건강보험 심사청구

건강보험요양급여비용의 내역 ················································································· 1
보건복지부 고시 제2019-214호 ·············································································· 1

제1편 행위급여·비급여목록 및 급여 상대가치점수 ········································································ 3
제1부 행위 급여 일반원칙 ··············································································································· 4
I. 일반기준 ······························································································································ 4
II. 요양기관 종별가산율 ········································································································· 6
III. 차등수가 ···························································································································· 7
IV. 예외규정 ···························································································································· 8
제2부 행위 급여 목록·상대 가치점수 및 산정지침 ····························································· 10
제1장 기본진료료 ················································································································ 10
산정지침 ··················································································································· 10
제2장 검사료 ······················································································································· 51
산정지침 ··················································································································· 51
해당검사 분류항목 ··································································································· 52
제1절 검체 검사료 ···································································································· 53
[일반진단검사] ······························································································ 54
[혈액질환검사] ······························································································ 56
[수혈검사] ····································································································· 57
[일반화학검사] ······························································································ 57
[내분비진단검사] ·························································································· 59
[심뇌혈관질환검사] ······················································································· 61
[종양검사] ····································································································· 61
[대사검사] ····································································································· 62
[약물⋅중독검사] ·························································································· 62
[임신관련 검사] ···························································································· 64
[감염검사] ····································································································· 64
[면역검사] ····································································································· 69
제2절 병리 검사료 ······························································································ 70
[조직병리검사] ························································································· 70
[세포병리검사] ························································································· 70
[특수병리검사] ························································································· 71
[사람유전자 분자유전검사] ······································································ 72
제3절 기능 검사료 ··································································································· 72
[호흡기 기능검사] ························································································· 72
[신경계 기능검사] ···················································································· 73
[평형 및 창각 기능검사] ·········································································· 75
[신장 및 비뇨기검사] ··············································································· 76
[시기능검사] ···························································································· 77
[내분비 기능검사] ···················································································· 78
[소화기 기능검사] ···················································································· 79
[알레르기 기능검사] ················································································ 79
[순환기 기능검사] ···················································································· 80
[생식, 임신 및 분만] ··············································································· 80
[핵의학 기능검사] ···················································································· 81
제4절 내시경, 천자 및 생검료 ············································································ 81
[내시경] ··································································································· 81
[천자] ······································································································· 83
[일반생검] ································································································ 83
제5절 초음파 검사료 ·························································································· 84
[기본 초음파] ··························································································· 84
[진단 초음파] ··························································································· 84
[유도 초음파] ··························································································· 87
[특수 초음파] ··························································································· 88
제3장 영상진단 및 방사선치료료 ··················································································· 91
산정지침 ············································································································· 91
기본원칙 ············································································································· 92
전산화단층영상진단(CT)의 급여기준 ·································································· 93
자기공명영상진단(MRI)의 급여기준 ···································································· 93
F-18 FDG 양전자방출단층촬영(F-18 FDG-PETI)의 급여기준 ··························· 98
I-123 FP-CIT & FP-CIT 뇌 단일광자단층촬영의 급여기준 ······························ 99
제1절 방사선단순영상진단료 ············································································· 100
제2절 방사선특수영상진단료 ············································································ 106
[소화기계] ······························································································ 107
[중추신경계] ·························································································· 107
[비뇨생식기계] ······················································································· 107
[기타 부위] ···························································································· 108
[전산화 단층영상진단] ··········································································· 108
[자기공명영상진단] ················································································ 108
[혈관조영촬영] ······················································································· 110
제3절 핵의학영상진단 및 골밀도검사료 ··························································· 110
제4절 방사선 치료료 ························································································ 114
[방사선 모의치료 및 치료계획] ······························································ 114
[방사선 치료] ························································································· 107
제4장 투약 및 조제료 ·································································································· 118
산정지침 ··········································································································· 118
[조제료] ································································································· 118
제5장 주사료 ··············································································································· 122
산정지침 ··········································································································· 122
제1절 주사료 ····································································································· 122
제2절 채혈 및 수혈료 ······················································································· 126
제6장 마취료 ··············································································································· 132
산정지침 ··········································································································· 132
제1절 마취료 ···································································································· 133
제2절 치과마취료 ····························································································· 135
제3절 신경차단술료 ·························································································· 135
제4절 신경파괴술료 ·························································································· 137
제7장 이학요법료 ········································································································ 140
제1절 기본물리치료 ·························································································· 140
제2절 단순재활치료료 ······················································································ 141
제3절 전문재활치료료 ······················································································ 142
제4절 기타 이학요법료 ····················································································· 144
제8장 정신요법료 ········································································································ 146
산정지침 ··········································································································· 146
제9장 처치 및 수술료 등 ····························································································· 150
제1절 처치 및 수술료 ······················································································ 150
산정지침 ··········································································································· 150
[기본 처치] ···························································································· 163
[피부 및 연부조직] ················································································ 166
[근골] ···································································································· 168
[코] ········································································································ 174
[후두] ···································································································· 174
[기관, 기관지 및 폐] ············································································· 175
[흉곽] ···································································································· 175
[순환기] ································································································· 175
[비장 및 림프절] ···················································································· 176
[입, 이하선] ··························································································· 176
[인두 및 편도] ······················································································· 177
[식도] ···································································································· 178
[복막 및 후복막] ···················································································· 178
[위] ········································································································ 178
[장, 장간막, 허니아] ·············································································· 180
[직장 및 항문] ······················································································· 182
[비뇨기] ································································································· 182
[남성 생식기] ························································································· 184
[여성 생식기, 임신과 분만] ··································································· 185
[내분비기] ······························································································ 191
[신경] ···································································································· 191
[감각기] ································································································· 192
[응급처치] ······························································································ 198
[중재적 방사선시술] ·············································································· 199
[투석] ···································································································· 200
[유방] ···································································································· 201
[간] ········································································································ 202
[담낭 및 담도] ······················································································· 202
[췌장] ···································································································· 202
[소화기 내시경하 시술] ········································································· 203
[장기이식] ······························································································ 204
[기타] ···································································································· 205
제2절 캐스트료 ································································································· 207
산정지침 ··········································································································· 207
[캐스트 기술료] ····················································································· 207
부위별 석고붕대 사용기준 ················································································ 207
부위별 합성 캐스트 사용기준 ··········································································· 207
제10장 치과 처치 · 수술료 ························································································· 211
산정지침 ········································································································· 211
제1절 치아질환 처치 ························································································ 213
제2절 수술 후 처치, 치주조직의 처치 등 ························································· 217
제3절 구강악안면 수술 ····················································································· 221
제4절 치주질환 수술 ························································································ 227
제11장 조산료 ··············································································································· 231
산정지침 ········································································································· 231
제12장 보건기관의 진료수가 ························································································· 232
산정지침 ········································································································· 232
제13장 한방 검사료(檢査料) ························································································· 235
산정지침 ········································································································· 235
제14장 한방 시술(施術) 및 처치료(處置料) ·································································· 236
산정지침 ········································································································· 236
제1절 시술료(施術料) ······················································································· 237
제2절 처치료(處置料) ······················································································· 239
제3절 한방 정신요법료(精神療法料) ································································ 240
제15장 약국 약제비 ······································································································· 242
산정지침 ········································································································· 242
제16장 전혈 및 혈액성분제제료 ···················································································· 245
산정지침 ········································································································· 245
제17장 입원환자 식대 ··································································································· 248
산정지침 ········································································································· 248
제18장 치과의 보철료 ······································································································ 253
산정지침 ········································································································· 253
제19장 응급의료수가 ····································································································· 258
제1절 응급 기본진료료 ····················································································· 258
제2절 응급의료행위 ·························································································· 262
제3절 권역외상센터 응급의료행위 ···································································· 263
제3부 행위 비급여 목록 ········································································································ 287
제1장 기본진료료 ········································································································ 287
제2장 검사료 ··············································································································· 291
제1절 검체 검사료 ···························································································· 291
제2절 병리 검사료 ···························································································· 293
제3절 기능 검사료 ···························································································· 294
제4절 내시경, 천자 및 생검료 ·········································································· 297
제5절 초음파 검사료 ························································································ 297
제3장 영상진단 및 방사선 치료료 ··············································································· 297
제5장 주사료 ··············································································································· 298
제7장 이학요법료 ········································································································ 298
제8장 정신요법료 ········································································································ 299
제9장 처치 및 수수료 등 ····························································································· 299
제10장 치과처치⋅수술료 ···························································································· 302
제13장 한방검사료(檢査料) ·························································································· 302
제14장 한방 시술 및 처치료 ························································································ 303

제2편 질병군 급여·비급여 목록 및 급여 상대가치점수 ···························································· 307
제1부 질병군 급여 일반원칙 ································································································· 308
제2부 질병군 급여 목록 ········································································································ 312
제1장 안 과 ················································································································· 312
제2장 이비인후과 ········································································································ 314
제3장 외 과 ················································································································ 315
제4장 산부인과 ············································································································ 319
제3부 질병군 급여 목록 ········································································································ 330
제4부 질병군 비급여 일반원칙 및 비급여 목록 ·································································· 332

부 록 ·············································································································································· 337
|요양급여비용 청구방법, 심사청구⋅명세서서식 및 작성요령| ·················································· 338
|요양기관종별 요양급여비용 청구체계| ···················································································· 351
|별지서식| ······································································································································· 353
|별첨| ·············································································································································· 359