (national health insurance) succeed.

Diagnosis

1. Press Alt+D or open the Diagnosis section.
2. Type a code (for example J06.9) or a term in Indonesian (such as "ispa", acute respiratory infection). The results show the code (in monospace) and its description.
3. Mark one diagnosis as primary; the others are secondary.
4. Choose the case type: new or existing.

Procedures

Search by ICD-9-CM code or procedure name. Procedures linked to a service tariff are added to the cashier's invoice automatically.

Tips

• Choose the most specific code supported by the examination.
• Inactive or unknown codes are rejected by SATUSEHAT; the error message appears in the visit's sync status.
• Code suggestions from the AI Assistant are only suggestions; the doctor decides.