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/PENGOBATAN Yang Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasive yang

memerlukan informed consent antara lain:
1

NO
KSM/INSTALA
S
I/UNIT
KSM Bedah
Saraf

TINDAKAN

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

18 Elevasi Kraniotomi Fraktur Impresi,Tanpa

Robekan
N
O

KSM/INSTAL
AS
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
42
43
44
45
46
47

N
O

KSMI/INSTA
LASI/UNIT

Mesencephalectomy (Pain)
Mikrodisekktomi HNP
MVD (Microvascular Decompression)
Neurektomi/Neurolise
Neuroendoskopi (Otak,Spinal)
Neuroplasti
Omaya drain

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
76 VP Shunt Satu Sisi

N KSM/INSTA
O LASI/UNIT
2. KSM Bedah
Kepala Leher

TINDAKAN
1 Aff Arch Barr
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

N
O

3.

KSM
/INSTALAS
I/UNIT

KSM BEDAH
THT-KSL

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 34 tempat
36 patahan
37 Internal fiksasi fraktur maksilofasial 5
tempat patahan
38 atau lebih
39 Laringectomi
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

17 Ethmoidektomi (Intranasal)
18 Ekstraksi Korpus Alienum Kavum Nasi

N
O

KSM/INSTAL
ASI/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 Laringoskopi Rigid

N
O

KSM/INSTAL
ASI/UNIT

TINDAKAN
49
50
51
52
53
54
55
56
57
58

Laringoskopi Fleksible
Laringoskopi Direkta
Maksilektomi Total+Rekontruksi
Mastoidektomi Radikal
Mini FESS
Myocutaneus Flap (Pectoral Mayor)
Myringoplasty/Timpaniplasti
Mandibulekromi
Neurektomi Saraf Vidian
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

N
O

KSM/INSTAL
ASI/UNIT

TINDAKAN

KSM
Orthopedi
Dan
Traumatologi

1 Abdominopelvic amputation
2 Achillotenotomy
3 Adductor tenotomy of hip
4 Advancement of tendon
5 Advancement of tendon of hand
6 Amputation above knee
7 Amputation and disarticulation of fingergeneral anaesthesia
8 Amputation and disarticulation of finger
-local anaesthesia
9 Amputation and disarticulation of thumbgeneral anaesthesia
10 Amputation and disarticulation of fingergeneral anaesthesia

11 Amputation and disarticulation of finger

-local anaesthesia
12 Amputation and disarticulation of thumbgeneral anaesthesia
13 Amputation and disarticulation of thumblocal 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
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

26 Application of hybrid external fixator

device
27 Arthrocentesis

N
O

KSM/INSTAL
ASI/UNIT

TINDAKAN
28
29
30
31
32

Arthrodesis
Arthrodesis
Arthrodesis
Arthrodesis
Arthrodesis

of
of
of
of
of

elbow
hip
knee
other specified joints
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
41
42
43
44
45
46

Aspiration of bursa
Aspiration of bursa of hand
Aspiration of other soft tissue
Aspiration of other soft tissue of hand
Atlas-axis spinal fusion
Biopsy of bone
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

53 Bursectomy of hand
54 Bursotomy

NO KSM/INSTAL
ASI/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

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/INSTAL
ASI/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

101 Excision of other lesion of soft tissue

of hand

NO KSM/INSTAL
ASI/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-onceramic
121 Hip bearing surface, ceramic-onpolyethylene, Hip bearing surface, oxidized
zirconium-on-polyethylene
122 Hip bearing surface, metal-on-metal
123 Hip bearing surface, metal-onpolyethylene
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)
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/INSTAL
ASI/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
141Insertion 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
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/INSTAL
ASIUNIT

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

179 Myotomy
180 Myotomy of hand
181 Neurectasis

NO

KSM/INSTAL
ASI/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

NO KSM/INSTAL
ASI/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 metatarsalsPlate & Screws
212 Open reduction of fracture with
internal fixation- tarsals and metatarsalssimple implants
213 Open reduction of fracture with
internal fixation-tibia and fibula -Simple
fracture
214 Open reduction of fracture with
internal fixation-tibia and fibulaComminutive 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

228 Other change in hand muscle or tendon length

229 Other change in muscle or tendon length
230 Other destruction of intervertebral

NO

KSM/INSTAL
ASI/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,

Suture of bursa
258 Other partial ostectomy (including : Bone
curretage, marginal resection/excision)

NO

KSM/INSTALASI
/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
283
284
285
286
287

Other total shoulder replacement

Partial hip replacement
Partial shoulder replacement
Patellar stabilization
Percutaneous denervation of facet
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
298 Refusion of atlas-axis spine
299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique

NO

KSM/INSTALA TINDAKAN
SI/UNIT
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

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

NO

KSM/INSTSALASI TINDAKAN
/UNIT
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

359 Suture of Artery

360 Suture of capsule or ligament of ankle and
foot

NO

KSM/INSTALAS TINDAKAN
I/UNIT
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

NO

KSM/INSTALAS TINDAKAN
I/UNIT

KSM BEDAH
THORAKS DAN
KARDIOVASKULA
R

1 Biopsi Terbuka Bronkhus

2 Biopsi Terbuka Diafragma
3 Biopsi Terbuka Mediastinum
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

38 Repair Fistula Bronkopleural

39 Repair Laserasi Diafragma

NO

KSM/INSTALASI/UN
IT

TINDAKAN
40 Revisi Thoraks drain/water sealed drainage (WSD)
(diluar alat)
41 Thoracal Symphatectomy dengan Video Assissted
Thoracoscopic Surgery (VATS)

42
43
44
45
46

Thoracocentesis
Thymectomy
Thymectomy dengan VATS
Torakoplasti (Air Plumbage/Muscle Plumbage)
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)

NO

KSM/INSTALA
SI/UNIT

Eksisi Biopsi
Tumor
Pembuluh
Darah

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)
1 Eksisi Tumor Pembuluh Darah Perifer
(Hemangioma)
2 Eksplorasi Vaskular (Trauma/Non trauma)
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
12 Mutilasi Digiti Ekstermitas

NO

KSM/INSTALA
SI/UNIT

KSM BEDAH
DIGESTIVE

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
1 Abdominal pull through (sfingter saving
procedure)
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

NO

KSM/INSTALA
SI/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)
59 Total gastrektomi

NO

KSM/INSTALASI/UNI TINDAKAN
T

KSM/BEDAH
UROLOGI

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
1 Adrenalektomi
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
23
24
25
26
27
28
29
30
31
32

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

33 Fistulektomi/Repair Fistel Uretra

NO

KSM
INSTALASI/UNIT

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

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

66
67
68
69
70
71
72
73
74
75

NO

KSM/INSTALASI/
UNIT

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

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
109
110
111
112
113
114
115
115
116
117

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

118 Sistoskopi
119 Sistoskopi ODS

NO

KSM/INSTALASI/U
NIT

KSM ILNU
KESEHATAN

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
1 Angkat Jahitan
2 Angkat Jahitan dengan GA
3 Anterior Chamber Tap/Parasintesis

MATA

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
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

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
36
37
38
39
40
41
42

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

43 Wide Eksisi + Compartement

Procedure
44 Wide Eksisi + Diseksi KGB
45 Wide Eksisi Tumor Ganas
46 Wide Eksisi Tumor Jinak +
Flap/Skin Graft

NO

KSM/INSTALASI/ TINDAKAN
UNIT
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 (TAFlap)
72 Total Parotidectomy
73 Total Thyyroidectomy
74 Transversus-Rectus Abdominis
Flap (Tram Flap)

NO
11

KSM/INSTALAS
TINDAKAN
I/UNIT
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
30 Herniotomi elektif tanpa penyulit
31 Herniotomi laparoskopik

NO KSM/INSTALAS
I/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)
59 Repair ekstrofia buli (57.8)
60 Repair hernia diafragma (53.7/53.8)

NO KSM/INSTALAS
I/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)

12

KSM BEDAH
PLASTIK

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)
1 Abdominoplasty
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

12 Blefaroptosis

N
O

KSM/INSTALASI/ TINDAKAN
UNIT
13
14
15
16
17
18
19

Bone rekonstruksi facial cleft

Bone rekonstruksi facial cleft
Cheilonasoraphy
Chordectomy
Chordectomy+urethroplasty
Closed Reduction Fr. Nasal
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)

N
O

KSM/INSTALASI/ TINDAKAN
UNIT
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
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

NO KSM/INSTALASI/
UNIT
13

KSM OBGYN

TINDAKAN
1
2
3
4
5
6

Cauter serviks
Cordosentesis
Debulking tumor ovarium
Eksplorasi vagina
Embryotomi
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
30 Operative histeroscopy/Ablasi
endometrium
31 Overectomi

NO KSM/INSTALASI/

TINDAKAN

UNIT
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

NO KSM/INSTALASI/
UNIT
14

KSM GIGI DAN

MULUT

TINDAKAN
1 Augmentasi Tulang Per Regio (Belum
Termasuk Bahan)
2 Debriment Mukosa dan Pengelolaan
Luka Sayat 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

NO

15

KSM/INSTALASI/U
NIT

DIVISI PEDIATRI GAWAT

DARURAT ILMU
KESEHATAN ANAK

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)
1 Intubasi Endotrakea
2 Krikotirotomi
T 3 Kanulasi vena perifer

16

KSM PENYAKIT JANTUNG &

PEMBULUH DARA

17

KSMU/PENYAKI
T DALAM

4 Vena sectie
5 Pungsi lumbal
6 Pungsiv Pleura
1 Diagnostik Kateterisasi Jantung
2 PTMC
3 PTCA/Stenting
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)
Endoscopy

B. Tindakan Anestesi & Sedasi ( Sedang dan

Dalam), tindakan yang memerlukan informed
consent tersebut 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
Pemasangan
Pemasangan
Pemasangan
Pemasangan
Pemasangan
Pemasangan
Pemasangan

intubasi ventilator
vena central
CRRT
Swan Ganz (Kateter Arteri Pulmonal)
Intra Arterial Catheher (Kateter Intra Arterial)
Percutaneous Dilatational Tracheostomy
Drain Intra Thorakal/Punksi Thorax
IABP

Pemasangan Drain Intra Abdominal

Pemasangan Gemo
Cardioversi
Bronchoskopi-FOB
TEE

C. Tindakan Pemberian Produk Darah dan

Komponen Darah,tindakan yang memerlukan
informed consent tersebut antara lain:
Transfusi darah:
a. Plasma sel

f. lain lain

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

D. Semua Tindakan Yang Berisiko Tinggi :

NO KSM/INSTALASI/
UNIT

KSM ANAK

TINDAKAN
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

THT-KL

KSM PATOLOGI
ANATOMI
INST.RADIOTHERAPI

KSM Neurologi

KSM PATOLOGI

16 Pemasangan nasogastrik tube

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
FNAB (Fine Needle Aspiration Biopsy)
TINDAKAN RADIOTHERAPI
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
Phlebotomi

KLINIK

KSM GIGI DAN

MULUT

8
9

POLI ANDROLOGI
KSM Kardiologi dan
Kedokteran Vaskular

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
Suntik Intra Cavernosal Penis
1 Dobutamin Stress Ekhokardiografi
2 Transophegal Ekhokardiografi
3 Treadmill Tes
4 Exercise Stress Ekhokardiografi
1 Bronchoscopy/FOB

10

KSM
Pulmonologi
dan Ilmu
Kedokteran
Respirasi

11

KSM Radiologi

12

KSM Neurologi

13
14
16

Instalasi Hemodialisis
KSM Rehabilitasi Medik

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
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
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
14 Neuro endovaskuler:
Coiling,Embolisasi,DSA
Setiap kali melakukan tindakan Hemodialisis
Elektromiografi dan Kecepatan Hantar Saraf
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
Semua injeksi dengan obat risiko tinggi

IRNA Jiwa

15