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1

CONTOH ;
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 diberikaninformed consent.
Tindakan tersebut yaitu :
A. Semua Tindakan Pembedahan dan Tindakan Invasive
B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam )
C. Semua Tindakan Pemberian Produk Darah & Komponen Darah
D. Semua Tindakan Yang Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasiveyang memerlukan informed
consentantara lain:

NO
KSM/INSTALAS
I/UNIT
TINDAKAN
1 KSM Bedah
Saraf
1 Amygdala Hypocampectomy (Epilepsi)

2 Anterior Temporomesial Lobectomi (Epilepsi)

3 Biopsi Saraf Tepi/Otot

4 Blok Saraf Perifer I

5 Cingulotomy (Psichiatric)

6 Corpus Callosotomi (Epilepsi)

7 Debrimen Rekonstruksi Vulnus Kulit Kepala

8 Dekompresi Saraf Tepi

9 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

2



18 Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
NO
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)

27
Insersi Elektrode Intradural
(Epilepsi,movement,psikiatrik)

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

3



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)

66
Transposisi kraniostenosis,dengan orbital
advancement

67
Transposisi kraniostenosis,tanpa orbital
advancement

68 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

4



76 VP Shunt Satu Sisi
NO
KSM/INSTALAS
I/UNIT
TINDAKAN
2. KSM Bedah 1 Aff Arch Barr

Kepala Leher 2 Aff Arch Barr dan suspensi maksila

3 Biopsy Insisional dengan anastesi lokal

4 Deseksi submandibula

5 Diseksi leher radikal/radikal neck dissection

6 Eksisi gld submandibula

7 Eksisi higroma leher

8 Eksisi kista tiroglosus

9 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

25
Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran
<2cm

26 Ekstirpasi kista dermoid


27 Endoscopic thyroidectomy
28
Fiksasi interna fraktur maksilofasial 1-2 tempat
patahan

5




No
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
3. KSM
Bedah THT-KL
1 Adenotonsilektomi
2 Anthrostomi+Sinuskopi
3 BLM Simple (Kista,Polip,Nodul,Granulasi)
4 Biopsi Tumor
5 Bronkoskopi Rigid
6 BLM Advance (Stenosis, Subjektif/Trakea, Papiloma
Laring/Trakea)
7 Cald Well Luc
8 Cochlear Implant/Implan Baha
9 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

6



17 Ethmoidektomi (Intranasal)
18 Ekstraksi Korpus Alienum Kavum Nasi
NO
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

7



48 Laringoskopi Rigid
NO
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

8




NO
KSM/INSTALAS
I/UNIT
TINDAKAN
4 KSM Orthopedi
1 Abdominopelvic amputation

Dan 2 Achillotenotomy

Traumatologi 3 Adductor tenotomy of hip

4 Advancement of tendon

5 Advancement of tendon of hand

6 Amputation above knee

7
Amputation and disarticulation of finger- general
anaesthesia

8
Amputation and disarticulation of finger -local
anaesthesia

9
Amputation and disarticulation of thumb-general
anaesthesia

10
Amputation and disarticulation of finger- general
anaesthesia

11
Amputation and disarticulation of finger -local
anaesthesia

12
Amputation and disarticulation of thumb-general
anaesthesia

13
Amputation and disarticulation of thumb-local
anaesthesia

14
Amputation of ankle through malleoli of tibia and
fibula

15 Amputation of toe-general anaesthesia

16 Amputation of toe-local anaesthesia

17 Amputation through foot

18 Amputation through forearm

19
Amputation through hand, Amputation through
carpals

20
Amputation through humerus, Upper arm
amputation

21 Amputation, not otherwise specified

22 Ankle fusion

23 Application of external fixator device

24
Application of external fixator device, monoplanar
system

25 Application of external fixator device, ring system

9




26 Application of hybrid external fixator device

27 Arthrocentesis
NO
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
Arthroplasty of carpocarpal or carpometacarpal joint
with implant

35
Arthroplasty of carpocarpal or carpometacarpal joint
without implant

36
Arthroplasty of metacarpophalangeal and
interphalangeal joint with implant

37
Arthroplasty of metacarpophalangeal and
interphalangeal joint without implant

38 Arthroscopy

39
Arthrotomy for removal of prosthesis without
replacement

40 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

49
Bone marrow or hematopoietic stem cell transplant
(all procedures included in this class

50
Bunionectomy with soft tissue correction and
arthrodesis

51
Bunionectomy with soft tissue correction and
osteotomy of the first metatarsal

52 Bursectomy

10




53 Bursectomy of hand

54 Bursotomy
NO
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
Closed reduction of dislocation of foot and toe-
general anaesthesia

61
Closed reduction of dislocation of foot and toe-local
anaesthesia

62
Closed reduction of dislocation of hand and finger-
general anaesthesia

63
Closed reduction of dislocation of hand and finger-
local 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

11




73
Closed reduction of fracture with internal fixation -
Femur (Including : MIPO, interlocking nail, TEN)

74
Closed reduction of fracture with internal fixation -
Humerus (including : Interlocking nail, TEN, MIPO)
NO
KSM/INSTALAS
I/UNIT
TINDAKAN


75
Closed reduction of fracture with internal fixation -
Intrarticular Major Bone

76
Closed reduction of fracture with internal fixation -
Phalang of foot

77
Closed reduction of fracture with internal fixation -
Phalang of hand

78
Closed reduction of fracture with internal fixation -
Radius and ulna (MIPO, TEN)

79
Closed reduction of fracture with internal fixation -
Tarsal and metatarsal

84 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

89
Dorsal and dorsolumbar fusion of the anterior
column, anterior technique

90
Dorsal and dorsolumbar fusion of the posterior
column, posterior technique

91 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

97
Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-General
anaesthesia

98
Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-Local
Anaestesi

99 Excision of muscle or fascia for graft

100 Excision of muscle or fascia of hand for graft

12





101 Excision of other lesion of soft tissue of hand
NO
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

105
Excision or correction of bunionette, That with
osteotomy

106
Excision or destruction of intervertebral disc,
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

121
Hip bearing surface, ceramic-on-polyethylene, Hip
bearing surface, oxidized zirconium-on-polyethylene

122 Hip bearing surface, metal-on-metal

123 Hip bearing surface, metal-on-polyethylene

124
Implantation of internal limb lengthening device with
kinetic distraction

125
Implantation of other internal limb lengthening
device

126
Implantation or replacement of peripheral
neurostimulator lead (s)

13




127
Implantation or replacement of spinal
neurostimulator lead(s)

128 Incision and drainage of palmar or thenar space

129
Injection of anesthetic into peripheral nerve for
analgesia
NO
KSM/INSTALASI
/UNIT
TINDAKAN


130 Injection of anesthetic into spinal canal for analgesia

131 Injection of destructive agent into spinal canal

132
Injection of locally-acting therapeutic substance into
other soft tissue

133
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

137 Injection of therapeutic substance into tendon

138
Injection of therapeutic substance into tendon of
hand

139 Insertion of bone growth stimulator

140 Insertion of bone void filler

141
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

145
Insertion of partial spinal disc prosthesis,
lumbosacral

146
Insertion of recombinant bone morphogenetic
protein

147
Insertion of spinal disc prosthesis, not otherwise
specified, Replacement of spinal disc, NOS

148 Insertion of spinal disc prosthesis, thoracic

149 Insertion of sternal fixation device with rigid plates

150 Insertion of total spinal disc prosthesis, cervical

14




152 Insertion of total spinal disc prosthesis, lumbosacral

153 Insertion or replacement of (cement) spacer

154
Insertion or replacement of facet replacement
device(s)
NO
KSM/INSTALAS
I/UNIT
TINDAKAN


155
Insertion or replacement of interspinous process
device(s)

156
Insertion or replacement of pedicle-based dynamic
stabilization device(s)

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

15





179
Myotomy


180
Myotomy of hand


181
Neurectasis
NO
KSM/INSTALASI/
UNIT
TINDAKAN

182 Open biopsy of cranial or peripheral nerve or ganglion

183 Open biopsy of soft tissue

184
Open reduction of dislocation of ankle - Neglected
dislocation

185 Open reduction of dislocation of elbow -Fresh dislocation

186
Open reduction of dislocation of hand and finger -Fresh
dislocation

187 Open reduction of dislocation of hip - Fresh dislocation

188
Open reduction of dislocation of hip - Neglected
dislocation

189
Open reduction of dislocation of knee - Neglected
dislocation

190 Open reduction of dislocation of knee -Fresh dislocation

191 Open reduction of dislocation of other specified sites

192
Open reduction of dislocation of shoulder -Fresh
dislocation

193
Open reduction of dislocation of shoulder -Neglected
dislocation

194
Open reduction of dislocation of unspecified site-Fresh
dislocation

195
Open reduction of dislocation of unspecified site-
Neglected dislocation

196 Open reduction of dislocation of wrist -Fresh dislocation

197
Open reduction of fracture with internal fixation- radius
and ulna-Simple fracture

198
Open reduction of fracture with internal fixation-
unspecified site (Periarticular Major Bone )

199
Open reduction of fracture with internal fixation-carpals
and metacarpals - plate & screws
Hand NOS -Plate & Screw

200
Open reduction of fracture with internal fixation-carpals
and metacarpals - plate & screws
Hand NOS -Plate & Screw

201
Open reduction of fracture with internal fixation-carpals
and metacarpals - simple implants (K-wire)
Hand NOS -implant sederhana (K-wire)

202
Open reduction of fracture with internal fixation-femur-
Comminutive or Segmental

203
Open reduction of fracture with internal fixation-femur-
Simple fracture

16






NO
KSM/INSTALAS
I/UNIT
TINDAKAN

204
Open reduction of fracture with internal fixation-
humerus - Simple fracture


205 Open reduction of fracture with internal fixation-
humerus - Comminutive or Segmental


206 Open reduction of fracture with internal fixation-
other specified bone (Intraartikular Major Bone )


207 Open reduction of fracture with internal fixation-
phalanges of foot - simple implants (K-wire)


208 Open reduction of fracture with internal fixation-
phalanges of foot-Plate & Screws


209 Open reduction of fracture with internal fixation-
phalanges of hand- Plate & Screws


210 Open reduction of fracture with internal fixation-
phalanges of hand- simple implants


211 Open reduction of fracture with internal fixation-
tarsals and metatarsals- Plate & Screws


212 Open reduction of fracture with internal fixation-
tarsals and metatarsals- simple implants


213 Open reduction of fracture with internal fixation-tibia
and fibula -Simple fracture


214 Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental


215
Open reduction of fracture without internal fixation


216
Open reduction of separated epiphysis


217
Osteoclasis (correction of bone deformity)


218
Other


219
Other (peripheral) vascular shunt or bypass


220
Other amputation below knee


221
Other anastomosis of cranial or peripheral nerve


222
Other and unspecified repair of the anulus fibrosus


223
Other arthrotomy


224
Other bunionectomy


225
Other bunionectomy with soft tissue correction


226 Other cervical fusion of the anterior column, anterior
technique


227 Other cervical fusion of the posterior column,
posterior technique

17





228
Other change in hand muscle or tendon length


229
Other change in muscle or tendon length


230
Other destruction of intervertebral disc
NO
KSM/INSTALAS
I/UNIT
TINDAKAN


231
Other diagnostic procedures on joint structures
232
Other diagnostic procedures on muscle, tendon, fascia, and
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
239
Other exploration and decompression of spinal canal,
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
250
Other injection of locally-acting therapeutic substance into
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,

18



Suture of bursa
258
Other partial ostectomy (including : Bone curretage,
marginal resection/excision)
NO
KSM/INSTALAS
I/UNIT
TINDAKAN

259
Other peripheral nerve or ganglion decompression or
lysis of adhesions Peripheral nerve neurolysis NOS
260 Other plastic operations on fascia
261 Other plastic operations on hand
262 Other plastic operations on muscle
263
Other repair of ankle
264
Other repair of elbow
265
Other repair of hand, fingers and wrist
266
Other repair of joint
267
Other repair of knee
268
Other repair of shoulder
269
Other repair of the collateral ligaments
270
Other repair of the cruciate ligaments
271
Other repair or plastic operations on bone
272
Other suture of flexor tendon of hand
273
Other suture of muscle or fascia
274
Other suture of other tendon of hand
275
Other suture of tendon
276
Other tendon transposition
277
Other tenodesis of hand
278
Other tenonectomy
279
Other tenonectomy of hand
280
Other tenoplasty of hand
281
Other tenotomy
282
Other total shoulder replacement
283
Partial hip replacement
284
Partial shoulder replacement
285
Patellar stabilization
286
Percutaneous denervation of facet
287
Percutaneous vertebral augmentation
288
Percutaneous vertebroplasty
289
Peripheral nerve injection, not otherwise specified
290
Plastic operation on hand with graft of muscle or fascia
291
Plastic operation on hand with other graft or implant

292 Pollicization operation carrying over nerves and blood
supply
293
Quadricepsplasty
294
Reattachment of muscle
295
Reattachment of muscle of hand
296
Reattachment of tendon
297
Reattachment of tendon of hand

19



298
Refusion of atlas-axis spine

299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique
NO
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

20


326 Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)



NO
KSM/INSTAL
ASI/UNIT
TINDAKAN


327 Removal of implanted devices from bone-tarsals and
metatarsals - Plate & Screw
328 Removal of internal limb lengthening device
329 Removal of pedicle screw(s) used in spinal fusion
330 Removal of peripheral neurostimulator lead(s)
331 Removal of skeletal muscle stimulator
332 Removal of spinal neurostimulator lead(s)
333 Reopening of laminectomy site
334 Repair of claw toe
335 Repair of cleft hand
336 Repair of hammer toe
337 Repair of hip, not elsewhere classified
338 Repair of macrodactyly
339 Repair of mallet finger
340 Repair of old traumatic injury of cranial and peripheral
nerves
341 Repair of recurrent dislocation of shoulder
342 Repair of the anulus fibrosus with graft or prosthesis
343 Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae,
Removal of bony spicules from spinal canal
344 Replacement of joint of foot and toe
345 Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
346 Resurfacing hip, partial, femoral head
347 Revision of total knee replacement, tibial insert (liner),
Replacement of tibial insert(liner)
348 Revision or replacement of artificial spinal disc
prosthesis, cervical
349 Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
350 Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
351 Revision or replacement of artificial spinal disc
prosthesis, thoracic
352 Rotator cuff repair
353 Separation of equal conjoined twins
354 Separation of unequal conjoined twins
355 Sequestrectomy
356 Spinal fusion, not otherwise specified
357 Subtalar fusion
358 Subtalar joint arthroereisis

21






359 Suture of Artery
360 Suture of capsule or ligament of ankle and foot
NO
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 Upper arm reattachment
393 Upper limb amputation, not otherwise specified
394 Wedge osteotomy

22





NO
KSM/INSTALASI
/UNIT
TINDAKAN

5 KSM BEDAH
1 Biopsi Terbuka Bronkhus
THORAKS
2 Biopsi Terbuka Diafragma
DAN
3 Biopsi Terbuka Mediastinum
KARDIOVASKULAR
4 Biopsi Terbuka Paru
5 Biopsi Terbuka Pleura
6 Biopsi Terbuka Pleura dengan VATS
7 Biopsi Terbuka Tumor Dinding Thoraks
8 Debridement Mediastinum (Sternotomi)
9 Eksisi Pada Bronkhus
10 Eksisi Pada Paru (Lung Volume Reduction)
11 Eksisi Pada Paru dengan VATS
12
Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding
Dada
13
Eksisi Tumor Mediastinum (Thymoma, Teratoma,
Neurogenic dsb)
14 Ekstraksi Corpus Alienum di Regio Toraks
15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS
16
Evakuasi Efusi Pleura/Empyema secara Torakoskopik
(VATS)
17 Fiksasi Costae (Clipp, Wire) (diluar Clipp)
18 Fiksasi Sternum (Wire, Plate) (diluar wire/plate)
19 Lobektomi Parsial (Reseksi Paru segmental)
20
Lobektomi Parsial (Reseksi Paru segmental) dengan
VATS
21 Lumbal Simpatektomi
22 Mediastinostomy
23
Pemasangan thorak drain/water sealed drainage (WSD)
(diluar alat)
24 Pleural window (Eloeser Flap)
25 Pleurektomi
26 Pleurodesis (Pleurosklerosis)
27 Plikase Bulae / Bleb Emfisematous
28 Plikasi diafragma
29 Pneumonectomy
30 Pneumonectomy dengan VATS
31 Pulmonary Decortication
32 Pulmonary Decortication dengan VATS
33 Pulmonary Lobectomy/Bilobectomy
34 Pulmonary Lobectomy/Bilobectomy dengan VATS
35 Redo Torakotomi
36 Rekonstruksi Sternum&Dinding Dada
37 repair deformitas Pectus

23



38
Repair Fistula Bronkopleural
39 Repair Laserasi Diafragma
NO
KSM/INSTALASI
/UNIT
TINDAKAN

40
Revisi Thoraks drain/water sealed drainage (WSD) (diluar
alat)
41
Thoracal Symphatectomy dengan Video Assissted
Thoracoscopic Surgery (VATS)
42 Thoracocentesis
43 Thymectomy
44 Thymectomy dengan VATS
45 Torakoplasti (Air Plumbage/Muscle Plumbage)
46 Torakotomi / sternotomi Eksplorasi
47
Torakotomi Eksplorasi pada Trauma jantung/Repair
Laserasi Jantung
48 Bedah Kardio (Jantung)
49 Aortic Valve Repair (AVR)
50 Aortic Valve Repair (AVR) dengan Bioprosthesis Valve
51 Aortic Valve Repair (AVR) dengan Mechanical Valve
52 Atrial septal Defect (ASD) Closure
53 Bidirectional Cavo-Pulmonary Shunt (BCPS)
54 Biopsi Jantung

55
Biopsi Perikardium

56
Blalock-Taussing Shunt (BT Shunt)

57
Coronary Artery Bypass Graft (CABG)

58
Eksisi Cardiac Myxoma

59
Fontan Operation (Atrium-Pulmonary Artery Conduit)

60
Internal Resusitasi/Cardiac Massage (Operasi Terbuka)

61
Ligasi Patent Ductus Arteriosus (PDA)

62
Mitral valve repair (MVr)

63
Mitral Valve Repair (MVR) dengan Bioprosthesis Valve

64
Mitral Valve Replacement (MVR) dengan Mechanical
Valve

65
Operasi Redo Open Heart (Valve Replacement)

66
Operasi Reopen oleh Karena sebab Perdarahan,
Tamponade Jantung

67
Pemasangan IABP
68 Pemasangan Pace Maker Permanen (diluar alat)
69
Pericardiocentesis
70
Perikardiektomi

71
Perikardiotomi/Pericardial Window

72
Pulmonal Valve Repair (PVR)

73
Pulmonal Valve Repair (PVR) dengan Bioprosthesis
Valve

74
Pulmonal Valve Repair (PVR) dengan Mechanical Valve
75
Pulmonary Artery Banding (PA)

24




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)
80
Repair Total Anomalous Pulmoanry Venous Connection
(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)
87
Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve
(35.27)
88
Tricuspid Valve Repair (TVR) dengan Mechanical Valve
(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)
6 Eksisi Biopsi 1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)
Tumor
Pembuluh
2 Eksplorasi Vaskular (Trauma/Non trauma)
Darah 3 Embolektomi/Trombektomi Aorta
4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal
5
Embolektomi/Trombektomi Pembuluh Darah Arteri
Ekstremitas Bawah
6
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
Atas (diluar alat)
7
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
Bawah(diluar alat)
8
Embolektomi/Trombektomi Pembuluh Darah Regio servikal
(Karotis, Jugular) (diluar alat)
9
Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/
Traumatik)
10 Fasciotomy
11 Ligasi Vaskular Ekstremitas

25



12 Mutilasi Digiti Ekstermitas
NO
KSM/INSTALASI
/UNIT
TINDAKAN

13
Pasang Double Lumen Hemodialisis (HD) (diluar
alat)
14
Pasang Implantable Central Venous Access (diluar
alat: porth-a-cath, celsite)
15
Pemasangan Central Venous Catheter (CVC) (diluar
alat)
16
Pemasangan Intra Aortic Baloon Pump (IABP) (diluar
alat)
17
Pemasangan Peritoneal Dyalisis (PD) Catheter
(diluar alat)
18 Pembedahan Teleangiectasis
19
Repair Aneurisma (True/false) Ekstremitas Superior
(diluar graft)
20
Repair Aneurisma Aorta Abdominalis (Diluar
Protesa)
21
Repair Pembuluh Darah Regio Servikal (Karotis,
Jugular)
22 Repair Ruptur Pembuluh Arteri Abdominal
23 Revisi Arteriovenous Shunt
24 Skleroterapi Vena (Varises, Hemangioma)
25 Stripping Varises Ekstremitas Inferior
26
Vascular Shunting (Splenorenal Shunt, De Palma
Shunt)
27 Vena Punctie, Kanulasi, Sectie
7 KSM BEDAH 1 Abdominal pull through (sfingter saving procedure)
DIGESTIVE 2
Abdominoperineal resection (miles) dengan penyulit
mayor
3
Abdominoperineal resection (miles) dengan penyulit
minor
4 Abdominoperineal resection (miles) tanpa penyulit
5 Abdominoplasty
6 Apendektomi
7 Apendektomi dgn penyulit major
8 Apendektomi dgn penyulit minor
9 Apendektomi laparoskopik
10 Bilio-difgestif anastomosis tanpa penyulit
11 Biliodigestif dengan penyulit mayor
12 Biliodigestif dengan penyulit minor
13 Biopsi insisional, local anastesi
14 Biopsi rectum
15 Eksisi hemoroid eksterna
16 Eksplorasi duktus bilier & cholangiografi intra operatif
17 Esofagotomi
18 Fistulotomi

26




NO
KSM/INSTALASI
/UNIT
TINDAKAN
19 Fistulotomi dgn penyulit mayor
20 Fistulotomi dgn penyulit minor
21 Gastrostomi
22 Hemikolektomi dengan penyulit mayor
23 Hemikolektomi dengan penyulit minor
24 Hemikolektomi tanpa penyulit
25 Hemoroid stapling (diluar alat)
26 Hemoroidektomi
27 Herniotomi
28 Herniotomi dgn penyulit mayor
29 Herniotomi dgn penyulit minor
30 Herniotomi laparoskopik
31 Jejunostomi / ileostomi
32 Laparotomi dengan penyulit minor
33 Laparotomi tanpa penyulit
34 Ligasi hemoroid (diluar alat)
35
Pankreatiko-duodenektomi cephalis (Whipple)
dengan penyulit mayor
36 Peritoneal dreanse (CAPD)
37 Peritoneal lavase
38 Polipektomi
39 Potong kolostomi
40 Prosedur Heller
41 Rektopexy
42 Repair fistel usus
43 Repair fistel vesicorectal
44 Repair hernia cicatricalis
45
Repair hernia cicatricalis dgn penyulit mayor (diluar
alat)
46
Repair hernia cicatricalis dgn penyulit minor (diluar
alat)
47 Repair Hernia Diafragmatika (diluar alat)
48 Reseksi anterior dengan penyulit mayor
49 Reseksi anterior dengan penyulit minor
50 Reseksi anterior tanpa penyulit
51 Reseksi esofagus-colon / ileum transposisi
52 Reseksi esofagus-end to end
53 Reseksi esofagus-esofago-gastrectomy
54 Reseksi hati
55
Second look laparoscopy
56
Splenektomi / splenoraphy traumatika
57
Splenektomi non trauma
58
Terminal esofagus proksimal gastrektomi (TEPG)

27



59
Total gastrektomi
NO
KSM/INSTALASI
/UNIT
TINDAKAN

60
Total pantreaktomi
61
Total prokto-kolektomi
62
Tutup burst abdomen (tanpa alat)
63
Tutup burst abdomen dengan penyulit mayor
64
Tutup burst abdomen dengan penyulit minor
65
Tutup kolostomi / ileostomi
66
Tutup kolostomi / ileostomi dengan penyulit mayor
67
Tutup kolostomi / ileostomi dengan penyulit minor
68 Repair Aorta Torakalis (38.34)
69 Repair Atrioventricular Septal Defect (35.54)
8 KSM BEDAH 1 Adrenalektomi
UROLOGI 2 Adrenalektomi (Abdominotorakal)
3 Anastomosis end to end Ureter
4 Augmentasi Buli
5 Biopsi Ginjal perkutan
6 Biopsi Ginjal Terbuka
7 Biopsi Penis
8 Biopsi Prostat
9 Biopsi Testis
10 Bladder Neck Rekonstruksi
11 Buried Penis
12 Businasi/Dilatasi Uretra
13 Cabut DJ Stent
14 Defooring Kista Ginjal per Laparoskopi
15 Deroofing/Unroofing Kista
16 Diseksi Kelenjar Getah Bening Inguinal
17 Diseksi Kelenjar Getah Bening pelvis
18
Diseksi Kelenjar Getah Bening Pelvis per
Laparoskopi
19 Divertikulektomi Buli
20 Divertikulum Uretra
21 Dorsumsisi
22 Drainase Periureter
23 Eksisi Chordae/Chordektomi
24 Eksisi Fibroma/Rekonstruksi Penis
25 Eksisi Plaque (Peyronie Disease)
26 Eksisi Webbed Penis
27 Eksplorasi testis (Microsurgery)
28 Ekstraksi Batu
29 Ekstrofi Buli Rekonstruksi
30 Epispadia
31 Evakuasi Bekuan Darah (Clot)
32 Extended Pyelolithotomy

28



33 Fistulektomi/Repair Fistel Uretra
NO
KSM/INSTALASI
/UNIT
TINDAKAN

34 Funikokelektomi
35 Ganti Nefrostomy
36 Hidrokel per Inguinal/Ligasi Tinggi
37 Hidrokel per Skrotal
38 Hipospadia Subkoronal
39 Holmium YaG Laser (Sewa)
40 Ileal Conduit (Bricker)
41 Insersi DJ Stent
42 Insisi Abses Perineum
43 Insisi Abses Skrotum
44 Insisi Posterior Urethral Valve
45 Johanson
46 Johanson I
47 Johanson II
48 Kalibrasi Uretra
49 Kauterisasi
50 Koreksi Horseshoe Kidney
51 Koreksi Priapismus
52 Laparoskopi Adrenalektomi
53 Laparotomi Eksplorasi
54 Ligasi V.Spermatika Interna (Microsurgery)
55
Limfadenektomi Ilioinguinal
56
Limfadenektomi Retroperitoneal/RPLND
57
Litholapaksi
58
Lithotripsi
59
Masase Prostat
60 Meatoplasti
61 Meatotomi
62
MMK/Sling Uretra
63
Nefrektomi
64
Nefrektomi Donor Transplant
65
Nefrektomi Parsial
66
Nefrektomi per Laparoskopi
67
Nefrektomi Radial
68 Nefropeksi/Renopeksi
69 Nefrostomi Perkutan/Temporer
70 Nefrostomi Terbuka/Permanen
71 Nefroureterektomi
72 Neobladder
73 Operasi Priapismus (prosedur Winter)
74 Operasi Repair Buli Trauma
75 Operasi Sistokel

29




NO
KSM/INSTALASI
/UNIT
TINDAKAN

76 Operasi Trauma Ginjal
77 Operasi Urakhus/Reseksi urakhus
78 Orkhidektomi
79 Orkhidektomi extended
80 Orkhidektomi Ligasi Tinggi
81 Orkhidektomi Subkapsuler
82 Orkhidopeksi (Torsio Testis)
83 Orkhidopeksi (UDT)
84 Orkhidopeksi per Laparoskopi
85 Pasang Kateter
86 Pasang Kateter dengan Mandrain
87 Pasang Kateter Tenckhoff untuk CAPD
88 PCNL/PNL
89 Penektomi Parsial
90 Penektomi Total/Amputasi Penis
91 PER (Primary Endoscopic Realignment)
92 Pielokalikotomi
93 Pielolitotomi
94 Pieloplasti
95 Pieloplasti per Laparoskopi
96 Prostatektomi Radikal
97 Prostatektomi Retropubik
98 Prostatektomi Terbuka
99 Prostatektomi Terbuka dan Sectio Alta
100 Psoas Hitch/Boari Flap
101 Punksi dan sklerosing Kista Ginjal
102 Railroading Rupture Uretra
103 Reimplantasi Ureter Bilateral
104
Reimplantasi Ureter
Unilateral/Ureteroneosistostomi
105 Rekontruksi Renovaskuler
106 Repair Fistel Enterovesika
107 Repair Fistel Vesikokutan
108 Repair Fistel Vesikorektal
109 Repair Fistel Vesikovagina
110 Repair Fistel Vesikovagina Kompleks
111 Reparasi Penis
112 Reseksi-anastomosis Uretra
113 RPG
114 Sectio Alta/Vesikolithotomi
115 Sirkumsisi
115 Sistektomi Parsial/Sistoplasti Reduksi
116 Sistektomi Per Laparoskopi
117 Sistektomi Total/Radikal

30



118 Sistoskopi
119 Sistoskopi ODS
NO
KSM/INSTALASI
/UNIT
TINDAKAN

120 Sistostomi perkutan
121 Sistostomi Terbuka
122 Skrotoplasti
123 Spermatokelektomi
124 Tailoring Ureter
125 Transplan Resipien
126 Transuretero-ureterostomi
127 TUR Prostat/TUIP/BNI
128 TUR Tumor Buli
129 TVP/TMP
130 Ureterokutaneostomi
131 Ureterolisis
132 Ureterolithotomi
133 Ureterolithotomi Distal
134 Ureterolithotomi Proksimal
135 Ureterosigmoidostomi (Caffey)
136 Ureterostomi
137 Ureterouretostomi
138 Uretroplasti Hipospadia
139 Uretroskopi/Uretrosistoskopi
140 Uretrotomi Interna (Sachse)
141 URS/Lithotripsi
142 Varikokelektomi (Palomo)
143 Vasektomi (anestesi lokal)
144 Vasektomi (narkose)
145 Vasoepididimostomi
146 Vasografi
147 Vasovasostomi
9 KSM ILMU 1 Angkat Jahitan
KESEHATAN 2 Angkat Jahitan dengan GA
MATA 3 Anterior Chamber Tap/Parasintesis
4 Aspirasi Massa Lensa
5 Blefaroplasty (2 Kelopak Mata)
6 Claw Lens
7 Cryopexy Kornea
8 Cyclo Cryo
9 Dacryocystorinostomi (Without Silicon Tube)
10 Dekompresi Orbital/Lateral Orbitotomi
11 Disisi Aspirasi & IOL
12 ECCE
13 ECCE & IOL
14 Eksenterasi
15 Eksisi Hordeolum / Chalazion

31




16 Ekstirpasi Corpus Alienum di Kornea
17 Ekstirpasi Pterygium + Graft Konjungtiva
NO
KSM/INSTALASI
/UNIT
TINDAKAN

18 Ekstripasi Corpus Alienum di Bilik Mata Depan
19 Enukleasi/Eviscerasi (DFG/Bonegraft)
20 Evakuasi Silikon Oil
21 Fornix Repair
22 ICCE
23 ICCE & IOL
24 Injeksi Intra Vitreal
25 Injeksi Periokuler Terapetik
26 IOL Explant
27 Iridectomi
28 Jahit Kelopak Mata Full Thickness & Lid Margin
29 Jahit Kornea
30 Keratoplasti (Corneal Transplantation)
31 Konjungtival Flap/Amnion Graft
32 Piggy Back IOL
33 Pneumoretinopexy
34 Repair Canalis Lacrimalis (Without Silicon Tube)
35 Repair Coloboma Palpebra (Skin/Mucosal Graft)
36 Reposisi IOL
37 Reposisi Iris
38 Resesi & Reseksi 2 Otot
39 Resesi & Reseksi 3 Otot
40 Resesi & Reseksi 4 Otot
41 Resesi/Reseksi 1 Otot
42 Sekunder Implant (Posterior Chamber)
43 Sekunder Implant Claw Lens / Fiksasi Sulcus
44 SICS
45 SICS & IOL
46 Simpel Vitrektomi
47 Skleral Buckle
48 Socket Repair (Contracted Socket)
49 Trabekulektomi
50 Trabekuletomi & Ollogen
51
Trabulektomi & Goniotomi pada Pediatric
Glaucoma
52 Tube Shunt (Express)
53 Viscocanulostomy
54 Vitrektomi +++
55
Vitrektomi Lengkap & Skleral Buckle
56
Wide Eksisi Tumor Kelopak Mata
57
Wide Eksisi Tumor Kelopak Mata + Flap + graft

32




NO
KSM/INSTALASI
/UNIT
TINDAKAN

10 Divisi Onkologi 1 Aspirasi Kista Mamma Single dan Multiple
2 Biopsi Core Lokal Anestesi
3 Biopsi Eksisi Lokal
4 Biopsi Eksisi Narkose
5 Biopsi Insisi Lokal
6 Biopsi Narkose
7 Breast Conserving Surgery (BCS)
8 Breast Conserving Surgery + LD Flap
9 Debriment Mamma
10 Diseksi Axilla
11 Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi
12 Eksisi Fibroadenoma Multiple Narkose
13 Eksisi Tumor Metastase Loco-regional
14 Eksplorasi Duktus Mama
15 Eksplorasi Duktus Mama+VC
16 Insisi Absces Mastitis Lokal
17 LD Flap + Eksisi Tumor
18 Mastectomy + Tram Flap
19 Modified Radical Mastectomy + Flap/Single Grafting
20 Modified Radical Mastectomy Single
21 Quadrantectomy / Partial Mastectomy
22 Simple Mastektomy + Flap/Skin Grafting
23 Simple Mastektomy Single
24 Tram Flap + Eksisi Tumor
25 Operasi Tumor Kulit
26 Biopsi Insisi Tumor Kulit Lokal
27 Biopsi Eksisi Tumor Kulit Narcose
28 Eksisi Tumor Jinak 3cm
29 Eksisi Tumor Jinak + Flap/Skin Graft
30 Eksisi Tumor Jinak Kulit >3cm
31 Wide Eksisi + Diseksi KGB
32 Wide Eksisi Tumor Ganas Kulit
33 Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft
34 Operasi Soft Tissue Tumor
35 Amputasi + Diseksi KGB
36 Amputasi Jari + Flap / Skin Graft
37 Amputasi Tungkai / Lengan
38 Biopsi Core soft Tissue
39 Biopsi Insisi Tumor Sof Tissue dengan Narcose
40 Biopsi Insisi Tumor Soft Tissue Lokal Anestesi
41 Eksisi Tumor Jinak > 3cm
42 Eksisi Tumor Jinak <3cm
43 Wide Eksisi + Compartement Procedure
44 Wide Eksisi + Diseksi KGB

33




45 Wide Eksisi Tumor Ganas
46 Wide Eksisi Tumor Jinak + Flap/Skin Graft
NO
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)

34




NO
KSM/INSTALASI
/UNIT
TINDAKAN

11 DIVISI BEDAH 1 Abdominal pull through (sfingter saving procedure)

ANAK 2 Adhesiolisis

3 Appendektomi dgn penyulit

4 Appendektomi laparoskopik

5 Appendektomi tanpa penyulit

6 Biliodigesif dengan penyulit mayor

7
Biliodigestif anastomosis tanpa penyulit atau penyulit
minor

8 Biopsi rectum

9 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 Endoskopik terapeutik


28
Gastrostomi


29
Hemikolektomi

35





30
Herniotomi elektif tanpa penyulit


31
Herniotomi laparoskopik
NO
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)

50 Polipektomi (48.36)

51 Posterosagital anorectoplasty (49.79)

52
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)

36




59 Repair ekstrofia buli (57.8)

60 Repair hernia diafragma (53.7/53.8)
NO
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
Transnasal endorectal pullthrough laparascopic
assisted (48.42)

69 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)

78 Wound repair (86.8)
12 KSM BEDAH 1 Abdominoplasty
PLASTIK 2 Aff archbar, Lokal Anastesi

3 Aff Suspensi, Lokal Anastesi

4 Amputasi above elbow

5 Amputasi bellow elbow

6 Amputasi digital

7 Amputasi jari >1

8 Amputasi jari single

9 Augmentasi mamae

10 Blefaroplasty (2 kelopak mata)

11 Blefaroplasty pada kasus sulit

37







12 Blefaroptosis
NO
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
Eksisi luas + rekonstruksi dengan bedah
mikrovaskular

26 Eksisi malformasi lymphatik / vaskuler
27 Ekstraksi ateroma / keloid
28 Ekstraksi korpus alienum
29 Elevasi ear rim cartilago
30 Excise hemangioma + rekonstruksi
31 Excise intra keloid
32 Excise polydactyly
33 Excise reduksi lymedema
34 Facial sling dengan allograft
35 Fasciotomy burn injury
36 Fasciotomy with complication
37 Flap lokal sederhana
38 Fr. Condylus mandibula open red
39 Fr. Maksila suspensi (IOID)
40 Fr. Nasal open reduction
41
Fraktur Prosesus alveolaris dengan inter dental
wiring (IDW) (per rahang)
42
Fraktur Prosesus alveolaris luas dengan IDW (per
rahang)
43
Fraktur rahang reduksi terbuka & inter oseus wiring
(IOW)

38




NO
KSM/INSTALASI
/UNIT
TINDAKAN

44 LD flap
45 Le fort I osteotomy
46 Liposuction
47 Lobuloplasti
48 Malarplasty
49 Mamma aberan unilateral
50 Mandibular distraksi
51 Mandibular rekonstruksi dengan costochondral graft
52 Mastopexi
53 Mentoplasty
54 Microsurgery
55
Multiple facial fraktur + implant
56
Muskulokutaneus flap
57
Myokutaneus flap/pectoralis mayor flap
58
Nasal repair dan rekonstruksi
59
Neo vagina
60 Operasi bedah mikro
61 Orif fraktur zygoma
62
Orif fraktur hand
63
Orif fraktur mandibula
64
Orif fraktur maxilla
65
Orif maksila plating
66
Orif mandibula plating
67
Orif mandibula wiring
68 Orif orbital wall
69 Orif orbital wall
70 Orif zygoma wiring
71 Osteotomy craniosynostosis reconstruction
72 Osteotomy facial rekonstruksi
73 Osteotomy genioplasti tanpa tarif bahan
74 Osteotomy maksila Le fort I
75 Osteotomy maksila Le fort II
76 Palatoplasti bilateral komplit
77 Palatoplasti bilateral tak komplit
78 Palatoplasti unilateral komplit
79 Palatoplasti unilateral tak komplit
80 Palatoraphy
81 Pasang archbar
82 Pasang back slab/fore slab
83 Pasang cast/gips tanpa reposisi
84 Recheiloraphy
85 Rekonstruksi dengan alloplastic material

39











86 Rekonstruksi facial cleft
87 Rekonstruksi nasal
NO
KSM/INSTALASI
/UNIT
TINDAKAN

88 Rekonstruksi palpebra
89 Released buried penis
90 Released syndactyly kompleks
91 Repair canalis lacrimalis (without silicon tube)
92 Repair coloboma palpebra (skin/mucosal graft)
93 Repair ductus nasolacrimalis
94 Repair fingertip injury
95 Repair fistel urethra
96 Replantation
97 Reposisi fraktur nasal sederhana
98 Reposisi fraktur os nasalis (complicated)
99 Reseksi mandibula + bone graft
100 Rhinoplasty
101 Rotation flap
102 Sagital Split osteotomi mandibula
103 Simple bone grafting
104 Simple skin grafting
105 Skin flap
106 Skin graft >5 cm
107 Skin graft sedang 5 cm
108 Skin grafting kecil
109 Skin grafting luas
110 Skin grafting sedang
111 Skin grafting with complication
112 Tendon reconstruction
113 Tendon transfer
114 Tendon transfer with complication
115 Tennoraphy
116 Tennoraphy with complication
117 TMJ arthroplasty
118 TMJ arthrostomy
119 Tram flap
120 Wound Dressing
121 Wound Repair

40




NO
KSM/INSTALASI/
UNIT
TINDAKAN

13 KSM
1 Cauter serviks
OBGYN 2 Cordosentesis

3 Debulking tumor ovarium

4 Eksplorasi vagina

5 Embryotomi

6 Extirpasi + kuret polip endoserviks

7 Extirpasi geboren mioma

8 Extirpasi geboren mioma+kuiretasi

9 Histeroctomy pada mola / chorio Ca

10 Histeroctomy radikal

11 Kistektomi

12 Konisasi serviks

13 Kuret abortus incompletes

14 Lap op: myomektomi

15
Laparoskopi (Kistektomi Ovarium, Salphingektomi,
Adhesiolisis)

16 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

41












30 Operative histeroscopy/Ablasi endometrium

31 Overectomi
NO
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 TAH+BSO dengan Penyulit

50
TAH+BSO dengan Penyulit Pemasangan Tampon
Abdomen

51 Total abdominal hysterectomy+bilateral salfingektomi

52 Tubektomi klinik

53 Tutup burst abdomen

42




NO
KSM/INSTALASI
/UNIT
TINDAKAN

14 KSM 1
Augmentasi Tulang Per Regio (Belum Termasuk
Bahan)
GIGI dan 2 Debriment Mukosa dan Pengelolaan Luka Sayat
MULUT 3 Dislokasi Sendi Mandibula

4 Eksisi Epulis Per Rahang

5 Eksisi Kelenjar Ludah Submandibula

6 Eksisi Kista Odontogenik Keratosis + Ostektomi

7 Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil

8 Eksisi Parsial + Marsupialisasi Ranula

9 Eksisi Plunging Ranula

10 Eksisional Biopsi Neoplasma Jinak

11 Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi

12
Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
Penyebab

13 Extirpasi Kista Dermoid

14 Extirpasi Sialolith

15 Extraksi Corpus Alienum dengan Teknik Lindorf

16
Extraksi Gigi Anak dengan Kelainan Jantung Per
Rahang

17 Extraksi Gigi Anak Per Rahang

18 Extraksi Gigi Dewasa Per Rahang

19 Fissure Sealant pada Autis

20 Fraktur Dento alveolar Dengan arch Bar

21
Fraktur Dento alveolar Dengan Bracket (belum
termasuk bahan)

22 fraktur Dento Alveolar dengan Eyelet

23 Fraktur Maksila dengan Suspensi Wiring

24 Fraktur Nasal close Reduksi

25 Fraktur Nasal Open Reduksi

26
Fraktur Rahang Reduksi Tertutup dengan
Intermaksila Fiksasi

27 Frenektomi Per Rahang

28 Genioplasty

29 Gingivektomi Per Rahang

43






NO
KSM/INSTALASI
/UNIT
TINDAKAN


30 Hemi Maksilektomi Tanpa Rekonstruksi

31 Insisi Abses / Phlegmon

32 Insisional Biopsi Neoplasma Jinak

33 Mandibular Distraksi

34 Odontektomi Per Gigi

35
ORIF Maksila + Zygoma + Mandibula (belum
termasuk implant)

36 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)
15
DIVISI PEDIATRI
1 Intubasi Endotrakea
GAWAT 2 Krikotirotomi
DARURAT 3 Kanulasi vena perifer
ILMU 4 Vena sectie
KESEHATAN 5 Pungsi lumbal

ANAK
6 Pungsiv Pleura
16
KSM PENYAKIT
1 Diagnostik Kateterisasi Jantung
JANTUNG & 2 PTMC
PEMBULUH 3 PTCA/Stenting
DARAH 4 Pacemaker Temporer&Permanen

5 IABP

6 Perikardiosintesis

7 Pemasangan Swan Ganz Kateter

8 Pemasangan Amplatzer/ADO/Coilling

9 CVC

10 Pelepasan Arch Bar (Intermaksila Fiksasi)
17
KSM PENYAKIT
DALAM
Endoscopy

44



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










45



D. Semua Tindakan Yang Berisiko Tinggi :
No
KSM /
INSTALASI
NAMA TINDAKAN
1
KSM Anak
1 Chest tube
2 Tindakan kemotherapi
3 Pemasangan Ventilator
4 Intubasi Endotrakea
5 Pemasangan Laryngeal mask
6 Krikotirotomi
7 Infus intraosseus
8 Kanulasi vena perifer
9 Vena sectie
10 Pengambilan darah intra vena dan intra arteri
11 Pungsi lumbal
12 Pungsiv Pleura
13 Pemasangan kateter urine
14 Pemasangan keteter rectal
15 Pemasangan orogastrik tube
16 Pemasangan nasogastrik tube
2
THT-KL
1 Pemeriksaan Audiometri
2 Pemeriksaan Timpanometri
3 Pemeriksaan Audiometri Tutur
4 Pemeriksaan Sisi&Tore Decay
5 Pemeriksaan Pendengaran Pada Anak
6 Pemeriksaan Brainstem Evoked Response
Audiometry
3
KSM Patologi
Anatomi
FNAB (Fine Needle Aspiration Biopsy)
4
Inst.
Radiotherapi
Tindakan Radiotherapi
5
KSM
Neurologi
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA
6 Lumbal Punksi
7 Pain Intervention
8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
6
KSM Patologi
Phlebotomi

46


Klinik
7
KSM Gigi dan
Mulut
1 Scaling
2 Curettage/root planning (jika diperlukan anestesi)
3 Gingivektomi
4 Frenektomi
5 Flap operasi (bone graft/membrance/GTR/interseptif)
6 Implant
7 Vital pulpektomi dan Partial Nekrose
8 Cauter
9 Retraksi Gingiva pada prep.crown
8
Poli
Andrologi
Suntik Intra Cavernosal Penis

9
KSM
Kardiologi
dan
Kedokteran
Vaskular
1 Dobutamin Stress Ekhokardiografi
2 Transophegal Ekhokardiografi
3 Treadmill Tes
4 Exercise Stress Ekhokardiografi

10
KSM
Pulmonologi
dan Ilmu
Kedokteran
Respirasi
1 Bronchoscopy/FOB
2 Tindakan kemotherapi
3 Thoracoscopy
4 Contra Ventil/WSD
5 Punctie Pleura
6 FNAB
7 Scalene Biopsy
8 Reposisi
9 Pleurodesis
10 AFF WSD
11 Perawatan Luka WSD
12 USG Thorax Marker

11
KSM
Radiologi
1 Tindakan Radiologi Injectee contrast
2 Tindakan Radiologi pada pasien dengan kelainan
cardiovaskuler
3 Tindakan Radiologi pada pasien dengan alergi
berat
4 Tindakan Radiologi pada pasien dengan KU yang
menurun
5 Tindakan Radiologi yang memerlukan FNAB
Guiding MSCT pada pasien dengan kelainan yang
berdekatan dengan organ vital
6 Tindakan Radiologi pada Ibu hamil yang
memerlukan foto

12
KSM
Neurologi
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA

47


6 Lumbal Punksi
7 Pain Intervention
8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
14 Neuro endovaskuler: Coiling,Embolisasi,DSA
13
Instalasi
Hemodialisis
Setiap kali melakukan tindakan Hemodialisis
14 KSM
Rehabilitasi
Medik
Elektromiografi dan Kecepatan Hantar Saraf
16 IRNA Jiwa
1
Psycho Analisa
2
Psycho Therapy Dalam
3
Pemeriksaan Calon Pimpinan Publik
4
Aborsi Provocatus Medicinalis
5
Tindakan terapi elektroconfusi
6
Pemeriksaan kandungan zat narkotika
7
Restraint / Fiksasi : mekanik dan psikotropika
8
Pemeriksaan sengketa/ konflik dalam keluarga
15
Semua injeksi dengan obat risiko tinggi