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Perihal* :
Proses Kredensial

Proses Rekredensial

Proses Penambahan Kewenangan Klinis


*) Tandai salah satu
Lampiran : 1 (Satu) Berkas

Kepada Yth,
Direktur Rumah Sakit Umum Citra Bunda Medical Center Padang
Di tempat.

Dengan hormat,
Dengan ini kami mengajukan permohonan surat penugasan klinis dan rincian kewenangan klinis
sebagai staf medis rumah sakit.
Demikianlah permohonan ini kami sampaikan, atas perhatiannya di ucapkan terima kasih.

Pemohon

Berkas yang diperlukan :


1. Foto copy STR
2. Foto copy Ijazah
3. Curiculume Vitae
4. Foto copy Surat Ijin praktek
5. Foto copy KTP
6. Pas Foto 4 x 6 Berwarna (1 lbr)
7. Format Rincian kewenangan klinik yang sudah diisi

RINCIAN KEWENANGAN KLINIS (CLINICAL PRIVILEGE)


2

BAGIAN BEDAH ORTHOPEDI


RUMAH SAKIT UMUM CITRA BUNDA MEDICAL CENTER PADANG

Nama Dokter : Spesialisasi : Tanda Tangan :

Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang saya minta dibidang
spesialisasi saya, termasuk melayani konsultasi dari dokter-dokter lain.
Saya juga menyatakan bahwa saya kompeten untuk melakukan prosedur teknis seperti yang tercantum di
bawah ini sebagai kewenangan klinis (clinical privilege) berdasarkan status kesehatan saat ini, pendidikan
dan atau pelatihan tambahan yang telah saya jalani, serta pengalaman yang saya miliki.
Sertifikasi
Universitas : Tanggal :

Kompetensi : Tanggal :

Pelatihan / Pendidikan tambahan : Tanggal : Institusi :

Surat Tanda Registrasi Konsil Kedokteran Indonesia


Spesialisasi : Berlaku Hingga Tanggal :

Petunjuk :
Untuk Dokter: Untuk Mitra Bestari:
Tuliskan jenis pelayanan munurut permintaan Mohon melakukan telaah pada setiap kategori dan
sejawat dan atau sesuai daftar pada bagian 5 yang Kewenangan Klinis yang diminta oleh setiap dokter
tersedia. Pengisian harus lengkap untuk seluruh sesuai dengan kode yang tersedia. Cantumkan
Kewenangan Klinis yang tercantum. Tanda tangan persetujuan yang tersedia. Persetujuan Mitra
dicantumkan pada akhir bagian 1 (kewenangan Bestari kepada Komite Medik untuk pemberian
Klinis). Jika terdapat revisi ini setujui, maka harus penugasan klinis (clinical appointment) dari
mengisi kembali formulir yang baru, Direktur Rumah Sakit. Bubuhkan tanda tangan
Recredencialling akan dilakukan setiap 2 tahun Mitra Bestari pada akhir bagian II (rekomendasi
atau bila diperlukan Mitra Bestari)
Kode untuk Dokter: Kode untuk Mitra Bestari:
1. Kompetensi sepenuhnya 1. Disetujui berwenang penuh.
2. Memerlukan supervisi 2. Disetujui dibawah supervisi.
3. Tidak dimintakan kewenangannya, karena 3. Tidak disetujui, karena bukan
diluar kompetensinya. kompetensinya.
4. Tidak dimintakan kewenangannya, karena 4. Tidak disetujui, karena fasilitas tidak
fasilitas tidak tersedia. tersedia.

Bagian I. Kewenangan Klinis (Clinical Privilege)


Kategori Kewenangan
3

Kewenangan klinis diberikan untuk memberikan pelayanan pengelolaan bidang Orthopedi dan
Traumatologi (PABOI) di Rumah Sakit Umum Citra Bunda Medical Center Padang berdasarkan pada
pelayanan yang dibutuhkan pasien.
Jenis Pelayanan Diminta Rekomendasi
1. Procedures and intervene, Not Elsewhere Classifieded
2. Computer assisted surgery (CAS), CT- feee navigation, image
guided navigation (IGN), imageless navigation. That without the
use of robotic (s) technology. Code also diagnostic or
therapeutic procedure. Excludes : robotic assisted produres
(17.41-17.49), stereotactic frame application only (93.59)
3. Computer assisted surgery with CT/CTA
4. Computer assisted surgery with MR/MRA
5. Computer assisted surgery with fluoroscopy
6. Imageless computer assisted surgery
7. Computer assisted surgery with multiple datasets
8. Other computer assisted surgery NOS
9. Other hip produres
10. Revision of hip replacement, both acetabular and femolar
components.
Total hip revision. Code also any : removal of (cement) (joint)
spacer (84.57) type of bearing surface, if known
11. Revision of hip replacement, acetabular component, partial,
accetabular component only. That with : exchange of cup and
liner, exchange of femoral head code also any type of bearing
surface, if known (00.74-00.77)
12. Revision of hip replacement, femoral component
13. Revision of hip replacement, acebular liner and or femolar
head only
14. Hip bearing surface, metal-on-polyethylene
15. Hip bearing surface, metal-on-metal
16. Hip bearing surface, ceramic-on-ceramic
17. Hip bearing surface, ceramic-on- polyethylene
18. Other knee and hip produres
19. Revision of knee replacement, total (all components),
replacement of femoral, tibial, and patellar components (all
components)
20. Revision of knee replacement, tibial component. Replacement
of tibial baseplate and tibial insert (liner)
21. Revision of knee replacement, femoral component. That with
replacement of tibial insert (liner)
22. Revision of knee replacement, patellar component
23. Revision of total knee replacement, tibial insert (liner).
Replacement of tibial insert (liner)
24. Resurfacing hip, total, acetabulum and femoral head. Hip
resurfacing arthroplasty, total
25. Resurfacing hip, partial, femoral head. Hip resurfacing
arthroplasty , NOS. Hip resurfacing arthroplasty, partial, femoral
head
26. Resurfacing hip, partial, acetabulum. Hip resurfacing
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arthroplasty
27. Other procedures and interventions
28. Transplant from cadaver
29. Intra-operative neurophysiologic monitoring
30. Operations on spinal cord and spinal canal structures
31. Exploration and decompression of spinal canal structures
32. Removal of foreign body from spinal canal (Cg)
33. Reopening of laminectomy site (Cg)
34. Other exploration and decompression of spinal canal.
Decompression : laminectomy, laminotomy. Expansile
laminoplasty. Exploration of spinal nerve root, foraminotomy
35. Division of intraspinal nerve root. Rhizotomy
36. Diagnostic procedures on spinal cord and spinal canal
structures
37. Biopsy of spinal cord or spinal meninges (Cg)
38. Excision or destruction of lesion of spinal cord or
spinalmeninges
Curettage of spinal cord or spinalmeninges
Debridement of spinal meninges
Marsupialization of cyst of spinal meninges
Resection of spinal cord or spinal meninges
39. Plastic operations on spinal cord structures
40. Repair of spinal meningocele
Repair of meningocele NOS
41. Repair of spinal myelomeningocele
42. Repair of vertebral fracture. Elevation of spinal bone
fragments. Reduction of fracture of vertebrae. Removal of bony
spicules from spinal canal (Cg)
43. Other repair and plastic operation on spinal cord structures.
Repair of : diastematomyelia, spina bifida NOS, spinal cord
NOS, spinal meninges NOS, vertebral arch defect
44. Lysis of adhesions of spinal cord and nerve roots
45. Injection of destructive agent into spinal canal
46. Other operations on spinal cord and spinal canal structures
47. Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances. Insertion of catheter into
epidural, subarachnoid, or subdural space space of spine with
intermittent or continuous infution of drug (with creation of any
reservoir)
48. Injection of anesthetic into spinal canal for analgesia
49. Injection of other agent into spinal canal. Intrathecal injection of
steroid subarachnoid perfusion of refrigerated saline
50. Implantation or replacement of spinal neurostimular lead (s)
51. Removal of spinal neurostimulator lead (s)
52. Percutaneous denervation of facet
53. Other
54. Operations on cranial and peripheral nerves
55. Incision, division and excision of cranial and peripheral nerves
56. Other excision or avulsion of cranial and peripheral nerves
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(Bs). Curettage of peripheral nerve debridement of peripheral


nerve. Resection of peripheral nerve. Excision of peripheral
neuroma (Mortons)
57. Diagnostic procedures on peripheral nervous system
58. Open biopsy of cranial or peripheral nerve or ganglion
59. Destruction of cranial and peripheral nerves. Destruction of
cranial or peripheral nerves by : cryoanalgesia, injection of
neurolytic agent, radiofrequency, radiofrequency,
radiofrequency ablation
60. Suture of cranial and perpheranerves
61. Lysis of adhesions and decompression of cranial and
peripheral nerves
62. Release of carpal tunnel
63. Release of tarsal tunnel
64. Other peripheral nerve or ganglion decompression or lysis of
adhesions peripheral nerve neurolysis NOS
65. Cranial or peripheral nerve graft
66. Transposition of cranial and peripheral nerves. Nerve
transpantation
67. Other cranial or peripheral neuroplasty
68. Hypoglossal-facial anastomosis
69. Accessory-facial anastomosis
70. Accessory-hypoglossal anastomosis
71. Other anastomosisi of cranial or peripheral nerve
72. Revision of previous of cranial and peripheral nerves
73. Repair of old traumatic injury of cranial and peripheral nerves
74. Other neuroplasty
75. Injection into peripheral nerve
76. Peripheral nerve injenction, not otherwise specified
77. Injection of anesthetic into peripheral nerve for analgesia
78. Injection of other agent, except neurolytic
79. Other operations on cranial and peripheral nerves
80. Neurectasis
81. Implantation or replacement of peripheralneurostimulator lead
(s)
82. Removal of peripheral neurostimulator lead (s) (Sd)
83. Incision, excision and occlusion of vessels
84. The following fourth- digit subclassification is for use with
appropriate categories in section 38.0,38.1, 38.5, 38.6, 38.8
and 38.9 according to site. Valid fourth-digits are in (brackets)
at the end of code/description 0 unspecified site 3 upper limb
vessels : axillary, Brachial, radial, ulnar
8 lower limb arteries: femoral (common) (superficial),
Popliteal, Tibial
9 lower limb veins: femoral, Popliteal, Saphenous, Tibial
85. incision of vessel. Embolectomy, Thrombectomy
86. resection of vessel with anastomosis. Angiectomy. Excision
of : aneurysm (arteriovenous) with anastomosis, blood vessel
(lesion) with anastomosis
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87. ligation and stripping of varicose


88. other excision of vessel. Excision of blood vessel (lesion)
NOS
89. other surgical occlusion of vessels. Clamping of blood vessel,
divison of blood operations on vessels
90. other operationson vessels
91. suture of vessel. Repair of laceration of blood vessel
92. suture of unspecified blood vessel
93. suture of artery (Bs)
94. Suture of vein (Bs)
95. Operatio on bone marrow and spleen
96. Bone marrow or hematopoietic stem cell transplant
97. Bone marrow transplant, not otherwise specified
98. Autologous bone marrow transplant without purging
99. Allogeneic bone marrow transplant with purging. Allograft of
bone marrow with in vitro removal (purging) of Tcells
100. Allogeniic bone morrow transplant without purging. Allograft
of bone marrow NOS
101. Autologous hematopoietic stem cell transplant without
purging
102. Allogeneic hematopoietic cell transplant without purging
103. Cord blood stem cell transplant
104. Autologous hematopoietic stem cell transplant with purging.
Cell depletion
105. Allogeneic hematopoietic stem cell transplant. Cell depletion
106. Autologous bone marrow transplant with purging. With
extracorporeal purging of malignant cells from marrow. Cell
depletion
107. INCISION EXCISION AND DIVISION OF OTHER BONES
The following fourth-digit subclassification is for use with
appropriate categories in section 77-78 to identify the site.
Valid fourth-digit categories are in code brackets under each
code.
0. Unspecified site
1. Scapula, clavicle and thorax (ribs and sternum)
2. Humerus
3. Radius and ulna
4. Carpals and metacarpals
5. Femur
6. Patella
7. Tibia and fibula
8. Tarsals and metatarsals
9. Other. Pelvic, phalanges (of foot) (of hand), vertebrae
108. Sequestrectomy
109. Other incision of bone without division. Reopening of
osteotomy
110. Wedge osteotomy
111. Other division of bone, Osteoarthrotomy
112. Biopsy of bone
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113. Excision and repair of bunion and other toe deformities


114. Bunionectomy with soft tissue correction and osteotomy of the
first metatarsal
115. Bunionectomy with soft tissue correction and arthrodesis
116. Other bunionectomy with soft tissue correction
117. Excision or correction of bunionette. That with osteotomy
118. Repair of hammer toe. Fusion of hammer toe, Phalangectomy
(partial) of hammer toe, Filleting of hammer toe
119. Repair of claw toe. Fusion of claw toe, Phalangectomy
(partial) of claw toe, Capsulotomy of claw toe, Tendon
lengthening of claw toe
120. Other excision, fusion and repair of toes. Cockup toe repair,
Overlapping toe repair. That with use of prosthetic materials
121. Other bunionectomy. Resection of hallux valgus joint with
insertion of prosthesis
122. Local excision of lesion or tissue of bone
123. Excision of bone for graft
124. Other partial ostectomy
125. Total ostectomy

126. Other operations on bones, except facial bones


127. Bone graft
Bone : Bank graft, graft (autogenous) (heterogenous)
That with debridement of bone graft site (removal of
sclerosed,
fibrous or necrotic bone or tissue), Transplantation of bone
128. Application of external fixator device.
Fixator with insertion of pins/wires/screws into bone
129. Limb shortening procedures. Epiphyseal stapling, open
opephysiodesis, Percutaneous epiphysiodesis,
Resection/osteotomy
130. Limb lengthening procedures. Bone graft with or without
internal faxation device or osteotomy. Distraction technique
with or wihaout cortocotomy/osteotomy
131. Other repair or plastic operations on bone. Other operation on
bone NEC. Repair of malunion or nonunion fracture NEC .
132. Internal faxation of bone without fracture reduction. Internal
faxation of bone (prophylactic), Reinsertion of internal
faxation
device, Revision of displaced or broken fixation device.
133. Revomal of implanted devices from bone. External fixator
device (invasive), Internal fixation device, Removal of bone
growth stimulator (invasive), Removal of internal limb
lengthening device, Removal of pedicle screw (s) used in
spinal fusion.
134. Osteoclasis
135. Diagnostic procedures on bone, not elsewhere classified
136. Insertion of bone growth stimulator. Insertion of : bone
stimulator (electrical) to aid bone healing, osteogenic
electrodes for bone growth stimulation, totally implanted
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device (invasive)
137. RDUCTION OF FRACTURE AND DISLOCATION
Includes : application of cast or splint reduction with
insertion of
traction device (Kirschner wire) (Steinmann pin). The
following
fourth-digit subclassification is for use with appropriate
categories in section 79 to identify the site. Valid fourth-digit
categories are in (brackets) under each code.
0 unspecified
1 humerus
2 radius an ulna, Arm NOS
3 carpals an metacarpals, Hand NOS
4 phalanges of hand
5 femur
6 tibia and fubula, Leg NOS
7 tarsals and metatarsals, foot NOS
8 phalanges of foot
9 other specified bone
138. Closed reduction of fracture without internal faxation
139. Closed reduction of fracture with internal faxation
140. Open reduction of fracture without internal internal fixation
141. Open reduction of fracture with internal faxation

142. Closed reduction of separated epiphysis, reduction with or


without internal fixation
143. Open reduction of separated epiphysis reduction with or
without internal fixation
144. Debridement of open fracture site. Debridement of compound
fracture.
145. Closed reduction of dislocation
Includes : closed reduction (with external traction device)
146. Closed reduction of dislocation of unspecified site
147. Closed reduction of dislocation of shoulder
148. Closed reduction of dislocation of elbow
149. Closed reduction of dislocation of wrist
150. Closed reduction of dislocation of hand and finger
151. Closed reduction of dislocation of hip
152. Closed reduction of dislocation of knee
153. Closed reduction of dislocation of foot and toe
154. Closed reduction of dislocation of other specilfied sites
155. Open reduction of dislocation
Includes : open reduction (with internal and external fixation
devices)
156. Open reduction of dislocation of unspecified site
157. Open reduction of dislocation of shoulder
158. Open reduction of dislocation of elbow
159. Open reduction of dislocation of wrist
160. Open reduction of dislocation of hand and finger
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161. Open reduction of dislocation of hip


162. Open reduction of dislocation of knee
163. Open reduction of dislocation of ankle
164. Open reduction of dislocation of foot and toe
165. Open reduction of dislocation of other specified sites
166. Unspecified operation on bone injury
167. Unspecified operation on bone injury, unspecified site
168. Unspecified operation on bone injury, shoulder
169. Unspecified operation on bone injury, elbow
170. Unspecified operation on bone injury, wrist
171. Unspecified operation on bone injury, hand and finger
172. Unspecified operation on bone injury, hip
173. Unspecified operation on bone injury, knee
174. Unspecified operation on bone injury, ankle
175. Unspecified operation on bone injury, foot and toe
176. Unspecified operation on bone injury, other specified sites
177. INCISION AND EXCISON OF JOINT STRUCTURES
Includes : operations on : capsule of join, cartilage, condyle,
ligament, meniscus, synovial membrane. The following
fourth- digit subclassification is for use with appropriate
categories in section 80 to identify the site :
0 unspecified site
1 Shoulder
2 Elbow
3 Wrist
4 Hand and finger
5 Hip
6 Knee
7 Ankle
8 Foot and toe
9 Other specified site, spine
178. Arthrotomy for removal of prosthesis. Includes remova, of
posterior spinal motion preservation (dynamic stabilization,
facet replacement, interspinou process) device (s)
179. Other arthrotomy. Arthrostomy
180. Athroscopy.
181. Biopsy of joint structure. Aspiration biopsy
182. Division of joint capsule, ligament or cartilage. Goldner
clubfoot release, Heyman-Herndon(strong) correction of
metatarsus varus. Release of : adherent or constrictive joint
capsule, joint ligament.
183. Excision, destruction and other repair of intervertebral disc
184. Excision or destruction of intervertebral disc, unspecified.
Unspecified as to excision or destruction
185. Excision of intervertebral disc, diskectomy, removal of
herniated nucleus pulposus. Level : cervical, thoracic, lumbar
(lumbosacral.That by laminotomy or hemilaminectomy.
That with decompression of spinal nerve root at same level
Requires additional code for any concomitant decompression
of spinal nerve root at different level from excision site.
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Code also any : concurrent spinal fusion repair of the anulus


fibrousus.

186. Intervertebral chemonucleolysis with aspiration of disc


fragments, with diskography. Injection of proteolytic enzyme
into intervertebral space (chymopapain)
187. Excision, destruction and other repair of intervertebral disc
188. Excision or destruction of intervertebral disc, unspecified
189. Excision of intervertebral disc, Diskectomy, Removal. Level:
cervical, thoracic, lumbar (lumbosacral). That by
laminotomy or hemilaminectomy. That with decompression of
spinal nerve root at same level. Requires additional code for
any concomitant decompression of spinal nerve root at
different level from excision site.
190. Intervertebral chemonucleolysis with aspiration of disc
fragments, with discography. Injection of proteolytic enzyme
into intervertebral space (chymopapain)
191. Repair of the annulus fibrosus with graft or prosthesis, anular
disc repair, closure (sealing) of the annulus fibrosus defect.
Includes : microsurgical suture repair with fascial autograft,
soft tissue reapproximation repair with tension bands, surgical
mesh repair
192. Other and unspecified repairof the annulus fibrosus, anular
disc repair, closure (sealing) of the annulus fibrosus defect,
Microsurgical suture repair without fascial autograft,
Percutaneous repair of the annulus fibrosus
193. Other destruction of intervertebral disc, destruction NEC, that
by laser
194. Excision of semilunar cartilage of knee, Excision of meniscus
of knee
195. Synovectomy, complete or partial resection of synovial
membrane
196. Other local excision or destruction of lesion of joint
197. Other excision of joint
198. Repair and plastic operations on joint structures
199. Spinal fusion. Includes : arthrodesis of spine with : bone graft,
internal fixation
200. Spinal fusion, not otherwise specified
201. Atlas axis spinal fusion. Craniocervical fusion by anterior,
transoral, or posterior technique
202. Other cervical fusion, anterior technique arthrodesis of C2
level or below : anterior (interbody) technique, anterolateral
tenchnique
203. Other cervical fusion, posterior technique. Arthrodes of C2
level or below : posterior (interbody) technique, posterolateral
technique
204. Dorsal and dorsolumbar fusion, anterior technique.
Arthrodesis of thoracic or thoracolumbar region : anterior
(interbody) technique, anterolateral technique
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205. Dorsal and dorsolumbar fusion, posterior technique.


Arthrodesis of thoracic or thoracolumbar region : posterior
(interbody) technique, posterolateral technique.
206. Lumbar and lumbosacral fusion, anterior technique. Anterior
lumbar interbody fusion (ALIF). Arthrodesis of lumbar or
lumbosacral region : anterior (interbody) technique,
anterolateral technique
207. Lumbar an lumbosacral fusion, lateral transverse process
technique
208. Lumbar and lumbosacral fucion, posterior technique.
Arthodesis of lumbar or lumbosacral region : posterior
(interbody) technique, posterolateral technique posterior
lumbar interbody fusion (PLIF), Transforaminal lumbar
interbody fusion (TLIF)
209. Arthrodsesis and arthoroereisis of foot and ankle. Includes :
arthrodesis of foot and ankle with : bone graft, external
fixation device
210. Ankle fusion, tibiotalar fusion
211. Triple arthrodesis. Talus to calcaneus and calcaneus to cuboid
and navicular
212. Subtalar fusion
213. Midtarsal fusion
214. Tarsometatarsal fusion
215. Metatarsophalangeal fusion
216. Other fusion of foot
217. Subtalar joint arthrodesis of other joint
218. Arthrodesis of other joint. Includes : arthrodesis with : bone
graft, external fixation device, exicion of bone ends and
compression
219. Arthrodesis of unspecified joint
220. Arthrodesis of hip
221. Arthrodesis of knee
222. Arthrodesis of shoulder
223. Arthrodesis of elbow
224. Carporadial fusion
225. Metacarpocarpal fusion
226. Metacarpophalangel fusion
227. Interphalangeal fusion
228. Arthorodesis of other specified joints
229. Refusion of spine. Includes : athrodesis of spine with : bone
graft, internal fixation, correction of pseudarthrosis of spine
230. Refusion of spine, not otherwise specified

231. Refusion of atlas axis spine, craniocervical fusion by


anterior, transoral, or posterior technique, C1-C2 fusion by
anterior, transpolar or posterior technique. Occiput C2 fusion
by anterior, transoral or posterior technique
232. Refusion of other cervical spine, anterior technique.
12

Arthrodesis of C2 level or below : anterior (interbody)


technique, anterolateral technique
233. Refusion of other cervical spine, posterior technique,
arthrodesis of C2 level or below : posterior (interbody)
technique, posterolateral technique
234. refusion of dorsal and dorsolumbar spine, anterior technique.
Artrodesis of thoracic or thoracolumbar region : anterior
(interbody) technique, anterolateral technique
235. refusion of dorsal and dorsolumbar spine, posterior technique.
Arthrodesis of thoracic or thoracolumbar region : posterior
(interbody)technique, posterolateral technique
236. refusion of lumbar and lumbosacral spine, anterior technique.
Anterior lumbar interbody fusion (ALIF) arthrodesis of
lumbar or lumbosacral region : anterior (interbody) technique,
anterolateral technique
237. refusion of lumbar and lumbosacral spine, lateral transverse
process technique
238. refusion of lumbar and lumbosacral spine, posterior technique.
Artrodesis of lumbar or lumbosacral region : posterior
(interbody) technique posterolateral technique. Posterior
lumbar interbody fusion (PLIF)
239. refusion of spine, not elsewhere classified
240. other repair of joint of lower extremity. Includes : arthroplasty
of lower extremity with : external traction of fixation, graft of
bone (chips) of cartilage, internal fixation device
241. repair of hip, not elsewhere classified
242. five-in-one repair of knee. Medial meniscectomy, medial
collateral ligament repair, vastus medialis advancement,
semitendinosus advancement, and pes anserinus transfer
243. triad knee repair. Medial meniscectomy with repair of the
anterior cruciate ligament and the medial collateral ligament.
ODonoghue procedure
244. patellar stabilization. Roux-Goldthwait operation for
recurrent dislocation of patellah
245. other repair of the cruciate dislocation of patella
246. other repair of the collateral ligaments
247. other repair of knee
248. other repair of ankle

249. Joint replacement of lower extremity. Includes : arthroplasty


of lower extremity with : external traction or fixation, graft of
bone (chips) or cartilage, internal fixation device or prosthesis
250. Total hip replacement. Replacement of both femoral head and
acetabulum by prosthesis. Total reconstruction of hip.
251. Partial hip replacement. Bipolar endoprosthesis.
252. Revision of hip replacement, not otherwise specified. Revision
of hip replacement, not specified as to components(s)
replaced, (acetabular, femoral or both)
253. Total knee replacement. Bicompartmental, Tricompartmental,
Unicompartmental (hemijoint)
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254. Revision of knee replacement, not otherwise specified


255. Total ankle pelpacement
256. Replacement of joint of foot and toe
257. Revision of joint replacement of lower extremity, not
elsewhere classfied
258. Other procedures on spine. Note : Number of vertebrae
259. Fusion or refusion of 2-3 vertebrae
260. Fusion or refusion 0f 4-8 vertebrae
261. Fusion or refusion of 9 or more vertebrae
262. Percutaneous vertebroplasty. Injection of bone void filler
(cement) (polymethylmethacrylate) (PMMA) into the diseased
of fractured vertebral body
263. Percutaneous vertebral augmentation. Insertion of inflatable
ballon, bone tamp, or other device displacing (removing)
(compacting) bone to create a pace (cavity (void) prior to the
injection of bone void filler (cement)
(polymenthylmethacrylate) (PMMA) or other substance.
Arcuplasty, Kyphoplasty, Spineoplasty
264. Arthroplasty and repair of hand, finger and wrist. Includes :
arthroplasty of hand and finger with : external traction or
fixation, graft of bone (chips) or cartilage, internal fixation
device or prosthesis
265. Arthroplasty of metacapophalangeal and interphalangeal and
interphalangeal joint with implant
266. Arthroplasty of metacarpophalangeal and interphalangeal joint
without implant.
267. Total wrist replacement
268. Artroplasty of carpocarpal or carpometacarpal joint with
implant
269. Arthroplasty of carpocarpal or carpometacarpal joint without
implant
270. Other repair of hand, finger and wrist

271. Arthroplasty and repair of shoulder and elbow. Includes :


arthroplasty of upper limb NEC with : external traction of
fixation, graft of bone (chips) or cartilage, internal fixation
device or prosthesis
272. Total shoulder replacement
273. Partial shoulder replacement
274. Repair of recurrent dislocation of shoulder
275. Other repair of shoulder. Revision of arthroplasty of shoulder
276. Total elbow replacement
277. Other repair of elbow
278. Other operation on joint structures
279. Athrocentesis. Joint aspiration
280. Injection of therapeutic substance into joint or ligament
281. Suture of capsule or ligament of upper extremity
282. Suture of capsule or ligament of ankle and foot
283. Suture capsule or ligament of other lower extremity
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284. Other repair of joint


285. Revision of joint replacement of upper extremity. Partial,
Removal of cement spacer, Total.
286. Other diagnostic procedures on joint structures
287. Other
288. Operations on muscle, tendon and fascia of hand. Includes :
operations on : aponeurosis, synovial membrane (tendon sheath),
tendon sheath
289. Incision of muscle, tendon, fascia and bursa of hand
290. Exploration of tendon sheath of hand, Incision og tendon sheath
of hand, removal of rice bodies in tendon sheath of hand
291. Myotomy of hand
292. Bursotomy of hand
293. Incision and drainage of palmar or thenar space
294. Transplantation of muscle and tendon of hand
295. Advancement of tendon of hand
296. Recession of tendon of hand
297. Reattachment of tendon of hand
298. Reattachment of muscle of hand
299. Other change in hand muscle or tendon length
300. Other hand tendon transfer or transplantation
301. Other hand tendon transposition
302. Other hand muscle transfer or transplantation
303. Other hand muscle transposition
304. Reconstruction of thumb. Includes : digital transfer to act as
thumb
305. Pollicization operation carrying over and nerves and blood
supply

306. Other reconstruction of thumb. Cocked-hat procedure [skin


flap and bone]. Grafts : bone to thumb skin (pedicle) to thumb
307. Plastic operation on hand with graft or implant
308. Tendon pulley reconstruction. Reconstruction for
opponensplasty
309. Plastic operation on hand with graft of muscle of fascia
310. Plastic operation on hand with other graft or implant. Tendon
graft to hand
311. Other plastic operations on hand
312. Transfer of finger, except thumb
313. Repair of cleft hand
314. Repair of macrodactyly
315. Repair of mallet finger
316. Other tenodesis of hand. Tendon fixation of hand NOS
317. Other tenoplasty of hand. Myotenoplasty of hand
318. Other plastic operations on hand. Placation of fascia. Repair of
facial hernia
319. Other operations on muscle, tendonand fascia of hand
320. Lysis of adhesions of hand. Freeing of bursa of hand
321. Aspiration of bursa of hand
15

322. Aspiration of other soft tissue of hand


323. Injection of therapeutic substance into bursa of hand
324. Injection of therapeutic substance into tendon of hand
325. Other injection of locally-acting therapeutic substance into soft
tissue of hand
326. Other operations on muscle, tendon and fascia of hand
327. Operations on muscle, tendon, fascia and bursa except hand.
Includes : operations on : aponeurosis, synovial membrane of
bursa and tendon sheaths, tendon sheaths
328. Incision of muscle, tendon, fascia and bursa
329. Exploration of tendon sheath. Incision of tendon sheath. Removal
of rice bodies from tendon sheath
330. Myotomy
331. Bursotomy. Removal of calcareous deposit of bursa
332. Other incision of soft tissue. Incision of fascia
333. Division of muscle, tendon and fascia
334. Achillotenotomy
335. Adductor tenotomy of hip
336. Other tenotomy. Aponeurotomy, Division of tendon, Tendon
realease, Tendon transaction, Tenotomy for thoracic outlet
decompression

337. Facciotomy. Division of fascia, Division of iliotibial band, Fascia


stripping, Release of Volkmans contracture by fasciotomy
338. Other division of soft tissue. Division of muscle, Muscle release,
myotomy for thoracic outlet decompression, Myotomy with
division, Scalenotomy, Transection of muscle
339. Diagnostic procedures on muscle, tendon, fascia and bursa
including that of hand
340. Biopsy of soft tissue
341. Other diagnostic procedures on muscle, tendon, fascia and bursa
including that of hand
342. Excision of lesion of muscle, tendon, fascia and bursa
343. Excision of lesion of tendon sheath. Excision of ganglion of
tendon sheath, except of hand
344. Excision of lesion of muscle. Excision of : heterotopic bone,
muscle scar for release of Volkmanns contracture, myositis
ossificans
345. Exsicion of lesion of other soft tissue. Excision of Bakers cyst
346. Other excision of muscle, tendon and fascia
347. Excision of tendon for graft
348. Other tenonectomy. Excision of : aponeurosis, tendon sheath,
Tenosynovectomy
349. Excision of muscle or fascia for graft
350. Other fasciectomy
351. Other myectomy. Debridement of muscle NOS. scalenectomy
352. Other excision of soft tissue
353. bursectomy
354. suture of muscle, tendon and fascia
16

355. suture of tendon sheath


356. delayed suture of tendon
357. rotator cuff repair
358. other suture of tendon. Achillorrhaphy, Aponeurorrhaphy
359. other suture of muscle or fascia. Repair of diastasis recti
360. reconstruction of muscle and tendon
361. advancement of tendon
362. recession of tendon
363. reattachment of tendon
364. reattachment of muscle
365. tendon transfer or transplantation
366. other tendon transposition
367. muscle transfer or transplantation. Release of Volkmanns
contracture by muscle transplantation

368. other muscle transposition


369. other plastic operations on muscle, tendon, and fascia
370. tendon graft
371. graft of muscle or fascia
372. tendon pulley recontruction
373. Release of clubfoot, not elsewhere classified. Evans operation on
clubfoot
374. Other change in muscle or tendon length. Hamstring lengthening,
Heel cord shortening, Plastic achillotenotomy, Tendon placation.
375. quadricepsplasty
376. Other plastic operations on muscle. Musculoplasty, Myoplasty
377. Other plastic operations on tendon. Myotenoplasty, Tendon
fixation, Tenodesis, Tenoplasty
378. Other plastic operations on fascia. Fascia lengthening,
Fascioplasty, Plication of fascia
379. Other operations on muscle, tendon, fascia and bursa
380. Lysis of adhesions of muscle, tendon, fascia and bursa
381. Insertion or replacement of skeletal muscle stimulator.
Implantation, insertion, placement or replacement of skeletal
muscle : electrodes, stimulator
382. Removal of skeletal muscle stimulator.
383. Aspiration of bursa
384. Aspiration of other soft tissue
385. Injection of therapeutic substance into bursa
386. Injection of therapeutic
387. Injection of locally-acting therapeutic substance into other soft
tissue.
388. Other operations on muscle, tendon, fascia and bursa. Suture of
bursa.
389. Other procedures on musculoskeletal system
390. Amputation of upper limb
391. Upper limb amputation, not otherwise specified amputation of
upper limb. Closeflap amputation of upper limb NOS. kineplastic
amputation of upper limb NOS. open or guillotine amputation of
17

upper limb NOS. Revision of current traumatic amputation of


upper limb NOS
392. Amputation and disarticulation of finger
393. Amputation and disarticulation of thumb
394. Amputation through hand. Amputation through carpals
395. Disarticulation of wrist
396. Amputation through forearm. Forearm amputation
397. Disarticulation of elbow
398. Amputation through humerus. Upper arm amputation

399. Disarticulation of shoulder


400. Interthoracoscapular amputation. Forequarter amputation
401. Amputation of lower limb
402. Lower limb amputation, not otherwise specified. Closed flap
amputation of lower limb NOS. Kineplastic amputation of lower
limb NOS. Open or guillotine amputation of lower limb NOS.
Revision of current traumatic amputation of lower limb NOS.
403. Amputation of toe. Amputation through metatarsophalangeal
joint. Disarticulation of toe. Metatarsal head amputation. Ray
amputation of food (disarticulation of the metatarsal head of the
toe)
404. Amputation through foot. Amputation of forefoot. Amputation
through middle of foot. Choparts amputation. Midtarsal
amputation. Transmetataresal amputation (amputation of the
forefoot, including all the toes)
405. Disarticulation of ankle
406. Amputation of ankle though malleoli of tibia and fibula
407. Other amputation below knee. Amputation of leg through tibia
and fibula NOS
408. Disarticulation of knee. Batch, Spitler and McFaddin amputation.
Mazet amputation
409. Amputation above knee. Amputation of leg through femur,
amputation of thigh. Conversion of below-knee amputation into
above- knee amputation. Supracondylar above-knee amputation.
410. Disarticulation of hip.
411. Andominopelvic amputation. Hemipelvectomy, Hindquarter
amputation
412. Reattachment of extremity
413. Thumb reattachment
414. Finger reattachment
415. Forearm, wrist, or hand reattachment
416. Upper arm reattachment. Reacttachment of arm NOS
417. Toe reattachment
418. Foot reattachment
419. Lower leg or ankle reattachment. Reattachment of leg NOS
420. Thigh Reattachment
421. Other reacttachment
422. Revision of amputation stump. Reamputation of stump,
Secondaryclosure of stump, Trimming of stump
18

423. Implantation or fitting of prosthetic limb device


424. Implantation or fitting of prosthetic limb device, not otherwise
specified

425. Fitting of prosthesis of upper arm and shoulder


426. Fitting of prosthesis of lower arm and hand
427. Fitting of prosthesis of arm, not otherwise specified
428. Implantation of prosthetic device of arm
429. Fitting of prosthesis above knee
430. Fitting prosthesis below knee
431. Fitting prosthesis of leg, not otherwise specified
432. Implantation of prosthetic device og leg
433. Implantation of other musculoskeletal devices and substances
434. Insertion of interbody spinal fusion device. Insertion of : cages
(carbon, ceramic, metal, plastic or titanium), interbody fusion
fusion cage, synthetic cages or spacers, threaded bone dewels
435. Insertion of recombinant bone morphogenetic protein. rhBMP.
That via collagen sponge, coral, ceramic and other carries
436. Implantation of internal limb lengthening device with kinetic
distraction
437. Implantation of other internal limblengthening device, Not
Otherwise Specified (NOS)
438. Insertion of bone void filler . insertion of : acrylic cement
(PMMA), bone void cement, calcium based bone void filler,
polymenthylmethacrylate (PMMA)
439. Insertion or replacement of (cement) spacer. Insertion or
replacement of joint (methylmenthacrylate) spacer
440. Removal of (cement) spacer. Removal of joint
(methylmethacrylate) spacer
441. Insertion of other spinal devices
442. Replacement of spinal disc. Includes : non-fusion arthroplasty of
the spine with insertion of artificial disc prosthesis
443. Insertion of spinal disc prosthesis, not otherwise specified.
Replacement of spinal disc, NOS. includes : diskectomy
(discectomy)
444. Insertion of partial spinal disc prosthesis, cervical. Nuclear
replacement device, cervical partial artificial disc prosthesis
(flexible), cervical. Replacement of nuclear disc (nucleus
pulposus), cervical. Includes : diskectomy (discectomy)
445. Insertion of total spinal disc prosthesis, cervical. Replacement of
servical spinal disc, NOS. Replacement of total spinal disc,
servical. Total artificial disc prosthesis (lexible), cervical.
Includes : diskectomy (discectomy)

446. Insertion of spinal disc prosthesis, thoracic, artificial disc


prosthesis (flexible), thoracic. Replacement of thoracic spinal
disc, partial or total. Includes : diskectomy (discectomy)
447. Insertion of partial spinal disc prosthesis, lumbosacral. Nuclear
replacement device, lumbar. Partial artificial disc prosthesis
19

(flexible), lumbar. Replacement of nuclear disc (nucleus pulposus


lumbar. Includes : diskectomy (discectomy)
448. Insertion of total spinal disc prosthesis, lumbosacral.
Replacement of lumbar spinal disc, NOS. replacement of total
spinal disc, lumbar. Total artificial disc prosthesis (flexible),
lumbar. Oncludes : diskectomy (discectomy)
449. Revision or replacement of artifiacial spinal disc prosthesis,
cervical. Removal of (partial) (total) spinal disc prosthesis with
synchronous insertion of new (partial) (total) spinal disc
prosthesis, cervical. Repair of previously inserted spinal disc
prosthesis, cervical
450. Revision of replacement of artificial spinal disc
prosthesisthoracic Removal of (partial (total) spinal disc
prosthesis with synchronous insertion of new (partial (total)
spinal disc prosthesis, thoracic. Repair of previously inserted
spinal disc prosthesis, thoracic.
451. Revision or replacement of srtificial spinal disc prosthesis,
lumbosacral. Removal of (partial) (total) spinal disc prosthesis
with synchronous insertion of new (partial) (total) spinal disc
prosthesis, lumbosacral. Repair of previously inserted spinal disc
prosthesis, lumbosacral.
452. Revision of replacement of artificial spinal disc prosthesis, not
otherwise specified. Removal of (partial) (total) spinal disc
prosthesis with synchronous insertion of new (partial) (total)
spinal disc prosthesis. Repair of previously inserted spinal disc
prosthesis
453. Adjunct codes for external fixator devices
454. Application of external fixator device, monoplanar system
455. Application of external fixator device, ring system. Ilizator type,
Sheffield type
456. Application of hybrid external fixator device. Computer
(assisted) (dependent) external fixator device. Hybrid system
using both ring and monoplanar device
457. Insertion, replacement and revision of posterior spinal motion
preservation device(s). includes any synchronous facetectomy
(partial, total) performed at the same level. Code also any
synchronous surgical decompression (foramonitomy,
laminectomy, laminotomy), if performed

458. Insertion or replacement of interspinous process device(s).


interspinous process decompression device(s). interspinous
process distraction device(s)
459. Revision of interspinous process device(s). repair of previously
inserted interspinous process device(s)
460. Insertion or replacement of pedicle-based dynamic stabilization
device(s)
461. Revision of pedicle-based dynamic stabilization device(s). repair
of previously inserted pedicle-based dynamic stabilization
device(s)
462. Insertion or replacement of facet replacement device(s). facet
20

arthoroplasty
463. Revision of facet replacement device(s). repair of previously
inserted facet replacement device(s)
464. Other operations on musculoskeletal system
465. Amputation, not otherwise specified
466. Separation of equal conjoined twins
467. Separation of unequal conjoined twins. Separation of conjoined
twins NOS
468. Other
469. Operations on skin and subcutaneous tissue. Includes : operations
on : hair follicles, male perineum, nails, sebaceous glands,
subcutaneous fat pads, sudoriferous glands, superficial fossae
470. Incision of skin and subcutaneous tissue
471. Aspiration of skin and subcutaneous tissue. Aspiration of :
abscess of nail, skin, or subcutaneous tissue. Hematoma of nail,
skin, or subcutaneous tissue. Seroma of nailhematoma of nail,
skin, or subcutaneous tissue. Seroma of nail, skin, or
subcutaneous tissue
472. Injection or tattooing of skin lesion or defect, Injection of filling
material, insertion of filling material, pigmenting of skin of
filling material.
473. Incision of pilonidal sinus or cyst.
474. Other incision with drainage of skin and subcutaneous tissue
475. Incision with removal of foreign body or device from skin and
subcutaneous tissue. Removal of carotid sinus baroreflex
activation device. Removal of loop recorder. Removal of
neurostimulator pulse generator (single array, dual array).
Removal of tissue expander(s) from skin or soft tissue other than
breast tissue

476. Insertion of totally implantable infusion pump


477. Insertion of totally implantable vascular access device [VAD].
Totally Implanted Port
478. Other incision of skin and subcutaneous tissue. Creation of
thalamic stimulator pulse generator pocket, new site.
Escharotomy. Exploration : sinus tract, skin & superficial fossa.
Relocation of subcutaneous device pocket NEC. Reopening
subcutaneous pocket for device revision without replacement,
undercutting of hair follicle
479. Diagnostic procedures on skin and subcutaneous tissue
480. Biopsy of skin and subcutaneous tissue
481. Other diagnostic prodcedures on skin and subcutaneous tissue
482. Excision or destruction of lesion or tissue of skin and
subcutaneous tissue
483. Excision of pilonidal cyst or sinus. Marsupialization of cyst
484. Excisional debridement of wound, infection, or burn. Removal
by excision of : devitalized tissue, necrosis, slough
485. Removal of nail, nail bed, or nail fold
486. Chemosurgery of skin, Chemical peel of skin
21

487. Dermabrasion, That with laser


488. Ligation of dermal appendage
489. Debridement of nail, nail bed, or nail fold. Removal of : nerrosis,
slough
490. Nonexcisional debridement of wound, infection of burn.
Debridement NOS. Maggot therapy. Removal of devitalized
tissue, necrosis and slough by such methods as : brushing,
irrigation (underpressure), scrubbing, washing. Water scapel (jet)
491. Other local excision or destruction of lesion or tissue of skin and
subcutaneous tissue. Destruction of skin by : cauterization
cryosurgery, fulguration, laser beam. That with Z-plasty
492. Radical excision of skin lesion. Wide excision of skin lesion
involving underlying or adjacent structure.
493. Suture or other closure of skin and subcutaneous tissue
494. Replantation of scalp
495. Closure of skin and subcutaneous tissue of other sites adhesive
(surgical) (tissue), staples, sutures
496. Free skin graft. Includes : excision of skin for autogenous graft
497. Free skin graft, not otherwise specified
498. Full-thickness skin graft to hand
499. Other skin graft to hand
500. Full- thickness skin graft to other sites

501. Heterograft to skin. Pigskin graft, Porcine graft


502. Homograft to skin
503. Homograft to skin. Graft to skin of : amnionic membrane from
donor skin from donor
504. Other skin graft to other sites
505. Pedicle graft or flaps
506. Pedicle or flap graft, not otherwise specified
507. Cutting and preparation of pedicle grafts of flaps. Elevation of
pedicle from its bed. Flap design and raising. Partial cutting of
pedicle or tube. Pedicle delay
508. Advancement of pedicle graft
509. Attachment of pedicle or flap graft to hand
510. Attachment of pedicle or flap graft to other sites. Attachment by :
advanced flap, double pedicled flap, pedicle graft, rotating flap,
sliding flap, tube graft
511. Revision of pedicle or flap graft. Debridement of pedicle or flap
graft. Defatting of pedicle or flap graft.
512. Other repair and reconstruction of skin and subcutaneous tissue
513. Repair for facial weakness
514. Facial rhytidectomy, face lift
515. Relaxation of scar or web contracture of skin. Z-plasty of skin
516. Correction of syndactyly
517. Onychoplasty
518. Other repair and reconstruction of skin and subcutaneous tissue
519. Other operations on skin and subcutaneous tissue
520. Excision of skin for graft. Excision of skin with closure of donor
22

site
521. Electrolysis and other epilation of skin
522. Insertion of tissue expander. Insertion (subcutaneous) (soft
tissue) of expander (one or more) in scalp (subgaleal space), face,
neck, trunk except breast, and upper and lower extremities for
development of skin flaps for donor use
523. Insertion or replacement of single array neurostimulator pulse
generator, not specified as rechargeable. Pulse generator (somgle
array, single channel) for intracranial, spinal and peripheral
neurostimulator.
524. Insertion or replacement of dual array neurostimulator pulse
generator, not specified as rechargeable. Pulse generator (dual
array, dual channel) for intracranial, spinal and peripheral
neurostimulator

525. Insertion or replacement of other neurostimulator pulse


generator.
526. Insertion or replacement of single array rechargeable
neurostimulator pulse generator. Rechargeable pulse generator
(single array, single channel) for intracranial, spinal, and
peripheral neurostimulator
527. Insertion or replacement of dual array rechargeable
neurostimulator pulse generator. Rechargeable pulse generator
(dual array, dual shannel) for intracranial, spinal and peripheral
neurostimulator.
528. Other
529. Physical therapy, respiratory therapy, rehabilitation and related
procedures
530. Diagnostic physical therapy
531. Functional evaluation
532. Orthotic evaluation
533. Prosthetic evaluation
534. Manual testing of muscle function
535. Range of motion testing
536. Measurement of limb length
537. Body measurement. Girth measurement, Measurement of skull
circumference.
538. Electromygraphy
539. other diagnostic physical therapy procedure
540. physical therapy exercises
541. assisting exercise
542. other active musculoskeletal exercise
543. resistive exercise
544. training in joint movements
545. mobilization of spine
546. mobilization of other joints
547. other passive musculoskeletal exercise
548. breathing exercise
549. exercise, not elsewhere classified
23

550. other physical therapy musculoskeletal manipulation


551. manual and mechanical traction
552. ambulation and gait training
553. fitting of orthotic device
554. training in use of prosthetic or orthotic device. Training in crutch
walking
555. forced extension of limb

556. Manual rupture of joint adhesions


557. Stretching of muscle or tendon
558. Stretching of fascia
559. Other forcible correction of deformity
560. Other physical therapy therapeutic procedures
561. Other hydrotherapy
562. Diathermy
563. Other heat therapy. Acupuncture with smouldering moxa,
Hotpacks, hyperthermia NEC, Infrared Irradiation, Moxibustion,
Paraffin bath
564. Combined physical therapy without mention of the components
565. Other physical therapy
566. Sketel traction and other traction
567. Spinal traction using skull device. Traction using : caliper tongs,
Crutchfield tongs, halo device, Vinke tongs
568. Other spinal traction. Cotrels traction
569. Intermittent skeletal traction
570. Other skeletal traction. Brynts traction, Dunlops traction,
Lyman Smith traction, Russells traction
571. Thomas splint traction
572. Other skin traction of limbs. Adhesive tape traction, Boot
traction, Bucks traction, Gallows traction.
573. Other immobilization, pressure and attention to wound
574. Application of plaster jacket
575. Application of neck support. Application of : cervical collar,
Minerva Jacket, molded neck support
576. Application of other cast
577. Application of splint. Plaster splint, Tray splint
578. Application of pressure dressing. Application of : Gibney
bandage, Robert Jones bandage, Shanz dressing
579. Application of other wound dressing. Porcine wound dressing
580. Application of pressure trousers. Application of : anti-shock
trousers, MAST trousers, vasopneumatic device
581. Other immobilization, pressure and attention to wound, elastic
stockings, Electronic gaiter, Intermittent pressure device,
Oxygenation of wound (hyperbaric), Stereotactic head frame
application strapping (non-traction), Velpeau dressing
582. Osteopathic manipulative treatment
583. Osteopathic manipulative treatment for general mobilization.
General articulatory treatment.
584. Osteopathic manipulative treatment using high-velocity, low-
24

amplitude force. Thrusting forces

585. Osteopathic manipulative treatment using low-velocity, high-


amplitude forces. Springing forces
586. Osteopathic manipulative treatment using isotonic, isometric
forces
587. Osteopathic manipulative treatment using indirect forces
588. Osteopathic manipulative treatment to move tissue fluids.
Lymphatic pump
589. Other specified osteopathic manipulative treatment
590. Replacement and removal of therapeutic appliances
591. Other nonoperative removal of therapeutic device
592. Removal of retroperitoneal drainage device
593. Removal of sutures from trunk, not elsewhere classified
594. Removal of packing from trunk, not elsewhere classified
595. Removal of other device from abdomen
596. Removal of other device from trunk
597. Removal of external immobilization device. Removal of : brace,
cast, splint
598. Removal of other therapeutic device
599. Nonoperative of other foreign body or calculus
600. Removal of other foreign body without incision
601. Removal of foreign body, not otherwise specified
602. Removal of superficial foreign body from eye without incision
603. Removal of other foreign body without incision from head and
neck. Removal of embedded foreigh body from eyelid or
conjunctiva without incision
604. Removal of foreign body from vulva without incision
605. Removal of foreign body from scrotum or penis without incision
606. Removal of other foreign body without incision from trunk
except scrotum, penis or vulva
607. Removal of foreign body from hand without incision
608. Removal of foreign body without incision from upper limb,
except hand
609. Removal of foreign body from foot without incision
610. Removal of foreign body without incision from lower limb,
except foot
25

Bagian II. Rekomendasi Mitra Bestari

Disetujui Disetujui dengan Catatan Tidak disetujui


Tanggal :

Catatan :

Daftar Mitra Bestari


No Nama Spesialisasi Tanda Tangan

Bagian III. Komite Medik/Sub-Komite Kredensial

Disetujui Disetujui dengan Catatan Tidak Disetujui


Tanggal :

Catatan :
26

Ketua Komite Medik Ketua Sub-Komite


Kredensial

(.................................................)
(............................................)