PERATURAN BPJS POLI GIGI

1. CEK rujukan, apakah tindakan perlu dilakukan di RS. Jika tidak, lebih baik
dikembalikan ke klinik

2. Tindakan yang bisa dijamin BPJS adalah:

a. PSA:
i. TKF/CHKM/ROCKLES/CRESOPENE/DEVITALISASI
ii. CALXYL/ENDOMETHASONE
iii. Restorasi post PSA: Glass Ionomer / Komposit
b. Ekstraksi
i. Lebih baik gigi 7 dan 8
ii. Atau disertai dengan abses
iii. Atau indikasi pencabutan karena fraktur
iv. Atau gigi 4 dan gigi 5 rahang atas (atau gigi lainnya) yang perlu
pengurangan tulang/separasi
v. Odontektomi
c. Obat-Obatan
i. Pasca Ekstraksi:
 Asam Mefenamat Maksimal 15
 Ibuprofen Maksimal 15
 Amoxicillin Maksimal 15
ii. PSA : TIDAK DITANGGUNG/TIDAK DIBERIKAN
 d. Gigi Palsu

ICD 10 VOL 2 TAHUN 2008

Diseases of oral cavity, salivary glands and jaws

(K00-K14)

K00Disorders of tooth development and eruption

Excl.:
embedded and impacted teeth (K01.-)
K00.0Anodontia
Hypodontia
Oligodontia
K00.1Supernumerary teeth
Distomolar
Fourth molar
Mesiodens
Paramolar
Supplementary teeth
K00.2Abnormalities of size and form of teeth
 Concrescence
 Fusion  of teeth
 Gemination
Dens:
 evaginatus
 in dente
 invaginatus
Enamel pearls
Macrodontia
 Microdontia
Peg-shaped [conical] teeth
Taurodontism
Tuberculum paramolare
Excl.:
tuberculum Carabelli, which is regarded as a normal variation and should not be coded
K00.3Mottled teeth
Dental fluorosis
Mottling of enamel
Nonfluoride enamel opacities
Excl.:
deposits [accretions] on teeth (K03.6)
K00.4Disturbances in tooth formation
Aplasia and hypoplasia of cementum
Dilaceration of tooth
Enamel hypoplasia (neonatal)(postnatal)(prenatal)
Regional odontodysplasia
Turner's tooth
Excl.:
Hutchinson's teeth and mulberry molars in congenital syphilis (A50.5)
mottled teeth (K00.3)
K00.5Hereditary disturbances in tooth structure, not elsewhere classified
 Amelogenesis
 Dentinogenesis  imperfecta
 Odontogenesis
Dentinal dysplasia
Shell teeth
K00.6Disturbances in tooth eruption
Dentia praecox
 Natal
 tooth
 Neonatal
Premature:
 eruption of tooth
 shedding of primary [deciduous] tooth
Retained [persistent] primary tooth
K00.7Teething syndrome
K00.8Other disorders of tooth development
Colour changes during tooth formation
Intrinsic staining of teeth NOS
K00.9Disorder of tooth development, unspecified
Disorder of odontogenesis NOS
K01Embedded and impacted teeth
Excl.:
embedded and impacted teeth with abnormal position of such teeth or adjacent teeth (K07.3)
K01.0Embedded teeth
An embedded tooth is a tooth that has failed to erupt without obstruction by another tooth.
K01.1Impacted teeth
An impacted tooth is a tooth that has failed to erupt because of obstruction by another tooth.
K02Dental caries
K02.0Caries limited to enamel
White spot lesions [initial caries]
K02.1Caries of dentine
K02.2Caries of cementum
K02.3Arrested dental caries
K02.4Odontoclasia
 Infantile melanodontia
Melanodontoclasia
K02.8Other dental caries
K02.9Dental caries, unspecified
K03Other diseases of hard tissues of teeth
Excl.:
bruxism (F45.8)
dental caries (K02.-)
teeth-grinding NOS (F45.8)
K03.0Excessive attrition of teeth
 Wear:
 approximal  of teeth
 occlusal
K03.1Abrasion of teeth
 Abrasion:
 dentifrice
 habitual
 occupational  of teeth
 ritual
 traditional
 Wedge defect NOS
K03.2Erosion of teeth
Erosion of teeth:
 NOS
 due to:
o diet
o drugs and medicaments
o persistent vomiting
 idiopathic
 occupational
K03.3Pathological resorption of teeth
Internal granuloma of pulp
Resorption of teeth (external)
K03.4Hypercementosis
Cementation hyperplasia
K03.5Ankylosis of teeth
K03.6Deposits [accretions] on teeth
Dental calculus:
 subgingival
 supragingival
Deposits [accretions] on teeth:
 betel
 black
 green
 materia alba
 orange
 tobacco
Staining of teeth:
 NOS
 extrinsic NOS
K03.7Posteruptive colour changes of dental hard tissues
Excl.:
deposits [accretions] on teeth (K03.6)
K03.8Other specified diseases of hard tissues of teeth
 Irradiated enamel
Sensitive dentine
Use additional external cause code (Chapter XX), if desired, to identify radiation, if radiation-induced.
K03.9Disease of hard tissues of teeth, unspecified
K04Diseases of pulp and periapical tissues
K04.0Pulpitis
Pulpal:
 abscess
 polyp
Pulpitis:
 acute
 chronic (hyperplastic)(ulcerative)
 suppurative
K04.1Necrosis of pulp
Pulpal gangrene
K04.2Pulp degeneration
Denticles
Pulpal:
 calcifications
 stones
K04.3Abnormal hard tissue formation in pulp
Secondary or irregular dentine
K04.4Acute apical periodontitis of pulpal origin
Acute apical periodontitis NOS
K04.5Chronic apical periodontitis
Apical or periapical granuloma
Apical periodontitis NOS
K04.6Periapical abscess with sinus
 Dental
 abscess with sinus
 Dentoalveolar
K04.7Periapical abscess without sinus
 Dental
 Dentoalveolar  abscess NOS
 Periapical
K04.8Radicular cyst
Cyst:
 apical (periodontal)
 periapical
 residual radicular
Excl.:
lateral periodontal cyst (K09.0)
K04.9Other and unspecified diseases of pulp and periapical tissues
K05Gingivitis and periodontal diseases
K05.0Acute gingivitis
Excl.:
acute necrotizing ulcerative gingivitis (A69.1)
herpesviral [herpes simplex] gingivostomatitis (B00.2)
K05.1Chronic gingivitis
Gingivitis (chronic):
 NOS
 desquamative
 hyperplastic
 simple marginal
 ulcerative
K05.2Acute periodontitis
Acute pericoronitis
Parodontal abscess
Periodontal abscess
Excl.:
acute apical periodontitis (K04.4)
periapical abscess (K04.7)
periapical abscess with sinus (K04.6)
K05.3Chronic periodontitis
Chronic pericoronitis
Periodontitis:
 NOS
 complex
 simplex
K05.4Periodontosis
Juvenile periodontosis
K05.5Other periodontal diseases
K05.6Periodontal disease, unspecified
K06Other disorders of gingiva and edentulous alveolar ridge
Excl.:
atrophy of edentulous alveolar ridge (K08.2)
gingivitis:
 NOS (K05.1)
 acute (K05.0)
 chronic (K05.1)
K06.0Gingival recession
Gingival recession (generalized)(localized)(postinfective)(post-operative)
K06.1Gingival enlargement
Gingival fibromatosis
K06.2Gingival and edentulous alveolar ridge lesions associated with trauma
Irritative hyperplasia of edentulous ridge [denture hyperplasia]
Use additional external cause code (Chapter XX), if desired, to identify cause.
K06.8Other specified disorders of gingiva and edentulous alveolar ridge
Fibrous epulis
Flabby ridge
Giant cell epulis
Peripheral giant cell granuloma
Pyogenic granuloma of gingiva
K06.9Disorder of gingiva and edentulous alveolar ridge, unspecified
K07Dentofacial anomalies [including malocclusion]
Excl.:
hemifacial atrophy or hypertrophy (Q67.4)
unilateral condylar hyperplasia or hypoplasia (K10.8)
K07.0Major anomalies of jaw size
Hyperplasia, hypoplasia:
 mandibular
 maxillary
Macrognathism (mandibular)(maxillary)
Micrognathism (mandibular)(maxillary)
Excl.:
acromegaly (E22.0)
Robin's syndrome (Q87.0)
K07.1Anomalies of jaw-cranial base relationship
Asymmetry of jaw
Prognathism (mandibular)(maxillary)
 Retrognathism (mandibular)(maxillary)
K07.2Anomalies of dental arch relationship
Crossbite (anterior)(posterior)
Disto-occlusion
Mesio-occlusion
Midline deviation of dental arch
Openbite (anterior)(posterior)
Overbite (excessive):
 deep
 horizontal
 vertical
Overjet
Posterior lingual occlusion of mandibular teeth
K07.3Anomalies of tooth position
 Crowding
 Diastema
 Displacement
 of tooth or teeth
 Rotation
 Spacing, abnormal
 Transposition
Impacted or embedded teeth with abnormal position of such teeth or adjacent teeth
Excl.:
embedded and impacted teeth without abnormal position (K01.-)
K07.4Malocclusion, unspecified
K07.5Dentofacial functional abnormalities
Abnormal jaw closure
Malocclusion due to:
 abnormal swallowing
 mouth breathing
 tongue, lip or finger habits
Excl.:
bruxism (F45.8)
teeth-grinding NOS (F45.8)
K07.6Temporomandibular joint disorders
Costen's complex or syndrome
Derangement of temporomandibular joint
Snapping jaw
Temporomandibular joint-pain-dysfunction syndrome
Excl.:
current temporomandibular joint:
 dislocation (S03.0)
 strain (S03.4)
K07.8Other dentofacial anomalies
K07.9Dentofacial anomaly, unspecified
K08Other disorders of teeth and supporting structures
K08.0Exfoliation of teeth due to systemic causes
K08.1Loss of teeth due to accident, extraction or local periodontal disease
K08.2Atrophy of edentulous alveolar ridge
K08.3Retained dental root
K08.8Other specified disorders of teeth and supporting structures
Enlargement of alveolar ridge NOS
Irregular alveolar process
Toothache NOS
K08.9Disorder of teeth and supporting structures, unspecified
K09Cysts of oral region, not elsewhere classified
 Incl.:
lesions showing histological features both of aneurysmal cyst and of another fibro-osseous lesion
Excl.:
radicular cyst (K04.8)
K09.0Developmental odontogenic cysts
Cyst:
 dentigerous
 eruption
 follicular
 gingival
 lateral periodontal
 primordial
Keratocyst
K09.1Developmental (nonodontogenic) cysts of oral region
Cyst (of):
 globulomaxillary
 incisive canal
 median palatal
 nasopalatine
 palatine papilla
K09.2Other cysts of jaw
Cyst of jaw:
 NOS
 aneurysmal
 haemorrhagic
 traumatic
Excl.:
latent bone cyst of jaw (K10.0)
Stafne's cyst (K10.0)
K09.8Other cysts of oral region, not elsewhere classified
 Dermoid cyst
 Epidermoid cyst  of mouth
 Lymphoepithelial cyst
Epstein's pearl
Nasoalveolar cyst
Nasolabial cyst
K09.9Cyst of oral region, unspecified
K10Other diseases of jaws
K10.0Developmental disorders of jaws
Latent bone cyst of jaw
Stafne's cyst
Torus:
 mandibularis
 palatinus
K10.1Giant cell granuloma, central
Giant cell granuloma NOS
Excl.:
peripheral giant cell granuloma (K06.8)
K10.2Inflammatory conditions of jaws
 Osteitis
 Osteomyelitis (neonatal)
 of jaw (acute)(chronic)(suppurative)
 Osteoradionecrosis
 Periostitis
Sequestrum of jaw bone
 Use additional external cause code (Chapter XX), if desired, to identify radiation, if radiation-induced.
K10.3Alveolitis of jaws
Alveolar osteitis
Dry socket
K10.8Other specified diseases of jaws
Cherubism
 Exostosis
 of jaw
 Fibrous dysplasia
Unilateral condylar:
 hyperplasia
 hypoplasia
K10.9Disease of jaws, unspecified
K11Diseases of salivary glands
K11.0Atrophy of salivary gland
K11.1Hypertrophy of salivary gland
K11.2Sialoadenitis
Excl.:
epidemic parotitis (B26.-)
uveoparotid fever [Heerfordt] (D86.8)
K11.3Abscess of salivary gland
K11.4Fistula of salivary gland
Excl.:
congenital fistula of salivary gland (Q38.4)
K11.5Sialolithiasis
 Calculus
 of salivary gland or duct
 Stone
K11.6Mucocele of salivary gland
 Mucous:
 extravasation cyst  of salivary gland
 retention cyst
Ranula
K11.7Disturbances of salivary secretion
Hypoptyalism
Ptyalism
Xerostomia
Excl.:
dry mouth NOS (R68.2)
K11.8Other diseases of salivary glands
Benign lymphoepithelial lesion of salivary gland
Mikulicz' disease
Necrotizing sialometaplasia
Sialectasia
 Stenosis
 of salivary duct
 Stricture
Excl.:
sicca syndrome [Sjögren] (M35.0)
K11.9Disease of salivary gland, unspecified
Sialoadenopathy NOS
K12Stomatitis and related lesions
Excl.:
cancrum oris (A69.0)
cheilitis (K13.0)
gangrenous stomatitis (A69.0)
herpesviral [herpes simplex] gingivostomatitis (B00.2)
 noma (A69.0)
K12.0Recurrent oral aphthae
Aphthous stomatitis (major)(minor)
Bednar's aphthae
Periadenitis mucosa necrotica recurrens
Recurrent aphthous ulcer
Stomatitis herpetiformis
K12.1Other forms of stomatitis
Stomatitis:
 NOS
 denture
 ulcerative
 vesicular
K12.2Cellulitis and abscess of mouth
Cellulitis of mouth (floor)
Submandibular abscess
Excl.:
abscess (of):
 periapical (K04.6-K04.7)
 periodontal (K05.2)
 peritonsillar (J36)
 salivary gland (K11.3)
 tongue (K14.0)
K13Other diseases of lip and oral mucosa
Incl.:
epithelial disturbances of tongue
Excl.:
certain disorders of gingiva and edentulous alveolar ridge (K05-K06)
cysts of oral region (K09.-)
diseases of tongue (K14.-)
stomatitis and related lesions (K12.-)
K13.0Diseases of lips
Cheilitis:
 NOS
 angular
 exfoliative
 glandular
Cheilodynia
Cheilosis
Perlèche NEC
Excl.:
ariboflavinosis (E53.0)
cheilitis due to radiation-related disorders (L55-L59)
perlèche due to:
 candidiasis (B37.8)
 riboflavin deficiency (E53.0)
K13.1Cheek and lip biting
K13.2Leukoplakia and other disturbances of oral epithelium, including tongue
 Erythroplakia
 of oral epithelium, including tongue
 Leukoedema
Leukokeratosis nicotina palati
Smoker's palate
Excl.:
hairy leukoplakia (K13.3)
K13.3Hairy leukoplakia
K13.4Granuloma and granuloma-like lesions of oral mucosa
 Eosinophilic granuloma
 Granuloma pyogenicum  of oral mucosa
 Verrucous xanthoma
K13.5Oral submucous fibrosis
Submucous fibrosis of tongue
K13.6Irritative hyperplasia of oral mucosa
Excl.:
irritative hyperplasia of edentulous ridge [denture hyperplasia] (K06.2)
K13.7Other and unspecified lesions of oral mucosa
Focal oral mucinosis
K14Diseases of tongue
Excl.:
 erythroplakia
 focal epithelial hyperplasia
 of tongue (K13.2)
 leukoedema
 leukoplakia
hairy leukoplakia (K13.3)
macroglossia (congenital) (Q38.2)
submucous fibrosis of tongue (K13.5)
K14.0Glossitis
 Abscess
 of tongue
 Ulceration (traumatic)
Excl.:
atrophic glossitis (K14.4)
K14.1Geographic tongue
Benign migratory glossitis
Glossitis areata exfoliativa
K14.2Median rhomboid glossitis
K14.3Hypertrophy of tongue papillae
Black hairy tongue
Coated tongue
Hypertrophy of foliate papillae
Lingua villosa nigra
K14.4Atrophy of tongue papillae
Atrophic glossitis
K14.5Plicated tongue
 Fissured
 Furrowed  tongue
 Scrotal
Excl.:
fissured tongue, congenital (Q38.3)
K14.6Glossodynia
Glossopyrosis
Painful tongue
K14.8Other diseases of tongue
 Atrophy
 Crenated
 (of) tongue
 Enlargement
 Hypertrophy
K14.9Disease of tongue, unspecified
Glossopathy NO