PEMERINTAH KABUPATEN SORONG SELATAN

RUMAH SAKIT UMUM DAERAH SCHOLOO KEYEN

Alamat:Kamp.Keyen jln Ayamaru-teminabuan kab.sorong selatan
Alamat E-mail rsudscholookeyen@yahoo.com

DAFTAR TINDAKAN TINDAKAN YANG

PERLU INFORMED CONSENT

Sesuai Undang Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa tindakan
kedokteran dan kedokteran gigi yang wajib diberikan informed consent. Tindakan tersebut
yaitu :
A. Semua Tindakan Pembedahan dan Tindakan Invasif
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 Invasif yang memerlukan informed consent

antara lain:

KSM/INSTALASI/
NO TINDAKAN
UNIT
1 KSM Bedah 1 Amygdala Hypocampectomy (Epilepsi)
Saraf 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 D rameter
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
1
17 Dura

2
 18 Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan

NO KSM/INSTALASI TINDAKAN
/UNIT
19 Dura
20 Extirpasi Tumor Jinak Saraf Kulit Kepala
21 Fusi Stabilisasi Corpus Vertebra
22 Graft/Transposisi Saraf Tepi
23 Hemisferektomi (Epilepsi)
24 Hemisferoktomi (Epilepsi)
25 Injeksi saraf perifer (dengan radiofrekuensi)
26 Injeksi spinal (Pain)
Insersi Elektrode Intradural
27
(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
 KSM/INSTALASI
NO TINDAKAN
/UNIT
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)
Transposisi kraniostenosis,dengan orbital
66 advancement
Transposisi kraniostenosis,tanpa orbital
67 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

KSM/INSTALAS
NO TINDAKAN
I/UNIT
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
Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran
25
<2cm
26 Ekstirpasi kista dermoid
27 Endoscopic thyroidectomy
Fiksasi interna fraktur maksilofasial 1-2 tempat
28 patahan

5
 KSM/INSTALAS
No TINDAKA
I
29 N
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
1 Adenotonsilektomi
3. KSM
Bedah THT-KL 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

KSM/INSTALASI
NO TINDAKA
/ UNIT
N
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

KSM/INSTALASI
NO / UNIT TINDAKA
N
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
 KSM/INSTALAS
NO TINDAKAN
I/UNIT
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
Amputation and disarticulation of finger- general
7 anaesthesia
Amputation and disarticulation of finger -local
8 anaesthesia
Amputation and disarticulation of thumb-general
9 anaesthesia
Amputation and disarticulation of finger- general
10 anaesthesia
Amputation and disarticulation of finger -local
11 anaesthesia
Amputation and disarticulation of thumb-general
12 anaesthesia
Amputation and disarticulation of thumb-local
13 anaesthesia
Amputation of ankle through malleoli of tibia and
14 fibula
15 Amputation of toe-general anaesthesia
16 Amputation of toe-local anaesthesia
17 Amputation through foot
18 Amputation through forearm
Amputation through hand, Amputation through
19 carpals
Amputation through humerus, Upper arm
20 amputation
21 Amputation, not otherwise specified
22 Ankle fusion
23 Application of external fixator device
Application of external fixator device, monoplanar
24 system
25 Application of external fixator device, ring system

9
 26 Application of hybrid external fixator device
27 Arthrocentesis

KSM/INSTALAS
NO TINDAKAN
I/UNIT
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
Arthroplasty of carpocarpal or carpometacarpal joint with
34 implant
Arthroplasty of carpocarpal or carpometacarpal joint
35 without implant
Arthroplasty of metacarpophalangeal and
36 interphalangeal joint with implant
Arthroplasty of metacarpophalangeal and
37 interphalangeal joint without implant
38 Arthroscopy
Arthrotomy for removal of prosthesis without
39 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
Bone marrow or hematopoietic stem cell transplant
49
(all procedures included in this class
Bunionectomy with soft tissue correction and
50 arthrodesis
Bunionectomy with soft tissue correction and
51 osteotomy of the first metatarsal
52 Bursectomy

1
0
 53 Bursectomy of hand
54 Bursotomy

NO KSM/INSTALAS TINDAKAN
I/UNIT
55 Bursotomy of hand

56 Carporadial fusion

Closed reduction of dislocation -General

57 anaesthesia

58 Closed reduction of dislocation of ankle

59 Closed reduction of dislocation of elbow

Closed reduction of dislocation of foot and toe-

60 general anaesthesia
Closed reduction of dislocation of foot and toe-local
61
anaesthesia
Closed reduction of dislocation of hand and finger-
62 general anaesthesia
Closed reduction of dislocation of hand and finger-
63 local anaesthesia

64 Closed reduction of dislocation of hip

65 Closed reduction of dislocation of knee

Closed reduction of dislocation of other specified

66 sites-general anaesthesia
Closed reduction of dislocation of other specified
67 sites-local anaesthesia
Closed reduction of dislocation of other specified
68 sites-local anaesthesia

69 Closed reduction of dislocation of shoulder

70 Closed reduction of dislocation of wrist

71 Closed reduction of dislocation-Local anaesthesia

Closed reduction of fracture with internal fixation -

72 Carpal and metacarpal

10
 Closed reduction of fracture with internal fixation -
73 Femur (Including : MIPO, interlocking nail, TEN)
Closed reduction of fracture with internal fixation -
74 Humerus (including : Interlocking nail, TEN, MIPO)

NO KSM/INSTALAS TINDAKAN
I/UNIT
Closed reduction of fracture with internal fixation -
75 Intrarticular Major Bone
Closed reduction of fracture with internal fixation -
76 Phalang of foot
Closed reduction of fracture with internal fixation -
77 Phalang of hand
Closed reduction of fracture with internal fixation -
78 Radius and ulna (MIPO, TEN)
Closed reduction of fracture with internal fixation -
79 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
Dorsal and dorsolumbar fusion of the anterior
89 column, anterior technique
Dorsal and dorsolumbar fusion of the posterior
90 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
Excision of lesion of tendon sheath of hand,
97 Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
Excision of lesion of tendon sheath of hand,
98 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

11
 101 Excision of other lesion of soft tissue of hand

NO KSM/INSTALAS TINDAKAN
I/UNIT
102 Excision of semilunar cartilage of knee
103 Excision of tendon for graft
104 Excision of tendon of hand for graft
Excision or correction of bunionette, That with
105 osteotomy
Excision or destruction of intervertebral disc,
106 unspecified
107 Exploration of tendon sheath
108 Exploration of tendon sheath of hand
109 Exploratory thoracotomy
110 Fasciotomy
111 Fasciotomy of hand
112 Finger reattachment
113 Five-in-one repair of knee
114 Foot reattachment
115 Forearm, wrist, or hand reattachment
116 Fusion or refusion of 2-3 vertebrae
117 Fusion or refusion of 4- 8 vertebrae
118 Fusion or refusion of 9 or more vertebrae
119 Graft of muscle or fascia
120 Hip bearing surface, ceramic-on-ceramic
Hip bearing surface, ceramic-on-polyethylene, Hip
121 bearing surface, oxidized zirconium-on-polyethylene
122 Hip bearing surface, metal-on-metal
123 Hip bearing surface, metal-on-polyethylene
Implantation of internal limb lengthening device with
124 kinetic distraction
Implantation of other internal limb lengthening
125 device
Implantation or replacement of peripheral
126 neurostimulator lead (s)

12
 Implantation or replacement of spinal
127 neurostimulator lead(s)
128 Incision and drainage of palmar or thenar space
Injection of anesthetic into peripheral nerve for
129 analgesia

Injection of anesthetic into peripheral nerve for analgesia

129

KSM/INSTALAS TINDAKAN
NO
I
130 Injection of anesthetic into spinal canal for analgesia
131 Injection of destructive agent into spinal canal
Injection of locally-acting therapeutic substance into
132 other soft tissue
Injection of other agent into spinal canal, Intrathecal
133 injection of steroid, Subarachnoid perfusion of
refrigerated saline
134 Injection of therapeutic substance into bursa
135 Injection of therapeutic substance into bursa of hand
Injection of therapeutic substance into joint or
136 ligament
137 Injection of therapeutic substance into tendon
Injection of therapeutic substance into tendon of hand
138
139 Insertion of bone growth stimulator
140 Insertion of bone void filler
Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances, Insertion of
141 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
Insertion of partial spinal disc prosthesis,
145 lumbosacral
Insertion of recombinant bone morphogenetic
146 protein
Insertion of spinal disc prosthesis, not otherwise
147 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
13
 152 Insertion of total spinal disc prosthesis, lumbosacral
153 Insertion or replacement of (cement) spacer
Insertion or replacement of facet replacement
154 device(s)

NO KSM/INSTALAS TINDAKAN
I/UNIT
Insertion or replacement of interspinous process
155
device(s)
Insertion or replacement of pedicle-based dynamic
156
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

14
 179
Myotomy
180
Myotomy of hand
181
Neurectasis

NO KSM/INSTALAS TINDAKA
I/ UNIT N
182 Open biopsy of cranial or peripheral nerve or ganglion
183 Open biopsy of soft tissue
Open reduction of dislocation of ankle - Neglected
184 dislocation
185 Open reduction of dislocation of elbow -Fresh dislocation
Open reduction of dislocation of hand and finger -Fresh
186 dislocation
187 Open reduction of dislocation of hip - Fresh dislocation
Open reduction of dislocation of hip - Neglected
188 dislocation
Open reduction of dislocation of knee - Neglected
189 dislocation
190 Open reduction of dislocation of knee -Fresh dislocation
191 Open reduction of dislocation of other specified sites
Open reduction of dislocation of shoulder -Fresh
192 dislocation
Open reduction of dislocation of shoulder -Neglected
193 dislocation
Open reduction of dislocation of unspecified site-Fresh
194 dislocation
Open reduction of dislocation of unspecified site-
195 Neglected dislocation
196 Open reduction of dislocation of wrist -Fresh dislocation
Open reduction of fracture with internal fixation-
197 radius and ulna-Simple fracture
Open reduction of fracture with internal
198 fixation- unspecified site (Periarticular Major
Open reduction of fracture with internal fixation-carpals
199 and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
200 and metacarpals - plate & screws
Hand NOS -Plate & Screw
Open reduction of fracture with internal fixation-carpals
201 and metacarpals - simple implants (K-wire)
Hand NOS -implant sederhana (K-wire)
Open reduction of fracture with internal fixation-
202 femur- Comminutive or Segmental
Open reduction of fracture with internal fixation-
203 femur- Simple fracture

15
 KSM/INSTALAS TINDAKAN
NO
I/UNIT
Open reduction of fracture with internal fixation-
204 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

16
 228
Other change in hand muscle or tendon length
229
Other change in muscle or tendon length
230
Other destruction of intervertebral disc

KSM/INSTALAS TINDAKAN
NO
I/UNIT
231 Other diagnostic procedures on joint structures
Other diagnostic procedures on muscle, tendon, fascia, and
232
bursa, including that of hand
233 Other division of bone
234 Other excision of joint
235 Other excision of soft tissue
236 Other excision of soft tissue of hand
237 Other excision or avulsion of cranial and peripheral nerves
238 Other excision, fusion and repair of toes
Other exploration and decompression of spinal canal,
239
Decompression
240 Other fasciectomy
241 Other fasciectomy of hand
242 Other fusion of foot
243 Other hand muscle transfer or transplantation
244 Other hand muscle transposition
245 Other hand tendon transfer or transplantation
246 Other hand tendon transposition
247 Other incision of bone without division
248 Other incision of soft tissue
249 Other incision of soft tissue of hand
Other injection of locally-acting therapeutic substance into
250
soft tissue of hand
251 Other local excision or destruction of lesion of joint
252 Other muscle transposition
253 Other myectomy
254 Other myectomy of hand
255 Other neuroplasty
256 Other operations on muscle, tendon, fascia, and bursa
257 Other operations on muscle, tendon, fascia, and bursa,

17
 Suture of bursa
Other partial ostectomy (including : Bone curretage,
258
marginal resection/excision)

KSM/INSTALAS TINDAKAN
NO
I/UNIT
Other peripheral nerve or ganglion decompression or
259 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

18
 298 Refusion of atlas-axis spine
299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique

KSM/INSTALAS TINDAKAN
NO
I/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

19
 326 Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)

KSM/INSTAL TINDAKAN
NO
ASI/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

20
 359 Suture of Artery
360 Suture of capsule or ligament of ankle and foot

KSM/INSTALASI TINDAKAN
NO
/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

21
 KSM/INSTALASI TINDAKAN
NO
/UNIT
5 KSM 1 Biopsi Terbuka Bronkhus
2 Biopsi Terbuka Diafragma
BEDAH
3 Biopsi Terbuka Mediastinum
THORAK 4 Biopsi Terbuka Paru
S DAN 5 Biopsi Terbuka Pleura
6 Biopsi Terbuka Pleura dengan VATS
KARDIOVASKU
LAR 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
Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding
12
Dada
Eksisi Tumor Mediastinum (Thymoma, Teratoma,
13 Neurogenic dsb)
14 Ekstraksi Corpus Alienum di Regio Toraks
15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS
Evakuasi Efusi Pleura/Empyema secara Torakoskopik
16
(VATS)
17 Fiksasi Costae (Clipp, Wire) (diluar Clipp)
18 Fiksasi Sternum (Wire, Plate) (diluar wire/plate)
19 Lobektomi Parsial (Reseksi Paru segmental)
Lobektomi Parsial (Reseksi Paru segmental) dengan
20
VATS
21 Lumbal Simpatektomi
22 Mediastinostomy
Pemasangan thorak drain/water sealed drainage (WSD)
23 (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

22
 38 Repair Fistula Bronkopleural
39 Repair Laserasi Diafragma

KSM/INSTALASI TINDAKAN
NO
/UNIT

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

40 alat)
Thoracal Symphatectomy dengan Video Assissted
41 Thoracoscopic Surgery (VATS)
42 Thoracocentesis
43 Thymectomy
44 Thymectomy dengan VATS
45 Torakoplasti (Air Plumbage/Muscle Plumbage)
46 Torakotomi / sternotomi Eksplorasi
Torakotomi Eksplorasi pada Trauma jantung/Repair
47 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
Mitral Valve Replacement (MVR) dengan Mechanical
64
Valve
65 Operasi Redo Open Heart (Valve Replacement)
Operasi Reopen oleh Karena sebab Perdarahan,
66 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)
Pulmonal Valve Repair (PVR) dengan Bioprosthesis
73
Valve
74 Pulmonal Valve Repair (PVR) dengan Mechanical Valve
75 Pulmonary Artery Banding (PA)

23
 KSM/INSTALASI/
NO TINDAKAN
UNIT
76 Rastelli Procedure (right Ventricle-Pulonary Artery
Conduit)
77 Repair (Eksisi) Aneurisma Jantung
78 Repair Aorta Torakalis (38.34)
79 Repair Atrioventricular Septal Defect (35.54)
Repair Total Anomalous Pulmoanry Venous Connection
80
(TAPVC) (35.82)
81 Repair Transposition of Great Arteries (TGA) (35.84)
82 Repair Trunkus Arteriosus (35.83)
83 Revisi/Aff Pace Maker Permanen (diluar alat) (37.89)
84 Septostomi Terbuka Septum Atrium (35.41)
85 Total Koreksi Tetralogy of Fallot (TOF) (35.81)
86 Tricuspid Valve Repair (TVR) (35.14)
Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve
87
(35.27)
Tricuspid Valve Repair (TVR) dengan Mechanical Valve
88
(35.28)
89 Ventricle Septal Defect (VSD) Closure (35.5)
90 Amputasi Above Knee (AK) (84.17)
91 Amputasi Below Knee (BK) (84.14)
92 Arterial Pungsi, Kanulasi, Sectie (38.91)
93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42)
94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27)
95 Bedah Varises Insisi Babcock (38.5)
96 Biopsi Pembuluh Darah (Perifer) (38.21)
97 Debriment-Nekrotomi Luka Gangren (86.22)
98 Disartikulasi Sendi Ekstremitas (84.13)
6 Eksisi Biopsi 1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)
Tumor
2 Eksplorasi Vaskular (Trauma/Non trauma)
Pembuluh
Darah 3 Embolektomi/Trombektomi Aorta
4 Embolektomi/Trombektomi Pembuluh Darah Arteri
Embolektomi/Trombektomi Pembuluh Darah Arteri
5 Ekstremitas Bawah
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
6 Atas (diluar alat)
Embolektomi/Trombektomi Pembuluh Darah Ekstremitas
7 Bawah(diluar alat)
Embolektomi/Trombektomi Pembuluh Darah Regio servikal
8 (Karotis, Jugular) (diluar alat)
Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/
9 Traumatik)
10 Fasciotomy
11 Ligasi Vaskular Ekstremitas

24
 12 Mutilasi Digiti Ekstermitas

KSM/INSTALASI TINDAKAN
NO
/UNIT
Pasang Double Lumen Hemodialisis (HD) (diluar
13 alat)
Pasang Implantable Central Venous Access (diluar alat:
14 porth-a-cath, celsite)
Pemasangan Central Venous Catheter (CVC) (diluar alat)
15
Pemasangan Intra Aortic Baloon Pump (IABP) (diluar alat)
16
Pemasangan Peritoneal Dyalisis (PD) Catheter
17
(diluar alat)
18 Pembedahan Teleangiectasis
Repair Aneurisma (True/false) Ekstremitas Superior
19
(diluar graft)
Repair Aneurisma Aorta Abdominalis (Diluar
20
Protesa)
Repair Pembuluh Darah Regio Servikal (Karotis,
21 Jugular)
22 Repair Ruptur Pembuluh Arteri Abdominal
23 Revisi Arteriovenous Shunt
24 Skleroterapi Vena (Varises, Hemangioma)
25 Stripping Varises Ekstremitas Inferior
Vascular Shunting (Splenorenal Shunt, De Palma
26
Shunt)
27 Vena Punctie, Kanulasi, Sectie
7 KSM BEDAH 1 Abdominal pull through (sfingter saving procedure)
DIGESTIVE Abdominoperineal resection (miles) dengan penyulit
2 mayor
Abdominoperineal resection (miles) dengan penyulit
3 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

25
 KSM/INSTALASI
NO TINDAKAN
/UNIT
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)
Pankreatiko-duodenektomi cephalis (Whipple)
35
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
Repair hernia cicatricalis dgn penyulit mayor (diluar
45 alat)
Repair hernia cicatricalis dgn penyulit minor (diluar
46 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)

26
 59 Total gastrektomi

KSM/INSTALASI TINDAKAN
NO
/UNIT
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
Diseksi Kelenjar Getah Bening Pelvis per
18
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

27
 33 Fistulektomi/Repair Fistel Uretra

KSM/INSTALASI TINDAKAN
NO
/UNIT
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

28
 KSM/INSTALASI TINDAKAN
NO
/UNIT
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
Reimplantasi Ureter
104
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

29
 118 Sistoskopi
119 Sistoskopi ODS

KSM/INSTALASI TINDAKAN
NO
/UNIT
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

30
 16 Ekstirpasi Corpus Alienum di Kornea
17 Ekstirpasi Pterygium + Graft Konjungtiva

KSM/INSTALASI TINDAKAN
NO
/UNIT
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
Trabulektomi & Goniotomi pada Pediatric
51
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

31
 KSM/INSTALASI TINDAKAN
NO
/UNIT
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

32
 45 Wide Eksisi Tumor Ganas
46 Wide Eksisi Tumor Jinak + Flap/Skin Graft

KSM/INSTALASI TINDAKAN
NO
/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 (TA-Flap)
72 Total Parotidectomy
73 Total Thyyroidectomy
74 Transversus-Rectus Abdominis Flap (Tram Flap)

33
 KSM/INSTALASI TINDAKAN
NO
/UNIT
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
Biliodigestif anastomosis tanpa penyulit atau penyulit
7 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

34
 30 Herniotomi elektif tanpa penyulit
31 Herniotomi laparoskopik

KSM/INSTALASI TINDAKAN
NO
/UNIT
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)
Other Repair of Abdominal Wall (Repair Omphacele)
49 (954.72)
50 Polipektomi (48.36)
51 Posterosagital anorectoplasty (49.79)
Posterosagital anorectoplasty urethro vaginoplasty
52
(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)

35
 59 Repair ekstrofia buli (57.8)
60 Repair hernia diafragma (53.7/53.8)

KSM/INSTALASI TINDAKAN
NO
/UNIT
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)
Transnasal endorectal pullthrough laparascopic
68 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

36
 12 Blefaroptosis

KSM/INSTALASI TINDAKAN
NO
/UNIT
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
Eksisi luas + rekonstruksi dengan bedah
25 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
Fraktur Prosesus alveolaris dengan inter dental
41 wiring (IDW) (per rahang)
Fraktur Prosesus alveolaris luas dengan IDW (per
42 rahang)
Fraktur rahang reduksi terbuka & inter oseus wiring
43
(IOW)

37
 KSM/INSTALASI TINDAKAN
NO
/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

38
 86 Rekonstruksi facial cleft
87 Rekonstruksi nasal

KSM/INSTALASI TINDAKAN
NO
/UNIT
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

39
 KSM/INSTALASI/ TINDAKAN
NO
UNIT
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
Laparoskopi (Kistektomi Ovarium, Salphingektomi,
15 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

40
 30 Operative histeroscopy/Ablasi endometrium
31 Overectomi

KSM/INSTALASI TINDAKAN
NO
/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
TAH+BSO dengan Penyulit Pemasangan Tampon
50
Abdomen
51 Total abdominal hysterectomy+bilateral salfingektomi
52 Tubektomi klinik
53 Tutup burst abdomen

41
 KSM/INSTALASI TINDAKAN
NO
/UNIT
Augmentasi Tulang Per Regio (Belum Termasuk
14 KSM 1
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
Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
12
Penyebab
13 Extirpasi Kista Dermoid
14 Extirpasi Sialolith
15 Extraksi Corpus Alienum dengan Teknik Lindorf
Extraksi Gigi Anak dengan Kelainan Jantung Per
16
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
Fraktur Dento alveolar Dengan Bracket (belum
21 termasuk bahan)
22 fraktur Dento Alveolar dengan Eyelet
23 Fraktur Maksila dengan Suspensi Wiring
24 Fraktur Nasal close Reduksi
25 Fraktur Nasal Open Reduksi
Fraktur Rahang Reduksi Tertutup dengan
26
Intermaksila Fiksasi
27 Frenektomi Per Rahang
28 Genioplasty
29 Gingivektomi Per Rahang

42
 KSM/INSTALASI TINDAKAN
NO
/UNIT
30 Hemi Maksilektomi Tanpa Rekonstruksi
31 Insisi Abses / Phlegmon
32 Insisional Biopsi Neoplasma Jinak
33 Mandibular Distraksi
34 Odontektomi Per Gigi
ORIF Maksila + Zygoma + Mandibula (belum
35 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 ILMU 3 Kanulasi vena perifer
KESEHATAN 4 Vena sectie
ANAK 5 Pungsi lumbal
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)
KSM PENYAKIT Endoscopy
17
DALAM

43
 B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang
memerlukan informed consenttersebut antara lain:
a. Semua tindakan anestesi dan sedasi di dalam kamar operasi b.
Semua tindakan anestesi dan sedasi di ICU

Tindakan Anestesi di ICU

Pemasangan intubasi ventilator

Pemasangan vena central
Pemasangan CRRT
Pemasangan Swan Ganz (Kateter Arteri Pulmonal)
Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)
Pemasangan Percutaneous Dilatational Tracheostomy
Pemasangan Drain Intra Thorakal/Punksi Thorax
Pemasangan IABP
Pemasangan Drain Intra Abdominal
Pemasangan Gemo
Cardioversi
Bronchoskopi-FOB
TEE

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

informed consenttersebut antara lain:
Transfusi darah:
a. Plasma sel b.
PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin
f. lain lain

44
D. Semua Tindakan Yang Berisiko Tinggi :
KSM /
No NAMA TINDAKAN
INSTALASI
1 Chest tube
2 Tindakan kemotherapi
3 Pemasangan Ventilator
4 Intubasi Endotrakea
5 Pemasangan Laryngeal mask
6 Krikotirotomi
7 Infus intraosseus
KSM Anak 8 Kanulasi vena perifer
1
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
1 Pemeriksaan Audiometri
2 Pemeriksaan Timpanometri
3 Pemeriksaan Audiometri Tutur
2 THT-KL 4 Pemeriksaan Sisi&Tore Decay
5 Pemeriksaan Pendengaran Pada Anak
6 Pemeriksaan Brainstem Evoked Response
Audiometry
KSM Patologi
3 FNAB (Fine Needle Aspiration Biopsy)
Anatomi
Inst.
4 Tindakan Radiotherapi
Radiotherapi
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA
KSM 6 Lumbal Punksi
5 7 Pain Intervention
Neurologi
8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
6 KSM Patologi Phlebotomi

45
 Klinik
1 Scaling
2 Curettage/root planning (jika diperlukan anestesi)
3 Gingivektomi
KSM Gigi dan 4 Frenektomi
7 5 Flap operasi (bone graft/membrance/GTR/interseptif)
Mulut
6 Implant
7 Vital pulpektomi dan Partial Nekrose
8 Cauter
9 Retraksi Gingiva pada prep.crown
Poli
8 Suntik Intra Cavernosal Penis
Andrologi
1 Dobutamin Stress Ekhokardiografi
KSM
Kardiologi 2 Transophegal Ekhokardiografi
dan 3 Treadmill Tes
9 4 Exercise Stress Ekhokardiografi
Kedokteran
Vaskular
1 Bronchoscopy/FOB
2 Tindakan kemotherapi
3 Thoracoscopy
4 Contra Ventil/WSD
KSM
5 Punctie Pleura
Pulmonologi
6 FNAB
dan Ilmu
10 7 Scalene Biopsy
Kedokteran
8 Reposisi
Respirasi
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
KSM 4 Tindakan Radiologi pada pasien dengan KU yang
11 Radiologi 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
KSM 2 AVM&Embolisasi
3 Aneurisma Coiling
12 Neurologi
4 Embolisasi pre operasi
5 Diagnosis DSA

46
 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
Instalasi
13 Setiap kali melakukan tindakan Hemodialisis
Hemodialisis

14 KSM
Rehabilitasi Elektromiografi dan Kecepatan Hantar Saraf
Medik
1 Psycho Analisa
2 Psycho Therapy Dalam
3 Pemeriksaan Calon Pimpinan Publik
4 Aborsi Provocatus Medicinalis
16 IRNA Jiwa
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

47