DAFTAR TINDAKAN TINDAKAN

YANG PERLU INFORMED CONSENT

Sesuai Undang Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa
tindakan kedokteran dan kedokteran gigi yang

wajib

diberikan informed

consent. Tindakan tersebut yaitu :

A. Semua Tindakan
Invasive

Pembedahan dan Tindakan

B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam )
C. Semua Tindakan Pemberian Produk Darah & Komponen Darah
D. Semua Tindakan/PENGOBATAN Yang Berisiko Tinggi.
A. Tindakan Pembedahan dan Tindakan Invasiveyang memerlukan
informed consentantara lain:

NO
1

KSM/INSTALAS
I/UNIT
KSM Bedah
1
Saraf
2

TINDAKAN
Amygdala Hypocampectomy (Epilepsi)
Anterior Temporomesial Lobectomi (Epilepsi)

Biopsi Saraf Tepi/Otot

Blok Saraf Perifer I

Cingulotomy (Psichiatric)

Corpus Callosotomi (Epilepsi)

Debrimen Rekonstruksi Vulnus Kulit Kepala

Dekompresi Saraf Tepi

Dekompresi Tulang Durameter

10

Dekortikasi Sinus Frontalis

11

Denervasi Facet

12

DREZ Lession (Pain)

13

Eksisi Ensefalokel/Mielokel

14

Eksisi Kista Jinak Kulit Kepala

15

Eksisi Osteoma/Osteositosis

16

Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan

17

Dura

18
NO

Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan

KSM/INSTALAS
I/UNIT

TINDAKAN
19

Dura

20

Extirpasi Tumor Jinak Saraf Kulit Kepala

21

Fusi Stabilisasi Corpus Vertebra

22

Graft/Transposisi Saraf Tepi

23

Hemisferektomi (Epilepsi)

24

Hemisferoktomi (Epilepsi)

25

Injeksi saraf perifer (dengan radiofrekuensi)

26

Injeksi spinal (Pain)

Insersi Elektrode Intradural
(Epilepsi,movement,psikiatrik)

27
28

Kordotomi Perkutan

29

Kordotomi Servikal Open (Pain)

30

Kordotomi Servikal Perkutan (Pain)

31

Kranioplasti dua sisi

32

Kranioplasti satu sisi

33

Kraniotomi Biopsi otak

34

Laminektomi Eksisi Tumor Spinal

35

Laminoplasti

36

Laminotomi Biopsi Mielum

37

Laminotomi Diskektomi HNP/Stenosis>1 level

38

Laminotomi Diskektomi HNP/Stenosis 1 level

39

Lesionectomy (Epilepsi)

40

Lobektomi (Epilepsi)

41

Mesencephalectomy (Pain)

42

Mikrodisekktomi HNP

43

MVD (Microvascular Decompression)

44

Neurektomi/Neurolise

45

Neuroendoskopi (Otak,Spinal)

46

Neuroplasti

47

Omaya drain

NO

KSM/INSTALAS
I/UNIT

TINDAKAN
48

Pallidotomi (movement Disorder)

49

Paravertebral Blok Perkutan

50

Pemasangan Traksi Servikal

51

Penjahitan Saraf Tepi

52

Punksi Cairan Otak

53

Reseksi Extra-Temporal (Epilepsi)

54

Revisi VP Shunt

55

Rhizotomi Selektif (Spastisitas)

56

Rhizotomy (Pain)

57

Selective Nerve Root Block

58

Selective Thalamotomi (Movement Disorder)

59

Simpatektomi Open (Pain)

60

Simpatektomi Perkutan

61

SLTH

62

Stereotactic Ablative Procedure (Psichiatric)

63

Subthalamotomy (Movement Disorder)

64

Suturektomi Kraniostenosis

65

Thalomotomy (Pain)

68

Transposisi kraniostenosis,dengan orbital

advancement
Transposisi kraniostenosis,tanpa orbital
advancement
Trepanasi Cedera Kepala (<4jam)

69

Trepanasi Cedera Kepala (>4jam)

70

Trepanasi CVA Bleeding

71

Trepanasi kelainan Saraf Kranial

72

Trepanasi Kelainan Vascular Otak

73

Trepanasi Tumor Otak

74

VA Shunt

75

VP Shunt Multiple

66
67

76

NO
2.

VP Shunt Satu Sisi

KSM/INSTALAS
I/UNIT
KSM Bedah
Kepala Leher

TINDAKAN
1

Aff Arch Barr

Aff Arch Barr dan suspensi maksila

Biopsy Insisional dengan anastesi lokal

Deseksi submandibula

Diseksi leher radikal/radikal neck dissection

Eksisi gld submandibula

Eksisi higroma leher

Eksisi kista tiroglosus

Eksisi luas tumor ganas bibir dengan rekontruksi

10

flap lokal

11

Eksisi luas tumor ganas dengan rekontruksi flap jauh

12

Eksisi luas tumor ganas kulit dengan rekontruksi

13

flap lokal

14

Eksisi luas tumor ganas rongga mulut dengan

15

rekontruksi flap lokal

16

Eksisi parsial+marsupialisasi Ranula

17

Eksisi tumor ganas kulit dengan flap local atau graft

18

kulit

19

Eksisi tumor ganas kulit dengan flap local jauh

20

Eksisi tumor ganas kulit tanpa rekontruksi

21

Eksisi tumor jinak dengan anastesi lokal

22

Ekskokleasi epulis

23

Ekskokleasi kista folikuler

24

Ekskokleasi kista radikuler

Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran
<2cm

25
26
27

Ekstirpasi kista dermoid

Endoscopic thyroidectomy

28

Fiksasi interna fraktur maksilofasial 1-2 tempat

patahan

No

3.

KSM/INSTALASI
/UNIT

TINDAKAN

29

Fiksasi interna fraktur nasal

30

Fiksasi interna pan-facial

31

Hemiglosektomi

32

Insisi abses dengan anastesi lokal

33

Insisi flegmon dasar mulut

34

Internal Fiksasi fraktur condylus mandibula

35

Internal Fiksasi fraktur maksilofasial 3-4 tempat

36

patahan

37

Internal fiksasi fraktur maksilofasial 5 tempat patahan

38

atau lebih

39

Laringectomi

KSM

Adenotonsilektomi

Bedah THT-KL

Anthrostomi+Sinuskopi

BLM Simple (Kista,Polip,Nodul,Granulasi)

Biopsi Tumor

Bronkoskopi Rigid

BLM Advance (Stenosis, Subjektif/Trakea, Papiloma

Laring/Trakea)

Cald Well Luc

Cochlear Implant/Implan Baha

Dekompresi Nervus Fasialis

10

DCR

11

Eksisi Ekstostosis

12

Ekstirpasi Kista Branchial

13

Ekstirpasi Kista Ductus Tiroglosus

14

Ekstraksi granulasi MAE/Kolesteatosis

15

Ekstraksi Polip

16

Esofagoskopi Rigid & Fleksibel

NO

17

Ethmoidektomi (Intranasal)

18

Ekstraksi Korpus Alienum Kavum Nasi

KSM/INSTALASI/
UNIT

TINDAKAN
19

Ekstraksi Korpus Alienum Kavum Nasi Endoskopi

20

Ekstirpasi Fistel Pre Aurikuler

21

Ekstraksi Korpus Alienum MAE

22

Ekstirpasi Kelenjar Sub Mandibula

23

Ekstirpasi Angiofibroma Nasofaring

24

Eksplorasi Abses Parafaringeal

25

Ekstirpasi Tumor Jinak Kepala & Leher (Aterom Lipoma)

26

Faringotomi

27

FESS

28

FESS Advance

29

Frontal Sinusotomi

30

Fore Head Flap

31

Fronto Etmoidektomi (Ekstranasal)

32

FOL

33

Glosektomi Total/Parsial

34

Glosektomi Total/Hemiglosektomi+RND

35

Hemiglosektomi+SOHND

36

Insisi Abses Leher Dalam

37

Inversi Grommet

38

Insisi Perikondritis

39

Irigasi Sinus Maksila

40

Insisi Abses Peritonsil

41

Imunoterapi

42

Konka Reduksi

43

Kaustik Konka Inferior

44

Laringektomi

45

Laringektomi+ND

46

Laringo Fisur/Eksplorasi Laring

47

Ligasi A. Karotis Eksternal

48

NO

Laringoskopi Rigid

KSM/INSTALASI/
UNIT

TINDAKAN

49

Laringoskopi Fleksible

50

Laringoskopi Direkta

51

Maksilektomi Total+Rekontruksi

52

Mastoidektomi Radikal

53

Mini FESS

54

Myocutaneus Flap (Pectoral Mayor)

55

Myringoplasty/Timpaniplasti

56

Mandibulekromi

57

Neurektomi Saraf Vidian

58

Osteotomi+Septum koreksi

68

Rekontruksi Fraktur Maksila Multiple

69

Rekontruksi Fraktur Maksila Sederhana

70

Rhinoplasti

71

Rinotomi Lateral+Maksilektomi Medial

72

Rekontruksi Laring Trakea

73

Reposisi Fraktur Os Nasal

74

Reposisi & Fiksasi Fraktur Mandibula

75

Septum Koreksi+Konkotomi

76

Stapedektomi

77

Skin Pricle Test

78

Tiroidektomi Sub-Total

79

Tonsilektomi/Adenoidektomi

80

Tracheostomi

81

Turbinektomi

82

Tiroidektomi Total+ND

83

Temporal Bone Resection

84

Terapi Wicara pada Anak-Anak dan dewasa

85

Terapi Wicara Tuna Laring

NO
4

KSM/INSTALAS
I/UNIT

TINDAKAN

KSM Orthopedi
Dan

Abdominopelvic amputation

Achillotenotomy

Traumatologi

Adductor tenotomy of hip

Advancement of tendon

Advancement of tendon of hand

Amputation above knee

15

Amputation and disarticulation of finger- general

anaesthesia
Amputation and disarticulation of finger -local
anaesthesia
Amputation and disarticulation of thumb-general
anaesthesia
Amputation and disarticulation of finger- general
anaesthesia
Amputation and disarticulation of finger -local
anaesthesia
Amputation and disarticulation of thumb-general
anaesthesia
Amputation and disarticulation of thumb-local
anaesthesia
Amputation of ankle through malleoli of tibia and
fibula
Amputation of toe-general anaesthesia

16

Amputation of toe-local anaesthesia

17

Amputation through foot

18

Amputation through forearm

7
8
9
10
11
12
13
14

21

Amputation through hand, Amputation through

carpals
Amputation through humerus, Upper arm
amputation
Amputation, not otherwise specified

22

Ankle fusion

23

Application of external fixator device

24

Application of external fixator device, monoplanar

system
Application of external fixator device, ring system

19
20

25

NO

26

Application of hybrid external fixator device

27

Arthrocentesis

KSM/INSTALAS
I/UNIT

TINDAKAN
28

Arthrodesis of elbow

29

Arthrodesis of hip

30

Arthrodesis of knee

31

Arthrodesis of other specified joints

32

Arthrodesis of shoulder

33

Arthrodesis of unspecified joint

34
35
36
37
38

Arthroplasty of carpocarpal or carpometacarpal joint

with implant
Arthroplasty of carpocarpal or carpometacarpal joint
without implant
Arthroplasty of metacarpophalangeal and
interphalangeal joint with implant
Arthroplasty of metacarpophalangeal and
interphalangeal joint without implant
Arthroscopy

40

Arthrotomy for removal of prosthesis without

replacement
Aspiration of bursa

41

Aspiration of bursa of hand

42

Aspiration of other soft tissue

43

Aspiration of other soft tissue of hand

44

Atlas-axis spinal fusion

45

Biopsy of bone

46

Biopsy of joint structure

47

Biopsy of spinal cord or spinal meninges

48

Bone graft
Bone marrow or hematopoietic stem cell transplant
(all procedures included in this class

39

49
50
51
52

Bunionectomy with soft tissue correction and

arthrodesis
Bunionectomy with soft tissue correction and
osteotomy of the first metatarsal
Bursectomy

NO

53

Bursectomy of hand

54

Bursotomy

KSM/INSTALAS
I/UNIT

TINDAKAN
55

Bursotomy of hand

56

Carporadial fusion

57

Closed reduction of dislocation -General

anaesthesia

58

Closed reduction of dislocation of ankle

59

Closed reduction of dislocation of elbow

60
61

Closed reduction of dislocation of foot and toegeneral anaesthesia

Closed reduction of dislocation of foot and toe-local
anaesthesia

62

Closed reduction of dislocation of hand and fingergeneral anaesthesia

63

Closed reduction of dislocation of hand and fingerlocal anaesthesia

64

Closed reduction of dislocation of hip

65

Closed reduction of dislocation of knee

66

Closed reduction of dislocation of other specified

sites-general anaesthesia

67

Closed reduction of dislocation of other specified

sites-local anaesthesia

68

Closed reduction of dislocation of other specified

sites-local anaesthesia

69

Closed reduction of dislocation of shoulder

70

Closed reduction of dislocation of wrist

71

Closed reduction of dislocation-Local anaesthesia

72

Closed reduction of fracture with internal fixation Carpal and metacarpal

1
0

10

1
1

73
74

NO

Closed reduction of fracture with internal fixation Femur (Including : MIPO, interlocking nail, TEN)
Closed reduction of fracture with internal fixation Humerus (including : Interlocking nail, TEN, MIPO)

KSM/INSTALAS
I/UNIT

TINDAKAN

84

Closed reduction of fracture with internal fixation Intrarticular Major Bone

Closed reduction of fracture with internal fixation Phalang of foot
Closed reduction of fracture with internal fixation Phalang of hand
Closed reduction of fracture with internal fixation Radius and ulna (MIPO, TEN)
Closed reduction of fracture with internal fixation Tarsal and metatarsal
Excision of bone for graft

85

Excision of intervertebral disc

86

Excision of lesion of muscle

87

Excision of lesion of muscle of hand

88

Excision of lesion of other soft tissue

75
76
77
78
79

91

Dorsal and dorsolumbar fusion of the anterior

column, anterior technique
Dorsal and dorsolumbar fusion of the posterior
column, posterior technique
Excision of bone for graft

92

Excision of intervertebral disc

93

Excision of lesion of muscle

94

Excision of lesion of muscle of hand

95

Excision of lesion of other soft tissue

96

Excision of lesion of tendon sheath

Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-Local
Anaestesi

89
90

97
98
99

Excision of muscle or fascia for graft

100

Excision of muscle or fascia of hand for graft

111
1

101

NO

Excision of other lesion of soft tissue of hand

KSM/INSTALAS
I/UNIT

TINDAKAN
102 Excision of semilunar cartilage of knee
103 Excision of tendon for graft
104 Excision of tendon of hand for graft
Excision or correction of bunionette, That with
105 osteotomy
Excision or destruction of intervertebral disc,
106 unspecified
107 Exploration of tendon sheath
108 Exploration of tendon sheath of hand
109 Exploratory thoracotomy
110 Fasciotomy
111 Fasciotomy of hand
112 Finger reattachment
113 Five-in-one repair of knee
114 Foot reattachment
115 Forearm, wrist, or hand reattachment
116 Fusion or refusion of 2-3 vertebrae
117 Fusion or refusion of 4- 8 vertebrae
118 Fusion or refusion of 9 or more vertebrae
119 Graft of muscle or fascia
120 Hip bearing surface, ceramic-on-ceramic
Hip bearing surface, ceramic-on-polyethylene, Hip
121 bearing surface, oxidized zirconium-on-polyethylene
122 Hip bearing surface, metal-on-metal
123 Hip bearing surface, metal-on-polyethylene
Implantation of internal limb lengthening device with
124 kinetic distraction
Implantation of other internal limb lengthening
125 device
Implantation or replacement of peripheral
126 neurostimulator lead (s)

12

Implantation or replacement of spinal

127 neurostimulator lead(s)
128 Incision and drainage of palmar or thenar space
Injection of anesthetic into peripheral nerve for
129 analgesia

NO

TINDAKAN

KSM/INSTALASI
/UNIT

130

Injection of anesthetic into spinal canal for analgesia

131

Injection of destructive agent into spinal canal

132
133

Injection of locally-acting therapeutic substance into

other soft tissue
Injection of other agent into spinal canal, Intrathecal
injection of steroid, Subarachnoid perfusion of
refrigerated saline

134

Injection of therapeutic substance into bursa

135

Injection of therapeutic substance into bursa of hand

136

Injection of therapeutic substance into joint or

ligament
Injection of therapeutic substance into tendon

137
138
139
140

141

Injection of therapeutic substance into tendon of

hand
Insertion of bone growth stimulator
Insertion of bone void filler
Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances, Insertion of
catheter into epidural, subarachnoid, or subdural
space of spine with intermittent or continuous
infusion of drug (with creation of any reservoir)

142

Insertion of interbody spinal fusion device

143

Insertion of other spinal devices

144

Insertion of partial spinal disc prosthesis, cervical

148

Insertion of partial spinal disc prosthesis,

lumbosacral
Insertion of recombinant bone morphogenetic
protein
Insertion of spinal disc prosthesis, not otherwise
specified, Replacement of spinal disc, NOS
Insertion of spinal disc prosthesis, thoracic

149

Insertion of sternal fixation device with rigid plates

150

Insertion of total spinal disc prosthesis, cervical

145
146
147

131
3

NO

152

Insertion of total spinal disc prosthesis, lumbosacral

153

Insertion or replacement of (cement) spacer

154

Insertion or replacement of facet replacement

device(s)

KSM/INSTALAS
I/UNIT

TINDAKAN
Insertion or replacement of interspinous process
device(s)
Insertion or replacement of pedicle-based dynamic
156
stabilization device(s)
155

157 Insertion or replacement of skeletal muscle stimulator

158
Internal fixation of bone without fracture reduction
159
Interphalangeal fusion
160 Interthoracoscapular amputation, Forequarter
amputation
161 Intra-operative neurophysiologic monitoring Neuromonitoring
162
Intervertebral chemonucleolysis
163
Limb lengthening procedures
164
Limb shortening procedures
165
Local excision of lesion or tissue of bone
166
Lower leg or ankle reattachment
167
Lower limb amputation, not otherwise specified
168 Lumbar and lumbosacral fusion of the anterior
column, anterior technique
169 Lumbar and lumbosacral fusion of the anterior
column, posterior technique
170 Lumbar and lumbosacral fusion of the posterior
column, posterior technique
171
Lysis of adhesions of hand
172 Lysis of adhesions of muscle, tendon, fascia, and
bursa
173
Lysis of adhesions of spinal cord and nerve roots
174
Metacarpocarpal fusion
175
Metacarpophalangeal fusion
176
Metatarsophalangeal fusion
177
Midtarsal fusion
178
Muscle transfer or transplantation

141
4

14

151
5

179
180
181

NO

Myotomy
Myotomy of hand
Neurectasis

KSM/INSTALASI/
UNIT

TINDAKAN
182

Open biopsy of cranial or peripheral nerve or ganglion

183

Open biopsy of soft tissue

184
185
186
187

Open reduction of dislocation of ankle - Neglected

dislocation
Open reduction of dislocation of elbow -Fresh dislocation
Open reduction of dislocation of hand and finger -Fresh
dislocation
Open reduction of dislocation of hip - Fresh dislocation

190

Open reduction of dislocation of hip - Neglected

dislocation
Open reduction of dislocation of knee - Neglected
dislocation
Open reduction of dislocation of knee -Fresh dislocation

191

Open reduction of dislocation of other specified sites

188
189

192
193
194
195
196
197
198
199
200
201
202
203

Open reduction of dislocation of shoulder -Fresh

dislocation
Open reduction of dislocation of shoulder -Neglected
dislocation
Open reduction of dislocation of unspecified site-Fresh
dislocation
Open reduction of dislocation of unspecified siteNeglected dislocation
Open reduction of dislocation of wrist -Fresh dislocation
Open reduction of fracture with internal fixation- radius
and ulna-Simple fracture
Open reduction of fracture with internal fixationunspecified site (Periarticular Major Bone )
Open reduction of fracture with internal fixation-carpals
and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
and metacarpals - simple implants (K-wire)
Hand NOS -implant sederhana (K-wire)
Open reduction of fracture with internal fixation-femurComminutive or Segmental
Open reduction of fracture with internal fixation-femurSimple fracture

161
6

NO

KSM/INSTALAS
I/UNIT

TINDAKAN
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227

Open reduction of fracture with internal fixationhumerus - Simple fracture

Open reduction of fracture with internal fixationhumerus - Comminutive or Segmental
Open reduction of fracture with internal fixationother specified bone (Intraartikular Major Bone )
Open reduction of fracture with internal fixationphalanges of foot - simple implants (K-wire)
Open reduction of fracture with internal fixationphalanges of foot-Plate & Screws
Open reduction of fracture with internal fixationphalanges of hand- Plate & Screws
Open reduction of fracture with internal fixationphalanges of hand- simple implants
Open reduction of fracture with internal fixationtarsals and metatarsals- Plate & Screws
Open reduction of fracture with internal fixationtarsals and metatarsals- simple implants
Open reduction of fracture with internal fixation-tibia
and fibula -Simple fracture
Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental
Open reduction of fracture without internal fixation
Open reduction of separated epiphysis
Osteoclasis (correction of bone deformity)
Other
Other (peripheral) vascular shunt or bypass
Other amputation below knee
Other anastomosis of cranial or peripheral nerve
Other and unspecified repair of the anulus fibrosus
Other arthrotomy
Other bunionectomy
Other bunionectomy with soft tissue correction
Other cervical fusion of the anterior column, anterior
technique
Other cervical fusion of the posterior column,
posterior technique

171
7

16

181
8

228
229
230

NO

Other change in hand muscle or tendon length

Other change in muscle or tendon length
Other destruction of intervertebral disc

KSM/INSTALAS
I/UNIT

TINDAKAN
231

Other diagnostic procedures on joint structures

Other diagnostic procedures on muscle, tendon, fascia, and

232

bursa, including that of hand

233

Other division of bone

234

Other excision of joint

235

Other excision of soft tissue

236

Other excision of soft tissue of hand

237

Other excision or avulsion of cranial and peripheral nerves

238

Other excision, fusion and repair of toes

Other exploration and decompression of spinal canal,

239

Decompression

240

Other fasciectomy

241

Other fasciectomy of hand

242

Other fusion of foot

243

Other hand muscle transfer or transplantation

244

Other hand muscle transposition

245

Other hand tendon transfer or transplantation

246

Other hand tendon transposition

247

Other incision of bone without division

248

Other incision of soft tissue

249

Other incision of soft tissue of hand

Other injection of locally-acting therapeutic substance into

250

soft tissue of hand

251

Other local excision or destruction of lesion of joint

252

Other muscle transposition

253

Other myectomy

254

Other myectomy of hand

255

Other neuroplasty

256

Other operations on muscle, tendon, fascia, and bursa

257

Other operations on muscle, tendon, fascia, and bursa,

191
9

Suture of bursa
258

NO

Other partial ostectomy (including : Bone curretage,

marginal resection/excision)

KSM/INSTALAS
I/UNIT

TINDAKAN
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297

Other peripheral nerve or ganglion decompression or

lysis of adhesions Peripheral nerve neurolysis NOS
Other plastic operations on fascia
Other plastic operations on hand
Other plastic operations on muscle
Other repair of ankle
Other repair of elbow
Other repair of hand, fingers and wrist
Other repair of joint
Other repair of knee
Other repair of shoulder
Other repair of the collateral ligaments
Other repair of the cruciate ligaments
Other repair or plastic operations on bone
Other suture of flexor tendon of hand
Other suture of muscle or fascia
Other suture of other tendon of hand
Other suture of tendon
Other tendon transposition
Other tenodesis of hand
Other tenonectomy
Other tenonectomy of hand
Other tenoplasty of hand
Other tenotomy
Other total shoulder replacement
Partial hip replacement
Partial shoulder replacement
Patellar stabilization
Percutaneous denervation of facet
Percutaneous vertebral augmentation
Percutaneous vertebroplasty
Peripheral nerve injection, not otherwise specified
Plastic operation on hand with graft of muscle or fascia
Plastic operation on hand with other graft or implant
Pollicization operation carrying over nerves and blood
supply
Quadricepsplasty
Reattachment of muscle
Reattachment of muscle of hand
Reattachment of tendon
Reattachment of tendon of hand

202
0

18

212
1

298
299

NO

Refusion of atlas-axis spine

Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique

KSM/INSTALAS
I/UNIT

TINDAKAN
300 Refusion of dorsal and dorsolumbar spine, posterior
column, posterior technique
301 Refusion of lumbar and lumbosacral spine, anterior
column, anterior technique
302 Refusion of lumbar and lumbosacral spine, anterior
column, posterior technique
303 Refusion of lumbar and lumbosacral spine, posterior
column, posterior technique
304 Refusion of other cervical spine, anterior column,
anterior technique
305 Refusion of other cervical spine, posterior column,
posterior technique
306 Refusion of spine, not elsewhere classified
307 Refusion of spine, not otherwise specified
308 Release of carpal tunnel
309 Release of clubfoot, not elsewhere classified
310 Release of tarsal tunnel
311 Removal of (cement) spacer
312 Removal of bone growth stimulator (invasive)
313 Removal of foreign body from spinal canal
314 Removal of implanted devices from bone - carpals
and metacarpals-Plate & screw
315 Removal of implanted devices from bone - carpals
and metacarpals-simple implants (K-wire)
316 Removal of implanted devices from bone - External
fixator device (invasive) (
317 Removal of implanted devices from bone - femur
318 Removal of implanted devices from bone - humerus
319 Removal of implanted devices from bone - radius and
ulna
320 Removal of implanted devices from bone - scapula,
clavicle, and thorax (ribs and sternum)
321 Removal of implanted devices from bone unspecified site (Phalanges (of foot) (of hand)) - Plate
& Screw
322 Removal of implanted devices from bone unspecified site (Phalanges (of foot) (of hand)) simple implants (K-wire)
323 Removal of implanted devices from bone -patella
324 Removal of implanted devices from bone- tarsals and
metatarsals- simple implants (K-wire)
325 Removal of implanted devices from bone- tibia and
fibula

222
2

326 Removal of implanted devices from bone-other

(Pelvic bone and Vertebraae)

NO

KSM/INSTAL
ASI/UNIT

TINDAKAN
327

352
353
354
355
356
357

Removal of implanted devices from bone-tarsals and

metatarsals - Plate & Screw
Removal of internal limb lengthening device
Removal of pedicle screw(s) used in spinal fusion
Removal of peripheral neurostimulator lead(s)
Removal of skeletal muscle stimulator
Removal of spinal neurostimulator lead(s)
Reopening of laminectomy site
Repair of claw toe
Repair of cleft hand
Repair of hammer toe
Repair of hip, not elsewhere classified
Repair of macrodactyly
Repair of mallet finger
Repair of old traumatic injury of cranial and peripheral
nerves
Repair of recurrent dislocation of shoulder
Repair of the anulus fibrosus with graft or prosthesis
Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae,
Removal of bony spicules from spinal canal
Replacement of joint of foot and toe
Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
Resurfacing hip, partial, femoral head
Revision of total knee replacement, tibial insert (liner),
Replacement of tibial insert(liner)
Revision or replacement of artificial spinal disc
prosthesis, cervical
Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
Revision or replacement of artificial spinal disc
prosthesis, thoracic
Rotator cuff repair
Separation of equal conjoined twins
Separation of unequal conjoined twins
Sequestrectomy
Spinal fusion, not otherwise specified
Subtalar fusion

358

Subtalar joint arthroereisis

328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351

232
3

20

242
4

NO

359

Suture of Artery

360

Suture of capsule or ligament of ankle and foot

KSM/INSTALASI
/UNIT

TINDAKAN
361

Suture of capsule or ligament of other lower

extremity

362

Suture of capsule or ligament of upper extremity

363

Suture of cranial and peripheral nerves

364

Suture of muscle or fascia of hand

365

Suture of tendon sheath

366

Suture of tendon sheath of hand

367

Suture of Vein

368

Synovectomy

369

Tarsometatarsal fusion

370

Tendon graft

371

Tendon pulley reconstruction

372

Tendon pulley reconstruction

373

Tendon transfer or transplantation

374

Tenotomy of hand

375

Thigh reattachment

376

Thumb reattachment

378

Toe reattachment

379

Total ankle replacement

380

Total elbow replacement

381

Total ostectomy

382

Total wrist replacement

383

Transplant from cadaver

384

Transposition of cranial and peripheral nerves Nerve transplantation

389

Triad knee repair

390

Triple arthrodesis

391

Unspecified operation on bone injury

392
393
394

Upper arm reattachment

Upper limb amputation, not otherwise specified
Wedge osteotomy

21

NO

KSM/INSTALASI
/UNIT

KSM BEDAH
THORAKS
DAN
KARDIOVASKULAR

TINDAKAN
1
2
3
4
5
6
7
8
9
10
11

Biopsi Terbuka Bronkhus

Biopsi Terbuka Diafragma
Biopsi Terbuka Mediastinum
Biopsi Terbuka Paru
Biopsi Terbuka Pleura
Biopsi Terbuka Pleura dengan VATS
Biopsi Terbuka Tumor Dinding Thoraks
Debridement Mediastinum (Sternotomi)
Eksisi Pada Bronkhus
Eksisi Pada Paru (Lung Volume Reduction)
Eksisi Pada Paru dengan VATS
Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding
12 Dada
Eksisi Tumor Mediastinum (Thymoma, Teratoma,
13 Neurogenic dsb)
14 Ekstraksi Corpus Alienum di Regio Toraks
15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS
Evakuasi Efusi Pleura/Empyema secara Torakoskopik
16 (VATS)
17 Fiksasi Costae (Clipp, Wire) (diluar Clipp)
18 Fiksasi Sternum (Wire, Plate) (diluar wire/plate)
19 Lobektomi Parsial (Reseksi Paru segmental)
Lobektomi Parsial (Reseksi Paru segmental) dengan
20
VATS
21 Lumbal Simpatektomi
22 Mediastinostomy
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

Pemasangan thorak drain/water sealed drainage (WSD)

(diluar alat)
Pleural window (Eloeser Flap)
Pleurektomi
Pleurodesis (Pleurosklerosis)
Plikase Bulae / Bleb Emfisematous
Plikasi diafragma
Pneumonectomy
Pneumonectomy dengan VATS
Pulmonary Decortication
Pulmonary Decortication dengan VATS
Pulmonary Lobectomy/Bilobectomy
Pulmonary Lobectomy/Bilobectomy dengan VATS
Redo Torakotomi
Rekonstruksi Sternum&Dinding Dada
repair deformitas Pectus

22

38 Repair Fistula Bronkopleural

39 Repair Laserasi Diafragma

NO

TINDAKAN

KSM/INSTALASI
/UNIT
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75

Revisi Thoraks drain/water sealed drainage (WSD) (diluar

alat)
Thoracal Symphatectomy dengan Video Assissted
Thoracoscopic Surgery (VATS)
Thoracocentesis
Thymectomy
Thymectomy dengan VATS
Torakoplasti (Air Plumbage/Muscle Plumbage)
Torakotomi / sternotomi Eksplorasi
Torakotomi Eksplorasi pada Trauma jantung/Repair
Laserasi Jantung
Bedah Kardio (Jantung)
Aortic Valve Repair (AVR)
Aortic Valve Repair (AVR) dengan Bioprosthesis Valve
Aortic Valve Repair (AVR) dengan Mechanical Valve
Atrial septal Defect (ASD) Closure
Bidirectional Cavo-Pulmonary Shunt (BCPS)
Biopsi Jantung
Biopsi Perikardium
Blalock-Taussing Shunt (BT Shunt)
Coronary Artery Bypass Graft (CABG)
Eksisi Cardiac Myxoma
Fontan Operation (Atrium-Pulmonary Artery Conduit)
Internal Resusitasi/Cardiac Massage (Operasi Terbuka)
Ligasi Patent Ductus Arteriosus (PDA)
Mitral valve repair (MVr)
Mitral Valve Repair (MVR) dengan Bioprosthesis Valve
Mitral Valve Replacement (MVR) dengan Mechanical
Valve
Operasi Redo Open Heart (Valve Replacement)
Operasi Reopen oleh Karena sebab Perdarahan,
Tamponade Jantung
Pemasangan IABP
Pemasangan Pace Maker Permanen (diluar alat)
Pericardiocentesis
Perikardiektomi
Perikardiotomi/Pericardial Window
Pulmonal Valve Repair (PVR)
Pulmonal Valve Repair (PVR) dengan Bioprosthesis
Valve
Pulmonal Valve Repair (PVR) dengan Mechanical Valve
Pulmonary Artery Banding (PA)

23

NO

KSM/INSTALASI/
UNIT

TINDAKAN
76 Rastelli Procedure (right Ventricle-Pulonary Artery
Conduit)
77 Repair (Eksisi) Aneurisma Jantung
78 Repair Aorta Torakalis (38.34)
79 Repair Atrioventricular Septal Defect (35.54)
Repair Total Anomalous Pulmoanry Venous Connection
80 (TAPVC) (35.82)
81 Repair Transposition of Great Arteries (TGA) (35.84)
82 Repair Trunkus Arteriosus (35.83)
83 Revisi/Aff Pace Maker Permanen (diluar alat) (37.89)
84 Septostomi Terbuka Septum Atrium (35.41)
85 Total Koreksi Tetralogy of Fallot (TOF) (35.81)
86 Tricuspid Valve Repair (TVR) (35.14)
Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve
87 (35.27)
Tricuspid Valve Repair (TVR) dengan Mechanical Valve
88 (35.28)
89 Ventricle Septal Defect (VSD) Closure (35.5)
90 Amputasi Above Knee (AK) (84.17)
91 Amputasi Below Knee (BK) (84.14)
92 Arterial Pungsi, Kanulasi, Sectie (38.91)
93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42)
94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27)
95 Bedah Varises Insisi Babcock (38.5)
96 Biopsi Pembuluh Darah (Perifer) (38.21)
97 Debriment-Nekrotomi Luka Gangren (86.22)
98 Disartikulasi Sendi Ekstremitas (84.13)

Eksisi Biopsi
Tumor
Pembuluh
Darah

Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)

Eksplorasi Vaskular (Trauma/Non trauma)

3
4

Embolektomi/Trombektomi Aorta
Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal
Embolektomi/Trombektomi Pembuluh Darah Arteri
Ekstremitas Bawah
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
Atas (diluar alat)
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
Bawah(diluar alat)
Embolektomi/Trombektomi Pembuluh Darah Regio servikal
(Karotis, Jugular) (diluar alat)

9
10
11

Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/

Traumatik)
Fasciotomy
Ligasi Vaskular Ekstremitas

5
6
7

24

12

NO

KSM/INSTALASI
/UNIT

TINDAKAN
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Mutilasi Digiti Ekstermitas

KSM BEDAH

27
1

DIGESTIVE

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Pasang Double Lumen Hemodialisis (HD) (diluar

alat)
Pasang Implantable Central Venous Access (diluar
alat: porth-a-cath, celsite)
Pemasangan Central Venous Catheter (CVC) (diluar
alat)
Pemasangan Intra Aortic Baloon Pump (IABP) (diluar
alat)
Pemasangan Peritoneal Dyalisis (PD) Catheter
(diluar alat)
Pembedahan Teleangiectasis
Repair Aneurisma (True/false) Ekstremitas Superior
(diluar graft)
Repair Aneurisma Aorta Abdominalis (Diluar
Protesa)
Repair Pembuluh Darah Regio Servikal (Karotis,
Jugular)
Repair Ruptur Pembuluh Arteri Abdominal
Revisi Arteriovenous Shunt
Skleroterapi Vena (Varises, Hemangioma)
Stripping Varises Ekstremitas Inferior
Vascular Shunting (Splenorenal Shunt, De Palma
Shunt)
Vena Punctie, Kanulasi, Sectie
Abdominal pull through (sfingter saving procedure)
Abdominoperineal resection (miles) dengan penyulit
mayor
Abdominoperineal resection (miles) dengan penyulit
minor
Abdominoperineal resection (miles) tanpa penyulit
Abdominoplasty
Apendektomi
Apendektomi dgn penyulit major
Apendektomi dgn penyulit minor
Apendektomi laparoskopik
Bilio-difgestif anastomosis tanpa penyulit
Biliodigestif dengan penyulit mayor
Biliodigestif dengan penyulit minor
Biopsi insisional, local anastesi
Biopsi rectum
Eksisi hemoroid eksterna
Eksplorasi duktus bilier & cholangiografi intra operatif
Esofagotomi
Fistulotomi

25

NO

KSM/INSTALASI
/UNIT

TINDAKAN
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58

Fistulotomi dgn penyulit mayor

Fistulotomi dgn penyulit minor
Gastrostomi
Hemikolektomi dengan penyulit mayor
Hemikolektomi dengan penyulit minor
Hemikolektomi tanpa penyulit
Hemoroid stapling (diluar alat)
Hemoroidektomi
Herniotomi
Herniotomi dgn penyulit mayor
Herniotomi dgn penyulit minor
Herniotomi laparoskopik
Jejunostomi / ileostomi
Laparotomi dengan penyulit minor
Laparotomi tanpa penyulit
Ligasi hemoroid (diluar alat)
Pankreatiko-duodenektomi cephalis (Whipple)
dengan penyulit mayor
Peritoneal dreanse (CAPD)
Peritoneal lavase
Polipektomi
Potong kolostomi
Prosedur Heller
Rektopexy
Repair fistel usus
Repair fistel vesicorectal
Repair hernia cicatricalis
Repair hernia cicatricalis dgn penyulit mayor (diluar
alat)
Repair hernia cicatricalis dgn penyulit minor (diluar
alat)
Repair Hernia Diafragmatika (diluar alat)
Reseksi anterior dengan penyulit mayor
Reseksi anterior dengan penyulit minor
Reseksi anterior tanpa penyulit
Reseksi esofagus-colon / ileum transposisi
Reseksi esofagus-end to end
Reseksi esofagus-esofago-gastrectomy
Reseksi hati
Second look laparoscopy
Splenektomi / splenoraphy traumatika
Splenektomi non trauma
Terminal esofagus proksimal gastrektomi (TEPG)

26

59

NO

KSM/INSTALASI
/UNIT

KSM BEDAH
UROLOGI

Total gastrektomi
TINDAKAN

60
61
62
63
64
65
66
67
68
69
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Total pantreaktomi
Total prokto-kolektomi
Tutup burst abdomen (tanpa alat)
Tutup burst abdomen dengan penyulit mayor
Tutup burst abdomen dengan penyulit minor
Tutup kolostomi / ileostomi
Tutup kolostomi / ileostomi dengan penyulit mayor
Tutup kolostomi / ileostomi dengan penyulit minor
Repair Aorta Torakalis (38.34)
Repair Atrioventricular Septal Defect (35.54)
Adrenalektomi
Adrenalektomi (Abdominotorakal)
Anastomosis end to end Ureter
Augmentasi Buli
Biopsi Ginjal perkutan
Biopsi Ginjal Terbuka
Biopsi Penis
Biopsi Prostat
Biopsi Testis
Bladder Neck Rekonstruksi
Buried Penis
Businasi/Dilatasi Uretra
Cabut DJ Stent
Defooring Kista Ginjal per Laparoskopi
Deroofing/Unroofing Kista
Diseksi Kelenjar Getah Bening Inguinal
Diseksi Kelenjar Getah Bening pelvis
Diseksi Kelenjar Getah Bening Pelvis per
Laparoskopi
Divertikulektomi Buli
Divertikulum Uretra
Dorsumsisi
Drainase Periureter
Eksisi Chordae/Chordektomi
Eksisi Fibroma/Rekonstruksi Penis
Eksisi Plaque (Peyronie Disease)
Eksisi Webbed Penis
Eksplorasi testis (Microsurgery)
Ekstraksi Batu
Ekstrofi Buli Rekonstruksi
Epispadia
Evakuasi Bekuan Darah (Clot)
Extended Pyelolithotomy

27

33
NO

KSM/INSTALASI
/UNIT

Fistulektomi/Repair Fistel Uretra

TINDAKAN

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75

Funikokelektomi
Ganti Nefrostomy
Hidrokel per Inguinal/Ligasi Tinggi
Hidrokel per Skrotal
Hipospadia Subkoronal
Holmium YaG Laser (Sewa)
Ileal Conduit (Bricker)
Insersi DJ Stent
Insisi Abses Perineum
Insisi Abses Skrotum
Insisi Posterior Urethral Valve
Johanson
Johanson I
Johanson II
Kalibrasi Uretra
Kauterisasi
Koreksi Horseshoe Kidney
Koreksi Priapismus
Laparoskopi Adrenalektomi
Laparotomi Eksplorasi
Ligasi V.Spermatika Interna (Microsurgery)
Limfadenektomi Ilioinguinal
Limfadenektomi Retroperitoneal/RPLND
Litholapaksi
Lithotripsi
Masase Prostat
Meatoplasti
Meatotomi
MMK/Sling Uretra
Nefrektomi
Nefrektomi Donor Transplant
Nefrektomi Parsial
Nefrektomi per Laparoskopi
Nefrektomi Radial
Nefropeksi/Renopeksi
Nefrostomi Perkutan/Temporer
Nefrostomi Terbuka/Permanen
Nefroureterektomi
Neobladder
Operasi Priapismus (prosedur Winter)
Operasi Repair Buli Trauma
Operasi Sistokel

28

NO

KSM/INSTALASI
/UNIT

TINDAKAN
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
115
116
117

Operasi Trauma Ginjal

Operasi Urakhus/Reseksi urakhus
Orkhidektomi
Orkhidektomi extended
Orkhidektomi Ligasi Tinggi
Orkhidektomi Subkapsuler
Orkhidopeksi (Torsio Testis)
Orkhidopeksi (UDT)
Orkhidopeksi per Laparoskopi
Pasang Kateter
Pasang Kateter dengan Mandrain
Pasang Kateter Tenckhoff untuk CAPD
PCNL/PNL
Penektomi Parsial
Penektomi Total/Amputasi Penis
PER (Primary Endoscopic Realignment)
Pielokalikotomi
Pielolitotomi
Pieloplasti
Pieloplasti per Laparoskopi
Prostatektomi Radikal
Prostatektomi Retropubik
Prostatektomi Terbuka
Prostatektomi Terbuka dan Sectio Alta
Psoas Hitch/Boari Flap
Punksi dan sklerosing Kista Ginjal
Railroading Rupture Uretra
Reimplantasi Ureter Bilateral
Reimplantasi Ureter
Unilateral/Ureteroneosistostomi
Rekontruksi Renovaskuler
Repair Fistel Enterovesika
Repair Fistel Vesikokutan
Repair Fistel Vesikorektal
Repair Fistel Vesikovagina
Repair Fistel Vesikovagina Kompleks
Reparasi Penis
Reseksi-anastomosis Uretra
RPG
Sectio Alta/Vesikolithotomi
Sirkumsisi
Sistektomi Parsial/Sistoplasti Reduksi
Sistektomi Per Laparoskopi
Sistektomi Total/Radikal

29

118
119
NO

Sistoskopi
Sistoskopi ODS

KSM/INSTALASI
/UNIT

KSM ILMU
KESEHATAN
MATA

TINDAKAN
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Sistostomi perkutan
Sistostomi Terbuka
Skrotoplasti
Spermatokelektomi
Tailoring Ureter
Transplan Resipien
Transuretero-ureterostomi
TUR Prostat/TUIP/BNI
TUR Tumor Buli
TVP/TMP
Ureterokutaneostomi
Ureterolisis
Ureterolithotomi
Ureterolithotomi Distal
Ureterolithotomi Proksimal
Ureterosigmoidostomi (Caffey)
Ureterostomi
Ureterouretostomi
Uretroplasti Hipospadia
Uretroskopi/Uretrosistoskopi
Uretrotomi Interna (Sachse)
URS/Lithotripsi
Varikokelektomi (Palomo)
Vasektomi (anestesi lokal)
Vasektomi (narkose)
Vasoepididimostomi
Vasografi
Vasovasostomi
Angkat Jahitan
Angkat Jahitan dengan GA
Anterior Chamber Tap/Parasintesis
Aspirasi Massa Lensa
Blefaroplasty (2 Kelopak Mata)
Claw Lens
Cryopexy Kornea
Cyclo Cryo
Dacryocystorinostomi (Without Silicon Tube)
Dekompresi Orbital/Lateral Orbitotomi
Disisi Aspirasi & IOL
ECCE
ECCE & IOL
Eksenterasi
Eksisi Hordeolum / Chalazion

424
2

30

434
3

16
17
NO

Ekstirpasi Corpus Alienum di Kornea

Ekstirpasi Pterygium + Graft Konjungtiva

KSM/INSTALASI
/UNIT

TINDAKAN
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57

Ekstripasi Corpus Alienum di Bilik Mata Depan

Enukleasi/Eviscerasi (DFG/Bonegraft)
Evakuasi Silikon Oil
Fornix Repair
ICCE
ICCE & IOL
Injeksi Intra Vitreal
Injeksi Periokuler Terapetik
IOL Explant
Iridectomi
Jahit Kelopak Mata Full Thickness & Lid Margin
Jahit Kornea
Keratoplasti (Corneal Transplantation)
Konjungtival Flap/Amnion Graft
Piggy Back IOL
Pneumoretinopexy
Repair Canalis Lacrimalis (Without Silicon Tube)
Repair Coloboma Palpebra (Skin/Mucosal Graft)
Reposisi IOL
Reposisi Iris
Resesi & Reseksi 2 Otot
Resesi & Reseksi 3 Otot
Resesi & Reseksi 4 Otot
Resesi/Reseksi 1 Otot
Sekunder Implant (Posterior Chamber)
Sekunder Implant Claw Lens / Fiksasi Sulcus
SICS
SICS & IOL
Simpel Vitrektomi
Skleral Buckle
Socket Repair (Contracted Socket)
Trabekulektomi
Trabekuletomi & Ollogen
Trabulektomi & Goniotomi pada Pediatric
Glaucoma
Tube Shunt (Express)
Viscocanulostomy
Vitrektomi +++
Vitrektomi Lengkap & Skleral Buckle
Wide Eksisi Tumor Kelopak Mata
Wide Eksisi Tumor Kelopak Mata + Flap + graft

444
4

NO
10

KSM/INSTALASI
/UNIT
Divisi Onkologi

TINDAKAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

Aspirasi Kista Mamma Single dan Multiple

Biopsi Core Lokal Anestesi
Biopsi Eksisi Lokal
Biopsi Eksisi Narkose
Biopsi Insisi Lokal
Biopsi Narkose
Breast Conserving Surgery (BCS)
Breast Conserving Surgery + LD Flap
Debriment Mamma
Diseksi Axilla
Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi
Eksisi Fibroadenoma Multiple Narkose
Eksisi Tumor Metastase Loco-regional
Eksplorasi Duktus Mama
Eksplorasi Duktus Mama+VC
Insisi Absces Mastitis Lokal
LD Flap + Eksisi Tumor
Mastectomy + Tram Flap
Modified Radical Mastectomy + Flap/Single Grafting
Modified Radical Mastectomy Single
Quadrantectomy / Partial Mastectomy
Simple Mastektomy + Flap/Skin Grafting
Simple Mastektomy Single
Tram Flap + Eksisi Tumor
Operasi Tumor Kulit
Biopsi Insisi Tumor Kulit Lokal
Biopsi Eksisi Tumor Kulit Narcose
Eksisi Tumor Jinak 3cm
Eksisi Tumor Jinak + Flap/Skin Graft
Eksisi Tumor Jinak Kulit >3cm
Wide Eksisi + Diseksi KGB
Wide Eksisi Tumor Ganas Kulit
Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft
Operasi Soft Tissue Tumor
Amputasi + Diseksi KGB
Amputasi Jari + Flap / Skin Graft
Amputasi Tungkai / Lengan
Biopsi Core soft Tissue
Biopsi Insisi Tumor Sof Tissue dengan Narcose
Biopsi Insisi Tumor Soft Tissue Lokal Anestesi
Eksisi Tumor Jinak > 3cm
Eksisi Tumor Jinak <3cm
Wide Eksisi + Compartement Procedure
Wide Eksisi + Diseksi KGB

454
5

32

464
6

45
46
NO

Wide Eksisi Tumor Ganas

Wide Eksisi Tumor Jinak + Flap/Skin Graft

KSM/INSTALASI
/UNIT

TINDAKAN
47

Operasi Tindakan Tertentu

48

Advancement Flap

49

Aspirasi Effusi Pleura

50

Aspirasi Paru + Pleurodhesis

51

Delto Pectoral Flap (DP Flap)

52

Diseksi Axilla

53

Diseksi Inguinal

54

Diseksi Para Aorta

55

Eksisi Tumor Lidah

56

Eksisi Tumor Sub Mandibula/Sub Mental

57

Insersi Chest Tube

58

Ismulobectomy

59

Kemoterapi Perinfus

60

Latissimus Dorsi Flap (LD Flap)

61

Maksilektomi Total

62

Mastopexy

63

Modifikasi RND

64

Operasi Compartement Otot

65

Ovariectomy Bilateral

66

Reseksi Mandibula

67

Rotation Flap

68

Skin Grafting

69

Sub Total Thyroidectomy

70

Superficial Parotidectomy

71

Thoraco Abdominal Flap (TA-Flap)

72

Total Parotidectomy

73

Total Thyyroidectomy

74

Transversus-Rectus Abdominis Flap (Tram Flap)

474
7

NO
11

KSM/INSTALASI
/UNIT
DIVISI BEDAH
ANAK

TINDAKAN
1

Abdominal pull through (sfingter saving procedure)

Adhesiolisis

Appendektomi dgn penyulit

Appendektomi laparoskopik

Appendektomi tanpa penyulit

Biliodigesif dengan penyulit mayor

7
8

Biliodigestif anastomosis tanpa penyulit atau penyulit

minor
Biopsi rectum

By pass usus dengan penyulit mayor / minor

10

Divertikulektomy

11

Drainase abses dengan general anasthesia

12

Drainase abses local anasthesia

13

Eksisi hygroma colli

14

Eksisi kista brachialis

15

Eksisi kista duktus tiroglossus

16

Eksisi neoplasma Jinak ( lipoma, atheroma dll )

17

Eksisi sinus/granuloma umbilikalis

18

Eksisi soft tissue tumor dengan penyulit

19

Eksisi soft tissue tumor tanpa penyulit

20

Eksisi teratoma dengan penyulit dan rekonstruksi

21

Eksisi teratoma tanpa penyulit

22

Eksisi tumor jinak wajah

23

Eksisi urachus

24

Ekstirpasi fistel pre aurikulae

25

Ekstirpasiranula

26

Endoskopik diagnostik

27
28

Endoskopik terapeutik

29

Hemikolektomi

Gastrostomi

484
8

34

494
9

NO

30

Herniotomi elektif tanpa penyulit

31

Herniotomi laparoskopik

KSM/INSTALASI
/UNIT

TINDAKAN
32

Hernitomi dgn penyulit / komplikasi

33

Hidrokolektomi

34

Intraoperatif kolangiografi

35

Intraoperatif kolangiografi laparoskopik

36

Jejenostomi / ileostomi dengan penyulit mayor

37

Jejenostomi / ileostomi dengan penyulit minor

38

Jejenostomi / ileostomi tanpa penyulit

39

Koledokotomi dengan penyulit mayor

40

Kolesistektomi

41

Kolesistektomi laparoskopik

42

Kolostomi / sigmoidostomi (46.11)

43

LADD Operation (54.95)

44

Laparoskopik diagnostik (61.6)

45

Ligasihemoroid (49.4)

46

Operasi kelainan umbilikal lain (54.3)

47

Orchidopexy (62.5)

48

Orchidopexy laparoskopik (62.5 + 61.6)

49

Other Repair of Abdominal Wall (Repair Omphacele)

(954.72)
Polipektomi (48.36)

50
51
52

Posterosagital anorectoplasty (49.79)

Posterosagital anorectoplasty urethro vaginoplasty
(70.79)

53

Potong kolostomi (46.14)

54

Potong Stump (84.3)

55

Prosedur Heller (44.6)

56

Prosedur Kasai (51.37)

57

Repair atresia esofagus (42.5)

58

Repair defek diafragma (53.8)

505
0

NO

59

Repair ekstrofia buli (57.8)

60

Repair hernia diafragma (53.7/53.8)

KSM/INSTALASI
/UNIT

TINDAKAN
61

Repair of Gastrochisis (54.71)

62

RPLND (40.59)

63

Separasi conjoined twin (84.9)

64

Sirkumsisi dengan general anesthesia (64.0)

65

Sirkumsisi dengan local anesthesia (64.0)

66

Splenektomi (41.5)

67

Splenorenal shunt (39.1)

68
69

Transnasal endorectal pullthrough laparascopic

assisted (48.42)
Transplantasi organ

70

Tutup burst abdomen dengan penyulit (54.61)

71

Tutup burst abdomen tanpa penyulit (54.61)

72

Tutup ileostomi dengan penyulit (46.5)

73

Tutup kolostomi / ileostomi (46.5)

74

Tutup Stoma (46.5)

75 Urethroplasty / chordectomy (64.42)

76 Vena Sectie Aksilaris (38.94)
77 Vena sectie Femoralis / saphena magna (38.94)
12

KSM BEDAH
PLASTIK

78

Wound repair (86.8)

1
2
3

Abdominoplasty
Aff archbar, Lokal Anastesi
Aff Suspensi, Lokal Anastesi

Amputasi above elbow

Amputasi bellow elbow

Amputasi digital

Amputasi jari >1

Amputasi jari single

Augmentasi mamae

10

Blefaroplasty (2 kelopak mata)

11

Blefaroplasty pada kasus sulit

515
1

36

525
2

12

NO

Blefaroptosis

KSM/INSTALASI
/UNIT

TINDAKAN
13

Bone rekonstruksi facial cleft

14

Bone rekonstruksi facial cleft

15

Cheilonasoraphy

16

Chordectomy

17

Chordectomy+urethroplasty

18

Closed Reduction Fr. Nasal

19

Comisuroplasty

20

Eks mamma aberan bilateral

21

Eksisi neoplasma jinak (lipoma, atheroma dll)

22

Eksisi luas + Deltopectoral flap

23

Eksisi luas + Fore head flap

24

Eksisi luas + Muskulocutan flap

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

Eksisi luas + rekonstruksi dengan bedah

mikrovaskular
Eksisi malformasi lymphatik / vaskuler
Ekstraksi ateroma / keloid
Ekstraksi korpus alienum
Elevasi ear rim cartilago
Excise hemangioma + rekonstruksi
Excise intra keloid
Excise polydactyly
Excise reduksi lymedema
Facial sling dengan allograft
Fasciotomy burn injury
Fasciotomy with complication
Flap lokal sederhana
Fr. Condylus mandibula open red
Fr. Maksila suspensi (IOID)
Fr. Nasal open reduction
Fraktur Prosesus alveolaris dengan inter dental
wiring (IDW) (per rahang)
Fraktur Prosesus alveolaris luas dengan IDW (per
rahang)
Fraktur rahang reduksi terbuka & inter oseus wiring
(IOW)

37

NO

KSM/INSTALASI
/UNIT

TINDAKAN
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85

LD flap
Le fort I osteotomy
Liposuction
Lobuloplasti
Malarplasty
Mamma aberan unilateral
Mandibular distraksi
Mandibular rekonstruksi dengan costochondral graft
Mastopexi
Mentoplasty
Microsurgery
Multiple facial fraktur + implant
Muskulokutaneus flap
Myokutaneus flap/pectoralis mayor flap
Nasal repair dan rekonstruksi
Neo vagina
Operasi bedah mikro
Orif fraktur zygoma
Orif fraktur hand
Orif fraktur mandibula
Orif fraktur maxilla
Orif maksila plating
Orif mandibula plating
Orif mandibula wiring
Orif orbital wall
Orif orbital wall
Orif zygoma wiring
Osteotomy craniosynostosis reconstruction
Osteotomy facial rekonstruksi
Osteotomy genioplasti tanpa tarif bahan
Osteotomy maksila Le fort I
Osteotomy maksila Le fort II
Palatoplasti bilateral komplit
Palatoplasti bilateral tak komplit
Palatoplasti unilateral komplit
Palatoplasti unilateral tak komplit
Palatoraphy
Pasang archbar
Pasang back slab/fore slab
Pasang cast/gips tanpa reposisi
Recheiloraphy
Rekonstruksi dengan alloplastic material

545
4

38

555
5

86
87
NO

Rekonstruksi facial cleft

Rekonstruksi nasal

KSM/INSTALASI
/UNIT

TINDAKAN
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121

Rekonstruksi palpebra
Released buried penis
Released syndactyly kompleks
Repair canalis lacrimalis (without silicon tube)
Repair coloboma palpebra (skin/mucosal graft)
Repair ductus nasolacrimalis
Repair fingertip injury
Repair fistel urethra
Replantation
Reposisi fraktur nasal sederhana
Reposisi fraktur os nasalis (complicated)
Reseksi mandibula + bone graft
Rhinoplasty
Rotation flap
Sagital Split osteotomi mandibula
Simple bone grafting
Simple skin grafting
Skin flap
Skin graft >5 cm
Skin graft sedang 5 cm
Skin grafting kecil
Skin grafting luas
Skin grafting sedang
Skin grafting with complication
Tendon reconstruction
Tendon transfer
Tendon transfer with complication
Tennoraphy
Tennoraphy with complication
TMJ arthroplasty
TMJ arthrostomy
Tram flap
Wound Dressing
Wound Repair

565
6

NO
13

KSM/INSTALASI/
UNIT
KSM
OBGYN

TINDAKAN
1
2

Cauter serviks
Cordosentesis

Debulking tumor ovarium

Eksplorasi vagina

Embryotomi

Extirpasi + kuret polip endoserviks

Extirpasi geboren mioma

Extirpasi geboren mioma+kuiretasi

Histeroctomy pada mola / chorio Ca

10

Histeroctomy radikal

11

Kistektomi

12

Konisasi serviks

13

Kuret abortus incompletes

14

Lap op: myomektomi

15
16

Laparoskopi (Kistektomi Ovarium, Salphingektomi,

Adhesiolisis)
Laparoskopi Histerektomi

17

Laparoskopi steril

18

Laparoskopik Diagnostik

19

Laparotomi dengan penyulit mayor

20

Laparotomi dengan penyulit minor

21

Laparotomi tanpa penyulit

22

LEEP

23

Micro kuretase DUB

24

Mikrokuret

25

Miomectomy

26

Neovagina

27

Operasi Ca vagina

28

Operasi kanker corpus uteri

29

Operasi tumor ganas ovarium

575
7

40

585
8

NO

30

Operative histeroscopy/Ablasi endometrium

31

Overectomi

KSM/INSTALASI
/UNIT

TINDAKAN
32

Painless labor

33

Persalinan normal

34

Persalinan normal dengan penyulit

35

Persalinan pervaginam tindakan operatif

36

Persalinan sungsang

37

Rekanalisasi

38

Rekanalisasi tuba

39

Salfingektomi unilateral

40

Salvingoovarectomi unilateral

41

Secound look surgery Ca ovarium

42

Seksio sesaria

43

Seksio sesaria dengan penyulit penyulit

44

Sirklase serviks

45

Seksio sesaria dengan penyulit penyulit

46

Sirklase serviks

47

Supra vaginal hyterectomy

48

Surgical staging

49
50

TAH+BSO dengan Penyulit

TAH+BSO dengan Penyulit Pemasangan Tampon
Abdomen

51

Total abdominal hysterectomy+bilateral salfingektomi

52

Tubektomi klinik

53

Tutup burst abdomen

414
1

NO

KSM/INSTALASI
/UNIT

TINDAKAN

14

KSM

GIGI dan
MULUT

2
3
4

Augmentasi Tulang Per Regio (Belum Termasuk

Bahan)
Debriment Mukosa dan Pengelolaan Luka Sayat
Dislokasi Sendi Mandibula
Eksisi Epulis Per Rahang

Eksisi Kelenjar Ludah Submandibula

Eksisi Kista Odontogenik Keratosis + Ostektomi

Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil

Eksisi Parsial + Marsupialisasi Ranula

Eksisi Plunging Ranula

10

Eksisional Biopsi Neoplasma Jinak

11

13

Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi

Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
Penyebab
Extirpasi Kista Dermoid

14

Extirpasi Sialolith

15

17

Extraksi Corpus Alienum dengan Teknik Lindorf

Extraksi Gigi Anak dengan Kelainan Jantung Per
Rahang
Extraksi Gigi Anak Per Rahang

18

Extraksi Gigi Dewasa Per Rahang

19

Fissure Sealant pada Autis

20

Fraktur Dento alveolar Dengan arch Bar

21
22

Fraktur Dento alveolar Dengan Bracket (belum

termasuk bahan)
fraktur Dento Alveolar dengan Eyelet

23

Fraktur Maksila dengan Suspensi Wiring

24

Fraktur Nasal close Reduksi

25

27

Fraktur Nasal Open Reduksi

Fraktur Rahang Reduksi Tertutup dengan
Intermaksila Fiksasi
Frenektomi Per Rahang

28

Genioplasty

29

Gingivektomi Per Rahang

12

16

26

424
2

42

434
3

NO

15

16

17

KSM/INSTALASI
/UNIT

DIVISI PEDIATRI
GAWAT
DARURAT ILMU
KESEHATAN
ANAK
KSM PENYAKIT
JANTUNG &
PEMBULUH
DARAH

KSM PENYAKIT
DALAM

TINDAKAN
30

Hemi Maksilektomi Tanpa Rekonstruksi

31

Insisi Abses / Phlegmon

32

Insisional Biopsi Neoplasma Jinak

33

Mandibular Distraksi

34

Odontektomi Per Gigi

35
36

ORIF Maksila + Zygoma + Mandibula (belum

termasuk implant)
ORIF Maksila Plating (belum termasuk implant)

37

ORIF Mandibula Plating (belum termasuk implant)

38

ORIF Zygoma Plating (belum termasuk implant)

39

Osteotomi Maksila le Fort I

40

Osteotomi Maksila le Fort II

41

Pelepasan Arch Bar (Intermaksila Fiksasi)

Intubasi Endotrakea
Krikotirotomi
Kanulasi vena perifer
Vena sectie
Pungsi lumbal
Pungsiv Pleura

1
2
3
4

Diagnostik Kateterisasi Jantung

PTMC
PTCA/Stenting
Pacemaker Temporer&Permanen

IABP

Perikardiosintesis

Pemasangan Swan Ganz Kateter

Pemasangan Amplatzer/ADO/Coilling

CVC

10

Pelepasan Arch Bar (Intermaksila Fiksasi)

2
3
4
5

Endoscopy

43

B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang

memerlukan informed consenttersebut antara lain:
a. Semua tindakan anestesi dan sedasi di dalam kamar operasi
b. Semua tindakan anestesi dan sedasi di ICU
Tindakan Anestesi di ICU
Pemasangan intubasi ventilator
Pemasangan vena central
Pemasangan CRRT
Pemasangan Swan Ganz (Kateter Arteri Pulmonal)
Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)
Pemasangan Percutaneous Dilatational Tracheostomy
Pemasangan Drain Intra Thorakal/Punksi Thorax
Pemasangan IABP
Pemasangan Drain Intra Abdominal
Pemasangan Gemo
Cardioversi
Bronchoskopi-FOB
TEE

C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang

memerlukan informed consenttersebut antara lain:
Transfusi darah:
a.

Plasma sel

b. PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin
f.

lain lain

44

D. Semua Tindakan Yang Berisiko Tinggi :

No

KSM /
INSTALASI

KSM Anak

THT-KL

KSM Patologi
3

Anatomi
Inst.

Radiotherapi

KSM
Neurologi

NAMA TINDAKAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
1
2
3
4
5
6

Chest tube
Tindakan kemotherapi
Pemasangan Ventilator
Intubasi Endotrakea
Pemasangan Laryngeal mask
Krikotirotomi
Infus intraosseus
Kanulasi vena perifer
Vena sectie
Pengambilan darah intra vena dan intra arteri
Pungsi lumbal
Pungsiv Pleura
Pemasangan kateter urine
Pemasangan keteter rectal
Pemasangan orogastrik tube
Pemasangan nasogastrik tube
Pemeriksaan Audiometri
Pemeriksaan Timpanometri
Pemeriksaan Audiometri Tutur
Pemeriksaan Sisi&Tore Decay
Pemeriksaan Pendengaran Pada Anak
Pemeriksaan Brainstem Evoked Response
Audiometry

FNAB (Fine Needle Aspiration Biopsy)

Tindakan Radiotherapi
1
2
3
4
5
6
7
8
9
10
11
12
13

Cerebral Angiografi
AVM&Embolisasi
Aneurisma Coiling
Embolisasi pre operasi
Diagnosis DSA
Lumbal Punksi
Pain Intervention
Injeksi Triger point
Injeksi Triger Fringer
Injeksi CTS
Sub Optical Functional
Injeksi botox
EMG

KSM Patologi Phlebotomi

45

Klinik

10

1
2
3
KSM Gigi dan 4
5
Mulut
6
7
8
9
Poli
Andrologi
KSM
Kardiologi
dan
Kedokteran
Vaskular

KSM
Pulmonologi
dan Ilmu
Kedokteran
Respirasi

Suntik Intra Cavernosal Penis

1
2
3
4

Dobutamin Stress Ekhokardiografi

Transophegal Ekhokardiografi
Treadmill Tes
Exercise Stress Ekhokardiografi

1
2
3
4
5
6
7
8
9
10
11
12
1
2

Bronchoscopy/FOB
Tindakan kemotherapi
Thoracoscopy
Contra Ventil/WSD
Punctie Pleura
FNAB
Scalene Biopsy
Reposisi
Pleurodesis
AFF WSD
Perawatan Luka WSD
USG Thorax Marker
Tindakan Radiologi Injectee contrast
Tindakan Radiologi pada pasien dengan kelainan
cardiovaskuler
Tindakan Radiologi pada pasien dengan alergi
berat
Tindakan Radiologi pada pasien dengan KU yang
menurun
Tindakan Radiologi yang memerlukan FNAB
Guiding MSCT pada pasien dengan kelainan yang
berdekatan dengan organ vital
Tindakan Radiologi pada Ibu hamil yang
memerlukan foto
Cerebral Angiografi
AVM&Embolisasi
Aneurisma Coiling
Embolisasi pre operasi
Diagnosis DSA

3
11

KSM
Radiologi

4
5
6

KSM
12

Neurologi

Scaling
Curettage/root planning (jika diperlukan anestesi)
Gingivektomi
Frenektomi
Flap operasi (bone graft/membrance/GTR/interseptif)
Implant
Vital pulpektomi dan Partial Nekrose
Cauter
Retraksi Gingiva pada prep.crown

1
2
3
4
5

46

6
7
8
9
10
11
12
13
14
13
14

16

15

Lumbal Punksi
Pain Intervention
Injeksi Triger point
Injeksi Triger Fringer
Injeksi CTS
Sub Optical Functional
Injeksi botox
EMG
Neuro endovaskuler: Coiling,Embolisasi,DSA

Instalasi
Hemodialisis

Setiap kali melakukan tindakan Hemodialisis

KSM
Rehabilitasi
Medik

Elektromiografi dan Kecepatan Hantar Saraf

IRNA Jiwa

Psycho Analisa

Psycho Therapy Dalam

Pemeriksaan Calon Pimpinan Publik

Aborsi Provocatus Medicinalis

Tindakan terapi elektroconfusi

Pemeriksaan kandungan zat narkotika

Restraint / Fiksasi : mekanik dan psikotropika

8 Pemeriksaan sengketa/ konflik dalam keluarga

Semua injeksi dengan obat risiko tinggi

47