DR Thurman HS Spot Fix

Perihal : Proses Kredensial
Proses Rekredensial
Proses Penambahan Kewenangan Klinis
Lampiran : 1 (Satu) Berkas
Kepada Yth
Direktur RSUD A. Dadi Tjokrodipo
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 diucapkan terimakasih.
………………………………..
Pemohon
dr. Thurman HS, Sp. OT
Berkas yang diperlukan:
1. Foto copy STR

2. Foto copy Ijazah
3. Curiculum vitae
4. Foto copy Surat Izin Praktek
5. Foto copy KTP
6. Pas Foto 4x6 Berwarna (1 lbr)
7. Format rincian kewenangan klinik yang sudah diisi.
Nomor : Bandar Lampung, ...................20....
Lampiran : 1( satu) berkas Kepada Yth.
Perihal : Rekomendasi Surat Penugasan Klinis Direktur RSUD A. Dadi Tjokrodipo
Dengan Rincian Kewenangan Klinis di Tempat
Dengan Hormat,
Menindak lanjuti rekomendasi direktur utama rumah sakit No……. tanggal……………..….

tentang Kredensial/Rekredensial bagi staf Medis di RSUD A. Dadi Tjokrodipo, setelah melalui
proses kredensial/rekredensial maka dengan ini Komite Medis merekomendasikan nama yang
tercantum dibawah ini untuk diberikan Surat Penugasan Klinis atas;
Nama : dr. Thurman HS, Sp. OT
Keahlian : SPESIALISASI ORTHOPEDI DAN TRAUMATOLOGI
Dengan kewenangan klinis sebagaimana tercantum dalam Rincian Kewenangan Klinis yang
terdapat dalam lampiran surat ini
Demikian dan terima kasih atas perhatiannya.
Hormat Kami,
Ketua Komite Medis
RSUD A Dadi Tjokrodipo
Dr.Upang Wijayanto Sp.THT

RINCIAN KEWENANGAN KLINIS
Rekomendasi Rincian Kewenangan klinis untuk dokter dalam menjalankan prosedur tindakan medis di
Rumah Sakit A. Dadi Tjokrodipo diberikan dalam rangka peningkatan kualitas pelayanan dan
keselamatan pasien dengan kemampuan bersikap secara bertanggung jawab dan mentaati semua
disiplin dan etika kedokteran serta moral yang baik kepada pasien, sejawat dan masyarakat.
Kewenangan ini diberikan kepada:
Kualifikasi : Dokter Spesialis Orthopedi dan Traumatologi
Kewenangan prosedur yang diberikan termasuk inti pelayanan yaitu melakukan diagnosis, pemeriksaan
penunjang, penatalaksanaan dan terapi konsultasi medis dalam penatalaksanaan penyakit dengn
rincian untuk prosedur tindakan sebagai berikut:
NO PROSEDUR TINDAKAN DISETUJUI KET
M DS
Shoulder dislocation, closed & open 

1 reduction
2 Orif fraktur shoulder region (glenoid, 

AC joint, prox humerus)
3 Elbow : dislocation, closed & open 

reduction
4 Orif pada fraktur aroundelbow 

(Olecranon, radial head, epicondyle,
coronoid )
5 Wrist : Dislocation, closed & open 

reduction
6 Orif fraktur around wristjoint 
7 Fiksasi eksterna 
8 Pemasangan eksternal support (gips, 

dll)
9 Hand (Carpal bones,metacarpals, 

phalanges dan joint) : Orif
11 Closed / open reduction + eksternal 

support
12 Close reduction + internal fiksasi 
13 Arthrodesis + orif 
14 Humerus : Orif 
16 Closed reduction + internal fiksasi 
17 Closed reduction + eksternal support 
18 Radius ulna : Fraktur & dislokasi : Orif 
20 Close reduction + eksternal support 
22 Femur & Hip : Fraktur & dislokasi : Orif 
23 Closed reduction & internal fiksasi 
M DS
24 Fiksasi eksternal 
Knee joint : Dislokasi & cedera ligament 

25 : Orif ( Fraktur patella, Tibial spine)
26 closed reduction + eksternal support 
27 fiksasi eksterna 
Tibasi & fibula, ankle & fraktur & 

28 dislokasi : Orif
29 Closed reduction & eksternal support 
30 Closed reduction & Internal fiksasi 
32 Arthodesis ankle dengan fiksasi 
33 Arthodesis knee dengan fiksasi 
Foot : ( Fraktur & dislokasi pada 

34 tarsilsbone, metatarsal phalangs) : Orif
Spine : Dekompresi ( Laminectomy, 

37 discectomy)
38 Stabilisasi posterior 
39 Stabilisasi anterior 
40 Debridement pada spine 
41 Repair tendon pada ekstremitas atas 
42 Repair tendon pada ekstremitas bawah 

43 Debridement 
44 Arthroplasty : Total hip Arthroplasty 
45 Hemi hip Arthroplasty 
46 Total knee Arthroplasty 
47 Elbow Anthroplasty 
48 Shoulder Arthroplasty 
49 Repair muscle 
50 Skin graft ( STSG, FTSG) 
51 Flap pada ekstremitas 
52 Arteri repair pada ekstremitas 
53 Vein repair 
54 Nerve repair pada ekstremitas 
Fasciotomy pada 
55 compontment syndrome
56 Arthroscopy knee : Debridement 
57 Ligament repair 
58 Orif pada fraktur pelvis 
59 Fiksasi eksterna pelvis 
60 Soft tissue lengthening 
61 Tenoplasty 
Procedures and interventions, Not 

62 Elsewhere Classified
63 Imageless computer assisted surgery 
64 Other hip procedures 
Other knee and hip procedures Note : 

Report up two components using 00.81-
00.83 to describe revision of knee
replacements. If all three components
65 are revised, report 00.80
Operations on spinal cord and spinal 

66 canal structures
Exploration and decompression of 

67 spinal canal structures
M DS
68 Removal of foreign body from spinal canal (Cg) 
69 Reopening of laminectomy site (Cg) 
Other exploration and decompression of spinal canal 
Decompression : laminectomy, laminotomy. Expansile

laminoplasty. Exploration of spinal nerve root,
foraminotomy. Code also any synchronous insertion,
replacement and revision of posterior spinal motion
70 preservation device (s), if performed (84.80-84.85)
Diagnostic procedures on spinal cord and spinal canal 

71 structures
72 Biopsy of spinal cord or spinal canal meninges (Cg) 
Excision or destruction of lesion of spinal cord or 

spinal meninges. Curretage of spinal cord or spinal
meninges. Debridement of spinal cord or spinal
meninges. Marsupialization of cyst of spinal cord or
spinal meninges. Resection of spinal cord or spinal
73 meninges
Repair of vertebral fracture. Elevation of spinal bone 

fragments . Reduction of fracture of vertebrae
74 Removal of bony spicules from spinal canal (Cg)
Other operations on spinal cord and spinal canal 

75 structures
Injection of anesthetic into spinal canal for analgesia 

76 (Sd)
Injection of other agent into spinal canal. Intrathecal 

injection of steroid. Subarachnoid perfusion of
77 refrigrated saline
78 Percutaneous denervation of facet 
79 Curretage of peripheral nerve 
Debridement of peripheral nerve. Resection of 

80 peripheral nerve
81 Excision of peripheral neuroma (Morton’s) 
82 Diagnostic procedures on peripheral nervous system 
83 Open biopsy of cranial or peripheral nerve or ganglion 
84 Release of carpal tunnel 
85 Release of tarsal tunnel 
Other peripheral nerve or ganglion decompression or 

86 lysis of adhesions peripheral nerve neurolysis NOS
87 Injection into peripheral nerve 

88 Peripheral nerve injection not otherwise specified 
Injection of anesthetic into peripheral nerve for 

89 analgesia
90 Injection of other agent except neurolytic 
The following fourth-digit subclassification is for use 

with appropriate categories in section
38.0,38.1,38.3,38.5,38.6,38.8 and 38.9 according to
site,validfourth-digits are in (brackets) at the end of
each 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,
91 Popliteal,Saphenous, Tibia
92 Suture of artery (Bs) 
93 Suture of vein (Bs) 
M DS
94 
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 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 bones, phalanges (of foot) (of hand),

verterbrae
95 Sequestrectomy (77.00-77.09) 
Other incision of bone without division. 
96 Reopening of osteotomy site (77.11-77.19)

97 Wedge osteotomy 
98 Other division of bone, Osteoarthrotomy (77.31-77.39) 
99 Biopsy of Bone (77.41-77.49) 
Excision and repair of bunion and other toe 

100 deformities
Bunionectomy with soft tissue correction and 

101 osteotomy of the first metatarsal

102 arthrodesis
103 Other bunionectomy with soft tissue correction 
Excision or correction of bunionette. That with 

104 osteotomy
Repair of hammer toe. Fusion of hammer toe, 

phalangectomy (partial) of hammer toe, filleting of
105 hammer toe
Repair of claw toe phalangectomy (partial) of claw toe, 

capsulotomy of claw toe, tendon lengthening of claw
106 toe
107 Other excision,fusion and repair of toes 
Other bunionectomy. Resection of hallux valgus joint 

108 with insertion of prosthesis
Local excision of lession or tissue of bone (77.61- 

109 77.69)
110 Excision of bone for graft (77.70-77.79) 
111 Other partial osteotomy (77.80-77.89), condylectomy 
112 Total osteotomy (77.90-77.99) 
113 Other operations on bones,except facial bones 
114 Bone graft (78.00-78.09) 
Application of external fixator device (78.10-78.19) 
Fixator with insertion of pins/wires/screws into bone
Code also any type of fixator device,if known (84.71-

115 84.73)
Limb shortening procedures (78.20,78.22-78. 

25,78.27-78.29) Epiphyseal stapling, open
epiphysiodesis,Percutaneous epiphysiodesis,
116 Resection/osteotomy
Limb lengthening procedures (78.30,78.32-78.35, 

78.37-78.39) Bone graft with or without internal
fixation divices or osteotomy.Distraction technique
with or without corticotomy/ostetotomy
117
Code also any applictaion of an external fixation
device (78.10-78.19)
M DS
Other repair or plastic operations on bone (78.40- 

78.49).Other operation on bone NEC. Repair of mal
118 union or non union fracture NEC
Internal fixation of bone without fracture reduction 

(78.50-78.59) Internal fixation of bone (prophylactic),
reinsertion of internal fixation device,revision of
119 displaced or broken fixation device
Removal of implanted devices from bone ( 78.60- 

78.69)
External fixator device (invasive), internal fixation

device, removal of bone growth stimulator (invasive)
removal of internal limb lengthening device, removal
120 of pedicle screw (s) used in spinal fusion
121 Osteoclasis (78.70-78.79) 
Diagnostic procedures on bone, not elsewhere 

122 classified (78.80-78.89)
Insertion of bone growth stimulator (78.90-78.99) 
Insertion of bone stimulator (electrical) to aid bone

healing, osteogenic electrodes for bone growth
123 stimulation, tottally impalnted device (invasive)
Reduction of fracture and dislocation , Includes : 

application of cast or splint reduction with insertion of
traction device (Kirschner wire) (steinmann pin)
Code also any : application of external fixator device

(78.10-78.19) & type of fixator devicem if known
(84.71-84.73)

with appropriate categories in section 79 to identify
the site. Valid forth-digit categories are in (brackets)
under each code.
0 unspecified site
1 humerus
2 radius and ulna, Arm NOS
3 Carpals and metacarpals, Hand NOS
4 Phalanges of hand
5 femur
6 tibia andm fibula, Leg NOS
124 7 tarsals and metatarsals , Foot NOS

8 Phalanges of foot
9 other specified bone
Closed reduction of fracture without internal fixation 

125 (79.00-79.09)
Closed reduction of fracture with internal fixation 

126 (79.10-19.19)
Open reduction of fracture without internal fixation 

127 (79.20-79.29)
Open reduction of fracture with internal fixation 

128 (79.30-79.39)
Closed reduction of separated spiphysis, reduction 

with or without internal fixation (79.40-79.42,79.45-
129 79.46,79.49)
Open reduction of separated epiphysis (79.50- 

79.52,79.55,79.56,79.59)
130 Reduction with or without internal fixation
Debridement of open fracture site (79.60-79.69) 
131 Debridement of compound fracture
Closed reduction of dislocation. Includes : closed 

132 reduction (with external traction device)
133 Closed reduction of dislocation of unspecified site 
134 Closed reduction of dislocation of shoulder 
135 Closed reduction of dislocation of elbow 
M DS
136 Closed reduction of dislocation of wrist 
137 Closed reduction of dislocation of hand and finger 
138 Closed reduction of dislocation of hip 
139 Closed reduction of dislocation of knee 
140 Closed reduction of dislocation of ankle 
141 Closed reduction of dislocation of foot and toe 
142 Closed reduction of dislocation of other specified sites 
Closed reduction of dislocation includes : open 

143 reduction (with internal and external fixation devices)
144 Open reduction of dislocation of unspecified site 
145 Open reduction of dislocation of shoulder 

146 Open reduction of dislocation of elbow 
147 Open reduction of dislocation of wrist 
148 Open reduction of dislocation of hand and finger 
149 Open reduction of dislocation of hip 
150 Open reduction of dislocation of knee 
151 Open reduction of dislocation of ankle 
152 Open reduction of dislocation of foot and toe 
153 Open reduction of dislocation of other specified site 
154 Unspecified operation on bone injury 
155 Unspecified operation on bone injury, unspecified site 
156 Unspecified operation on bone injury, shoulder 
157 Unspecified operation on bone injury, elbow 
158 Unspecified operation on bone injury, wrist 
159 Unspecified operation on bone injury, hand and finger 
160 Unspecified operation on bone injury,hip 
161 Unspecified operation on bone injury, knee 
162 Unspecified operation on bone injury, ankle 
163 Unspecified operation on bone injury, foot and toe 
Unspecified operation on bone injury, other specified 

164 sites
Incision and excision of joint structures 
Includes : operations on : capsule of joint,

cartilage,condyle,ligament,meniscus,synovial
membrane

the site :
0 unspecified site
1 shoulder
2 elbow
3 wrist
4 hand and finger
5 hip
6 knee
7 ankle
165 8 foot and toe

9 other specified site, Spine
M DS
Arthrotomy for removal of prosthesis (80.00-80.09) 
Includes remova : of posterior spinal motion

preservation (dynamic stabilization,facet replacement,
interspinous process) device 9s)
Code also any : insertion of (cement)
(joint) (methylmethacrylate) spacer (84.56), removal of

166 (cement)(joinT) (methylmethacylate) spacer (84.57)
167 Other arthrotomy (80.10-80.19) Arthrostomy 
168 Arthroscopy (80.20-80.29) 
Biopsy of joint structure (80.30-80.39). aspiration 

169 biopsy
Division of joint capsule, ligament or cartilage (80.40- 

80.49)
Goldner clubfoot release, Heyman-Herndon(strong)

correction of metatarsus varus
Release of : adherent or constrictive joint capsule,joint

170 ligament
Excision, desctruction and other repair of 

171 intervertebral disc
Excision or desctruction, unspecified. Unspecified as 

172 to excision or desctruction
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.
Code also any : concurrent spinal fusion (81.00-

81.09)
173 Repair of the anulusfibrousus (80.53-80.54)
Excision of semilunar cartilage of knee, excision of 

174 meniscus knee
Synovectomy , complete or partial resection of 

175 synovial merabrane(80.70-80.79)
Other local excision or desctruction of lesion of joint 

176 (80.80-80.89)
177 Other excision of joint (80.90-80.99) 
178 Repair and plastic operations on joint structures 
Spinal fusion 
Includes : arthrodesis of spine with : bone graft,

internal fixation,
Code also any insertion of interbody spinal fusion

device (84.51
Any insertion of recombinant bone morphogenetic

protein (84.52)
Any synchronous excision of (locally) harvested bone

for graft (77.70-77.79)
179 The total number of vertebrae fused (81.62-81.64)
180 Spinal fusion, not otherwise specified 
Dorsal and dorsolumbar fusion, posterior technique 
Arthrodesis of thoracic or thoracolumbar region :

posterior (interbody) technique, posterolateral
181 technique
Lumbar and lumbosacral fusion,anterior 

technique,anterior lumbar interbody fusion (ALIF)
Arthrodesis of lumbar or lumbosacral region anterior

182 (Interbody) technique, anterolateral technique
Lumbar and lumbosacral fusion, lateral transverse 

183 process technique
M DS
Lumbar and lumbosacral fusion, posterior technique 
Arthrodesis of lumbar or lumbosacral region :
Posterior (interbody) technique, posterolateral

technique
Posterior lumbar interbody fusion (PLIF)
184 Transforaminal lumbar interbody fusion (TLIF)
Arthrodesis and arthroereisis of foot and ankle, 

includes :
Arthrodesis of foot and ankle with : bone graft,

185 external fixation device
186 Ankle fusion, tibiotalar fusion 
187 
Triple arthrodesis. Talus to calcaneus and calcaneus
to cuboid and navicular
188 Subtalar fusion 
189 Midtarsal fusion 
190 Tarsometatarsal fusion 
191 Metatarsophalangeal fusion 
192 Other fusion of foot 
193 Subtalar joint arthroereisis 
Arthrodesis of other joint 
Includes :
Arthrodesis with : bone graft, external fixation device,

194 excision of bone ends and compression
195 Arthrodesis of unspecified joint 
196 Arthrodesis of hip 
197 Arthrodesis of knee 
198 Arthrodesis of shoulder 
199 Arthrodesis of elbow 
200 Carporadial fusion 
201 Metacarpophalangeal fusion 
202 Interphalangeal fusion 
203 Arthrodesis of other specified joints 
Refusion of spine, includes : arthrodesis of spine with 

: bone graft , internal fixation, correction of
pseudarthrosis of spine, code also any insertion of
interbody spinal fusion device (84.51), any insertion of
recombinant bone morphogenetic protein (84.52)

graft (77.70-77.79)
205 Refusion of spine, not otherwise specified 
Refusion of dorsal and dorsolumbar spine, anterior 

technique. Arthrodesis of thoracic or thoracolumbar
region : anterior (intrerbody) technique, anterrolateral
206 technique
Refusion of lumbar and lumbosacral spine, posterior 

technique, arthrodesis of lumbar of lumbosacral
region : posterior (interbody) technique, posterolateral
technique
Posterior lumbar interbody fusion (PLIF),

208 Refusion of spine, not elsewhere classified 
Other repair of joint of lower exteremity 
Includes : arthroplasty of lower extremity

with:external traction of fixation, graft of bone (chips)
209 or cartilage, internal fixation device
M DS
210 
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
211 
Total hip replacement.
Replacement of both femoral head and acetabulum by

prosthesis
Total reconstruction of hip
Code also any type of bearing surface, if known (

00.74-00.77)
212 
Partial hip replacement. Bipolar endoprosthesis. Code
also any type of bearing surface, if known (00.74-
00.77)
213 
Total knee replacement Bicompartmental,
tricompartmental, unicompartmental (hemijoint)
214 
Other procedures on spine Note : number of vertebrae
Teh vertebral spine consists of 25 vertebrae in the

following order and number :
Cervical : C1 (atlas), C2 (axis), C3, C4,C5,C6,C7
Thoracic or Dorsal :T1,T2,T3.T4,T5,T6,T7,T8,

T9,T10,T11,T12. Lumbar and sacral :L1,L2,L3,L4,
L5,S1. Coders should report only one code from the
series 81.62 or 81.63 or 81.64 to show the total
number of vertebrae fused on the patient.
Code also the level and approach of fusion or refusion

(81.00-81.08),81.30-81.39)
215 Fusion or refusion of 2-3 vertebrae 

217 Fusion or refusion of 9 or more vertebrae 
218 Suture of capsule or ligament of other lower extremity 
Operations on msucle, tendon, and fascia of hand 
Includes : operations on : aponeurosis, synovial

219 membrane (tendon sheath), tendon sheath
220 Incision of muscle, tendon, fascia, and bursa of hand 
Exploration of tendon sheath of hand, incision of 

tendon sheath of hand: Removal of rice bodies in
221 tendon sheath of hand
222 Myotomy of hand 
223 Bursotomy of hand 
224 Incision and drainage of palmar or thenar space 
225 Advancement of tendon of hand 
226 Recession of tendon of hand 
227 Reattachment of tendon of hand 
228 Reattachment of muscle of hand 
229 Other change in hand muscle or tendon length 
230 Other hand tendon transfer or transplantation 
231 Other hand tendon transposition 
232 Other hand muscle transfer or transplantation 
233 Other hand muscle transposition 
Reconstruction of thumb . includes : digital transfer to 

act as thumb
Code also any ampuattion for digital transfer

234 (84.01,84.11)
Policization operation carrying over nerves and blood 

235 supply
Other reconstruction of thumb. “Cooked-hat” 

procedure (skin fla and bone)
236 Grafts : bone to thumb skin (pedicle)to thumb
M DS
237 Plastic operation on hand with graft or implant 
238 
Tendon pulley reconstruction. Reconstruction for
apponenspalsty
Plastic operation on hand with graft of muscle or 

239 fascia
Plastic operation on hand with other graft or implant. 

240 Tendon graft to hand
241 Other plastic operation on hand 
242 Transfer of finger, except thumb 
243 Repair of cleft hand 
244 Repair of macrodactyly 
245 Repair of mallet finger. 
246 Other tenodesis of hand. Tendon fixation of hand NOS 
247 Other tenoplasty of hand. Myeotenoplasty of hand 
Other plastic operations on hand. Plication of fascia. 

248 Repair of fascial hernia
Other operations on muscle, tendon and fascia of 

249 hand
Lysis of adhesions of hand 
Freeing of adhesions of fascia, muscle, and tendon of

250 hand
251 Aspiration of bursa of hand 
252 Aspiration of other soft tissue of hand 
253 Injection of therapeutic substance into bursa of hand 
254 Injection of therapeutic substance into tendon of hand 
Other injection of locally-acting therapeutic substance 

255 into soft tissue of hand
Other operations on muscle, tendon, and fascia of 

256 hand
Fasciotomy. Division of fascia, division of iliotibial 

band, fascia stripping, release of Volkmann’s
257 contracture by fasciotomy
Other division of soft tissue. Division of muscle, 

muscle release, Myotomy for thoracic outlet
decompression, myotomy with division, Scalenotomy,
258 transection of muscle
Diagnostic procedures on muscle, tendon, fascia, and 

259 bursa, including that of hand
260 Excision of lesion of muscle, tendon, fascia, and bursa 
261 Excision of lesion of tendon sheath 
262 Excision of ganglion of tendon sheath, except of hand 

Excision of lesion of muscle 
Excision of : heterotopic bone,
Muscle scar for release of Volkmann’s contracture,

263 myositis ossificans
Excision of lesion of other soft tissue. Excision of 

264 Baker’s Cyst
265 Other excision of muscle, tendon, and fascia 
267 Excision of tendon for graft 
268 Other fascietomy 
Other myectomy. Debridement of muscle NOS. 

269 Scalenectomy
270 Other excision of soft tissue 
271 Bursectomy 
272 Suture of muscle,tendon, and afscia 
273 Suture of tendon sheath 
M DS
274 Delayed suture of tendon 
275 Rotator cuff repair 
Other suture of tendon. Archillorrhaphy, 

276 aponeurorrhapy
Other suture of muscle or fascia. Repair of diastasis 

277 recti
278 Reconstruction of muscle and tendon 
279 Advancement of tendon 
280 Recession of tendon 
281 Reattachment of tendon 
282 Reattachment of muscle 
283 Tendon transfer or transplantation 
284 Other tendon transposition 
Muscle transfer or transplantation. 
Release of Volkmann’s contracture by muscle

285 transplantation
286 Other muscle transposition 

287 Other plastic operations on muscle,tendon and fascia 
288 Tendon graft 
289 Graft of muscle or fascia 
290 Tendon pulley reconstruction 
Release of clubfoot, not elsewhere classified. Evans 

291 operation on clubfoot
Other change in muscle or tendon length 
Hamstring lengthening, heel cord shortening, Plastic

292 achillotenotomy, Tendon plication
293 Quadricepsplasty 
Other plastic operations on muscle. Musculoplasty, 

294 myoplasty
Other plastic operations on tendon. 
295 Myotenoplasty, Tendon fixation, tenodesis, Tenoplasty
Other plastic operations on fascia 
296 Fascia lengthing, Fascioplasty, Plication of fascia
297 Other operations on muscle, tendon, fascia and bursa 
Lysis of adhesions of muscle, tendon, fascia and 

298 bursa
Insertion or replacement of skeletal muscle, 

stimulator
Implantation, insertion, placement, or replacement of

299 skeletal muscle : electrodes, stimulator
300 Removal of skeletal muscle stimulator 
301 Aspiration of bursa 
302 Aspiration of other soft tissue 
303 Injection of therapeutic substance into bursa 
304 Injection of therapeutic substance into tendon 
Injection of locally-acting therapeutic substance into 

305 other soft tissue
Other operations on muscle, tendon, fascia and 

306 bursa. Suture of bursa
307 Other procedures on muscoloskeletal system 
308 Amputation of upper limb 

M DS
309 
Upper limb amputation, not otherwise specified
Amputation of upper limb
Closed flap amputation of upper limb NOS
Kineplastic amputation of upper limb NOS
Open or guillotine amputation of upper limb NOS
Revision of current traumatic amputation of upper

limb NOS
310 Amputation and disarticulation of finger 
311 Amputation and disarticulation of thumb 
Amputation through hand. Amputation through 

312 carpals
313 Disarticulation of elbow 
314 Amputation through forearm. Forearm amputation 
Interthocoscapular amputation. Forequarter 

316 amputation
317 Amputation of lower limb 
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

318 limb NOS
Amputation of toe. Amputation through 

metatarsophalangel joint.
Disarticulation of toe.
Metatarsal head amputation
Ray amputation of foot (disarticulation of the

metatarsal head of the toe
Extending across the forefoot just proximal to the

319 metatarsophalangeal crease)
Amputation through foot. Amputation of forefoot. 
Amputation through middle of foot. Chopart’s

amputation.
Midtarsal amputation. Transmetatrsal amputation

320 (amputation of the forefoot, including all the toes)
321 Disarticualtion of ankle 
Amputation of ankle through malleoli of tibia and 

322 fibula
Other amputation below knee. Amputation of leg 

323 through tibia and fibula NOS
Disarticulation of knee. Batch,Spitler, and McFaddin 

amputation.Mazet amputation. S.P. Roger’s
324 amputation
Amputation above kneee. Amputation of leg through 

femur.
Amputation of thigh. Conversion of below-knee

325 amputation
326 Disarticulation of hip. 
Abdominopelvic amputation. Hemipelvectomy, 

327 hindquarter amputation
328 Reattachment of extremity 
329 Thumb reattachment 
330 Finger reattachment 
331 Forearm, wrist, or hand reattachment 
M DS
332 Upper arm reatachment. Reattachment of arm NOS 
333 Toe attachment 
334 Foot attachment 
Lower leg ankle reattachment. Reattachment of leg 

335 NOS
336 Thigh reattachment 
337 Other reattachment 
Revision of amputation stump. 
Reamputation of stump, secondary closure of stump,

338 Trimming of stump
339 Implantation or fitting of prosthetic limb device 
Implantation or fitting of prosthetic limb device, not 

340 otherwise specified
341 Fitting of prosthetic of upper arm and shoulder 
342 Fitting of prosthetic of lower arm and hand 
343 Fitting of prosthesis of arm, not otherwise specified 

345 Implantation of prosthetic device of arm 
346 Fitting of prosthetic above knee 
347 Fitting of prosthetic below knee 
348 Fitting of prosthetic of leg, not otherwise specified 
349 Implantation of prosthetic device of leg 
Implantation of other musculoskletal devices and 

350 substances
351 
Insertion of interbody spinal fusion device
Insertion of : cages (carbon,ceramic,metal,plastic or

titanium),
Interbody fusion cage, synthetic cages or spacers,

threaded bone dowels
Code also refusion of spine (81.30-81.39).
Code also spinal fusion (81.00-81.08)
352 
Insertion of recombinant bone morphogenetic protein.

rhBMP.
That via collagen sponge,coral,ceramic and other

carriers
Code also primary procedure performed : fracture

repair (79.00-79.99), spinal fusion (81.00-81.08),
spinal refusion (81.30-81.39)
353 
Implantation of internal limb lengthening device with
kinetic distraction
Code also limb lengthening procedure (78.30-78.39)
M DS
354 Implantation of other internal limb lengthening 

deevice
Implangtation of internal limb lengthening device, Not

Otherwise Specified (NOS)
355 
Insertion of bone void filler
Insertion of : acrylic cement (PMMA), bone void

cement, calcium based bone void filler,
polymethylmethacrylate (PMMA)
356 
Insertion or replacement of (cement) spacer.
Insertion or replacement of joint (methylmethacrylate)

spacer.
357 
Removal of (cement) spacer. Removal of joint
(methylmethacrylate) spacer
358 Insertion of other spinal devices 
Adjunct codes for external fixator devices 
Code also any primary procedure performed :

application of external fixator device (78.10,78.12-
78.13,78.17-78.19), reduction of fracture and
359 dislocation (79.00-79.89)
Application of external fixator device, monoplanar 

360 system
Application of external fixator device, ring system. 
361 Iiizarov type,sheffield type
Application of hybird external fixator device. 

Computer (assisted) (dependent) external fixator
device.
Hybird system using both ring and monoplanar

362 devices
363 Other operations on musculoskeletal system 
364 Amputation, not otherwise specified 
365 Separation of equal conjoined twins 
Separation of unequal conjoined twins. Separation of 

366 conjoined twins NOS
Other operations on skin and subcutaneous tissue 
Includes : operations on : hair follicles, male perineun,

nails, sebaceous glands, subcutaneous fat
367 pads,sudoriferous glands, superficial fossae
368 Incision of skin and subcutaneous tissue 
Aspiration of skin and subcutaneous tissue 
Aspiration of : abscess of nail,skin,or subcutaneous

tissue. Hematoma of nail, skin,or subcutaneous
tissue. Seroma of nail hematoma of nail, skin, or
subcutaneous tissue. Seroma of nail, skin or
369 subcutaneous tissue
Injection or tattooing of skin lesion or defect, Injection 

of filling material, insertion of filling material,
370 pigmenting of skin of filling material.
Diagnostic procedures on skin and subcutaneous 

371 tissue
372 Biopsy of skin and subcutaneous tissue 
M DS
Other diagnostic procedures on skin and 

Excision or desctruction of lesion or tissue of skin and 

Other local excision or destruction of lesion or tissue 

of skin and subcutaneous tissue
Destruction of skin by : cauterization cryosurgery,

375 fulguration, laser beam. That with Z-plasty
Radical excision of skin lesion 
Wide excision of skin lesion involving underlying or

adjacentstructure
376 Code also any lymph node dissection (40.3-40.5)
Closure of skin and subcutaneous tissue of other 

377 sites.adhesive (surgical) (tissue), staples,sutures
Free skin graft, Includes : excision of skin for 

378 autogenous graft
379 Free skin graft, not otherwise specified 
380 Full-thickness skin graft to other sites 
381 Hair transplant 
382 Heterograft to skin. Pigskin graft, Porcine graft 
Homograft to skin. 
383
Graft to skin of : amnionic membrane from donor skin
from donor
384 Pedicle grafts or flaps 
385 Pedicle or flap graft, not otherwise specified 
Cutting and preparation of pedicle grafts or flaps. 

Elevation of pedicle from its bed. Flap design and
386 raising. Partial cutting of pedicle or tube. Pedicle delay
387 Advancement of pedicle graft 
388 Attachment of pedicle or flap graft to hand 
Attachment of pedicle or flap graft to other sites. 

Attachment by : advanced flap, double pedicle flap,
389 pedicle graft, rotating flap, sliding flap, tube graft
Revision of pedicle or flap graft. Debridement of 

390 pedicle or flap graft. Defatting of pedicle or flap graft
Other repair and reconstruction of skin and 


393 Other operations on skin and subcutaneous tissue 
Excision of skin for graft. Excision of skin with closure 

394 of donor site
Physical therapy, respiratory therapy, rehabilitation, 

395 and related procedures
396 Diagnostic physical therapy 
397 Functional evaluation 
398 Orthotic evaluation 
399 Prosthetic evaluation 
400 Manual testing of muscle function 
401 Range of motion testing 
Measurement. Girth measurement, measurement of 

402 skull circumference
403 Electromyography 
M DS
404 Other diagnostic physical therapy procedure 
405 Physical therapy exercises 
406 Assisting exercise 

407 Training in joint movements 
408 Mobilization of spine 
409 Mobilization of other joints 
410 Other passive musculoskeletal exercise 
411 Exercise, not elsewhere classified 
412 Other physical therapy musculoskeletal manipulation 
413 Manual and mechanical traction 
414 Ambulation and gait training 
415 Fitting of orthotic device 
Training in use of prosthetic or orthotic device. 

416 Training in cructh walking
417 Forced extension of limb 
418 Manual rupture of joint adhesions 
419 Strecthing of muscle or tendon 
420 Strecthing of fascia 
421 Other forcible correction of deformity 
422 Other physical therapy therapeutic procedures 
Combined physical therapy without mention of the 

423 components
424 Other physical therapy 
425 Skeletal traction and other traction 
Spinal traction using skull device. Traction using : 

caliper tongs, Crutchfield tongs, halo device, Vinke
426 tongs
427 Other spinal traction. Cotrel’s traction 
428 Intermittent skeletal traction 
Other skeletal traction 
Bryant’s traction, Dunlop’s traction, Lyman Smith

429 traction, Russell’s traction
430 Thomas’ splint traction 
Other skin traction of limbs 
Adhesive tape traction., Boot traction, Buck’s traction,

431 Gallows traction
Other immobilzation, pressure, and attention to 

432 wound
433 Application of plaster jacket 

Application of nek support. Aplication of : cervical
434 collar, Minerva jacket, molded neck support
435 Applcation of other cast 
436 Application of splint. Plaster splint, Tray splint 
437 Removal of other device from trunk 
Removal of external immobilization device. Removal of

438 : brace,cast, splint
439 Removal of other therapeutic device 
KETERANGAN :
M : Mandiri
DS : Dibawah Supervisi
TA : Tak Ada Alat
TK : Tak Ada Kompetensi
Demikianlah RINCIAN KEWENANGAN KLINIS ini diberikan sebagai acuan dalam melaksanakan penata
laksanaan prosedur tindakan, dengan ketentuan dilarang melakukan prosedur tindakan diluar rincian
kewenangan klinis kecuali dalam keadaan darurat dan tidak ada sejawat lain yang memiliki
kewenangan tersebut
Mengetahui ………………………
Ketua Komite Medis Ketua Sub Komite Kredensial
Dr. Upang W, SpTHT Dr. Dika Oriputra, SpOG

PEMERINTAH KOTA BANDAR LAMPUNG
RUMAH SAKIT UMUM DAERAH (RSUD)
Dr. A DADI TJOKRODIPO
Jl. Basuki Rahmat No.73 Telukbetung Bandar Lampung,
Telp.0721 – 471723, 470177
KEPUTUSAN DIREKTUR UTAMA

RUMAH SAKIT UMUM DAERAH (RSUD)
Dr. A DADI TJOKRODIPO
Nomor : II.05/ 30 / SK-KPS / / 201
Tentang
Surat Penugasan Klinis dan Rincian Kewenangan Klinis

Rumah Sakit Umum Daerah (RSUD) Dr. A. Dadi Tjokrodipo Bandar
Lampung
DIREKTUR UTAMA RUMAH SAKIT (RSUD) Dr. A. DADI TJOKRODIPO

BANDAR LAMPUNG
Menimbang : Bahwa untuk mendukung terwujudnya pelayanan medis

yang optimal dan meningkatkan Keselamatan Pasien,
perlu ditetapkan Surat Penugasan Klinis dengan Rincian
Kewenangan Klinis
Mengingat : Peraturan Menteri Kesehatan Republik Indonesia No

755/MENKES/PER/IV/2011 tanggal 11 April 2011
tentang penyelenggaraan Komite Medik di Rumah Sakit.
Menetapkan :
MEMUTUSKAN
PERTAMA : Nama dr. Thurman HS Sp. OT Kualifikasi : SPESIALISASI

SPESIALISASI BEDAH ORTHOPEDI DAN TRAUMATOLOGI
mendapat Surat Penugasan Klinis dengan Rincian
Kewenangan Klinis di lingkungan Rumah Sakit Umum
Daerah (RSUD) Dr. A. Dadi Tjokrodipo Bandar Lampung
KEDUA : Surat Penugasan Klinis ini memberikan hak kepada yang

bersangkutan untuk melaksanakan kegiatan profesinya
dilingkungan Rumah Sakit Umum Daerah (RSUD) Dr. A.
Dadi Tjokrodipo Bandar Lampung sesuai dengan Rincian
Kewenangan Klinik terlampir
KETIGA : Rincian Kewenangan Klinis dapat dikurangi atau

ditambah atas rekomendasi Komite Medis cq Sub Komite
Kredensial
KEEMPAT : Surat Penugasan Klinis Staf Medis berlaku untuk jangka

waktu 3 tahun, dan atau tidak melebihi masa berlaku
STR yang bersangkutan
KELIMA : Keputusan ini berlaku sejak tanggal ditetapkan, bila

kemudian hari diketemukan kekeliruan akan diadakan
perbaikan sebagaimana mestinya.
Ditetapkan di : Bandar Lampung

Pada tanggal :
Direktur Utama
dr. Hj. Indrasari Aulia, MHKEs

Nip 19600620 198910 2 002
LAMPIRAN I : Keputusan Direktur Utama Rumah
Sakit Umum Daerah (RSUD) Dr. A.
Dadi Tjokrodipo Bandar Lampung
Nomor:II.05/30/SK-KPS/ /201
Tanggal :
Rincian Kewenangan klinis diberikan kepada dokter dalam menjalankan

prosedur/tindakan medis dan diberikan dalam rangka peningkatan kualitas
pelayanan dan keselamatan pasien agar supaya dokter bersikap, bertindak dan
berperilaku secara bertanggung jawab dan mentaati semua disiplin dan etika
kedokteran serta moral yang baik kepada pasien, sejawat dan masyarakat.
Rincian Kewenangan Klinis ini diberikan kepada:
Kualifikasi :SPESIALISASI ORTHOPEDI DAN TRAUMATOLOGI
Kewenangan yang diberikan termasuk inti pelayanan yaitu melakukan diagnosis,

pemeriksaan penunjang, dan terapi serta konsultasi medis dalam penanganan
penyakit dalam bidang spesialisasinya dengan rincian untuk Prosedur / tindakan
sebagai berikut:
M DS
1 Shoulder dislocation, closed & open reduction 
2 Orif fraktur shoulder region (glenoid, AC joint, prox 

humerus)
3 Elbow : dislocation, closed & open reduction 
4 Orif pada fraktur aroundelbow (Olecranon, radial 

head, epicondyle, coronoid )
5 Wrist : Dislocation, closed & open reduction 
6 Orif fraktur around wristjoint 
8 Pemasangan eksternal support (gips, dll) 
9 Hand (Carpal bones,metacarpals, phalanges dan joint) 

: Orif
11 Closed / open reduction + eksternal support 

13 Arthrodesis + orif 
14 Humerus : Orif 
16 Closed reduction + internal fiksasi 
17 Closed reduction + eksternal support 
18 Radius ulna : Fraktur & dislokasi : Orif 
20 Close reduction + eksternal support 
22 Femur & Hip : Fraktur & dislokasi : Orif 
M DS
24 Fiksasi eksternal 
Knee joint : Dislokasi & cedera ligament : Orif ( 

25 Fraktur patella, Tibial spine)
26 closed reduction + eksternal support 
27 fiksasi eksterna 
28 Tibasi & fibula, ankle & fraktur & dislokasi : Orif 
30 Closed reduction & Internal fiksasi 
32 Arthodesis ankle dengan fiksasi 
33 Arthodesis knee dengan fiksasi 
Foot : ( Fraktur & dislokasi pada tarsilsbone, 

34 metatarsal phalangs) : Orif
37 Spine : Dekompresi ( Laminectomy, discectomy) 
38 Stabilisasi posterior 
39 Stabilisasi anterior 
40 Debridement pada spine 

41 Repair tendon pada ekstremitas atas 
42 Repair tendon pada ekstremitas bawah 
43 Debridement 
44 Arthroplasty : Total hip Arthroplasty 
45 Hemi hip Arthroplasty 
46 Total knee Arthroplasty 
47 Elbow Anthroplasty 
48 Shoulder Arthroplasty 
49 Repair muscle 
50 Skin graft ( STSG, FTSG) 
51 Flap pada ekstremitas 
52 Arteri repair pada ekstremitas 
53 Vein repair 
54 Nerve repair pada ekstremitas 
55 Fasciotomy pada compontment syndrome 
56 Arthroscopy knee : Debridement 
57 Ligament repair 
58 Orif pada fraktur pelvis 
59 Fiksasi eksterna pelvis 
60 Soft tissue lengthening 
61 Tenoplasty 
Procedures and interventions, Not Elsewhere 

62 Classified
63 Imageless computer assisted surgery 
64 Other hip procedures 
Other knee and hip procedures Note : Report up two 

components using 00.81-00.83 to describe revision of
knee replacements. If all three components are
65 revised, report 00.80
66 Operations on spinal cord and spinal canal structures 
Exploration and decompression of spinal canal 

67 structures
M DS
68 Removal of foreign body from spinal canal (Cg) 

69 Reopening of laminectomy site (Cg) 
Other exploration and decompression of spinal canal 
Decompression : laminectomy, laminotomy. Expansile

laminoplasty. Exploration of spinal nerve root,
foraminotomy. Code also any synchronous insertion,
replacement and revision of posterior spinal motion
70 preservation device (s), if performed (84.80-84.85)
Diagnostic procedures on spinal cord and spinal canal 

71 structures
72 Biopsy of spinal cord or spinal canal meninges (Cg) 
Excision or destruction of lesion of spinal cord or 

spinal meninges. Curretage of spinal cord or spinal
meninges. Debridement of spinal cord or spinal
meninges. Marsupialization of cyst of spinal cord or
spinal meninges. Resection of spinal cord or spinal
73 meninges
Repair of vertebral fracture. Elevation of spinal bone 

fragments . Reduction of fracture of vertebrae
74 Removal of bony spicules from spinal canal (Cg)
Other operations on spinal cord and spinal canal 

75 structures
Injection of anesthetic into spinal canal for analgesia 

76 (Sd)
Injection of other agent into spinal canal. Intrathecal 

injection of steroid. Subarachnoid perfusion of
77 refrigrated saline
78 Percutaneous denervation of facet 
79 Curretage of peripheral nerve 
Debridement of peripheral nerve. Resection of 

80 peripheral nerve
81 Excision of peripheral neuroma (Morton’s) 
82 Diagnostic procedures on peripheral nervous system 
83 Open biopsy of cranial or peripheral nerve or ganglion 
84 Release of carpal tunnel 
85 Release of tarsal tunnel 
Other peripheral nerve or ganglion decompression or 

86 lysis of adhesions peripheral nerve neurolysis NOS
87 Injection into peripheral nerve 
88 Peripheral nerve injection not otherwise specified 
Injection of anesthetic into peripheral nerve for 

89 analgesia
90 Injection of other agent except neurolytic 
The following fourth-digit subclassification is for use 

with appropriate categories in section
38.0,38.1,38.3,38.5,38.6,38.8 and 38.9 according to
site,validfourth-digits are in (brackets) at the end of
each 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,
91 Popliteal,Saphenous, Tibia
92 Suture of artery (Bs) 
93 Suture of vein (Bs) 
M DS
94 
Incision,Excision and division of other bones

with appropriate categories in section 77-78 to
identify the site. Valid fourth-digit categories are
In 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 bones, phalanges (of foot) (of hand),

verterbrae
95 Sequestrectomy (77.00-77.09) 
Other incision of bone without division. 
96 Reopening of osteotomy site (77.11-77.19)
97 Wedge osteotomy 
98 Other division of bone, Osteoarthrotomy (77.31-77.39) 

99 Biopsy of Bone (77.41-77.49) 
Excision and repair of bunion and other toe 

100 deformities

101 osteotomy of the first metatarsal

102 arthrodesis
103 Other bunionectomy with soft tissue correction 
Excision or correction of bunionette. That with 

104 osteotomy
Repair of hammer toe. Fusion of hammer toe, 

phalangectomy (partial) of hammer toe, filleting of
105 hammer toe
Repair of claw toe phalangectomy (partial) of claw toe, 

capsulotomy of claw toe, tendon lengthening of claw
106 toe
107 Other excision,fusion and repair of toes 
Other bunionectomy. Resection of hallux valgus joint 

108 with insertion of prosthesis
Local excision of lession or tissue of bone (77.61- 

109 77.69)
110 Excision of bone for graft (77.70-77.79) 
111 Other partial osteotomy (77.80-77.89), condylectomy 
112 Total osteotomy (77.90-77.99) 
113 Other operations on bones,except facial bones 
114 Bone graft (78.00-78.09) 
Application of external fixator device (78.10-78.19) 
Fixator with insertion of pins/wires/screws into bone
Code also any type of fixator device,if known (84.71-

115 84.73)
Limb shortening procedures (78.20,78.22-78. 

25,78.27-78.29) Epiphyseal stapling, open
epiphysiodesis,Percutaneous epiphysiodesis,
116 Resection/osteotomy
Limb lengthening procedures (78.30,78.32-78.35, 

78.37-78.39) Bone graft with or without internal
fixation divices or osteotomy.Distraction technique
with or without corticotomy/ostetotomy
Code also any applictaion of an external fixation

117 device (78.10-78.19)
M DS
Other repair or plastic operations on bone (78.40- 

78.49).Other operation on bone NEC. Repair of mal
118 union or non union fracture NEC
Internal fixation of bone without fracture reduction 

(78.50-78.59) Internal fixation of bone (prophylactic),
reinsertion of internal fixation device,revision of
119 displaced or broken fixation device
Removal of implanted devices from bone ( 78.60- 

78.69)
External fixator device (invasive), internal fixation

device, removal of bone growth stimulator (invasive)
removal of internal limb lengthening device, removal
120 of pedicle screw (s) used in spinal fusion
121 Osteoclasis (78.70-78.79) 
Diagnostic procedures on bone, not elsewhere 

122 classified (78.80-78.89)
Insertion of bone growth stimulator (78.90-78.99) 
Insertion of bone stimulator (electrical) to aid bone

healing, osteogenic electrodes for bone growth
123 stimulation, tottally impalnted device (invasive)
Reduction of fracture and dislocation , Includes : 

application of cast or splint reduction with insertion of
traction device (Kirschner wire) (steinmann pin)
Code also any : application of external fixator device

(78.10-78.19) & type of fixator devicem if known
(84.71-84.73)

the site. Valid forth-digit categories are in (brackets)
under each code.
0 unspecified site
1 humerus
2 radius and ulna, Arm NOS
3 Carpals and metacarpals, Hand NOS
4 Phalanges of hand
5 femur
6 tibia andm fibula, Leg NOS
7 tarsals and metatarsals , Foot NOS
8 Phalanges of foot
124 9 other specified bone

Closed reduction of fracture without internal fixation 
125 (79.00-79.09)
Closed reduction of fracture with internal fixation 

126 (79.10-19.19)
Open reduction of fracture without internal fixation 

127 (79.20-79.29)
Open reduction of fracture with internal fixation 

128 (79.30-79.39)
Closed reduction of separated spiphysis, reduction 

with or without internal fixation (79.40-79.42,79.45-
129 79.46,79.49)
Open reduction of separated epiphysis (79.50- 

79.52,79.55,79.56,79.59)
130 Reduction with or without internal fixation
Debridement of open fracture site (79.60-79.69) 
131 Debridement of compound fracture
Closed reduction of dislocation. Includes : closed 

132 reduction (with external traction device)
133 Closed reduction of dislocation of unspecified site 
134 Closed reduction of dislocation of shoulder 
135 Closed reduction of dislocation of elbow 
M DS
136 Closed reduction of dislocation of wrist 
137 Closed reduction of dislocation of hand and finger 
138 Closed reduction of dislocation of hip 
139 Closed reduction of dislocation of knee 
140 Closed reduction of dislocation of ankle 
141 Closed reduction of dislocation of foot and toe 
142 Closed reduction of dislocation of other specified sites 
Closed reduction of dislocation includes : open 

143 reduction (with internal and external fixation devices)
144 Open reduction of dislocation of unspecified site 
145 Open reduction of dislocation of shoulder 
146 Open reduction of dislocation of elbow 
147 Open reduction of dislocation of wrist 

148 Open reduction of dislocation of hand and finger 
149 Open reduction of dislocation of hip 
150 Open reduction of dislocation of knee 
151 Open reduction of dislocation of ankle 
152 Open reduction of dislocation of foot and toe 
153 Open reduction of dislocation of other specified site 
154 Unspecified operation on bone injury 
155 Unspecified operation on bone injury, unspecified site 
156 Unspecified operation on bone injury, shoulder 
157 Unspecified operation on bone injury, elbow 
158 Unspecified operation on bone injury, wrist 
159 Unspecified operation on bone injury, hand and finger 
160 Unspecified operation on bone injury,hip 
161 Unspecified operation on bone injury, knee 
162 Unspecified operation on bone injury, ankle 
163 Unspecified operation on bone injury, foot and toe 
Unspecified operation on bone injury, other specified 

164 sites
Incision and excision of joint structures 
Includes : operations on : capsule of joint,

cartilage,condyle,ligament,meniscus,synovial
membrane

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
165 9 other specified site, Spine

M DS
Arthrotomy for removal of prosthesis (80.00-80.09) 
Includes remova : of posterior spinal motion

preservation (dynamic stabilization,facet replacement,
interspinous process) device 9s)
Code also any : insertion of (cement)
(joint) (methylmethacrylate) spacer (84.56), removal of

166 (cement)(joinT) (methylmethacylate) spacer (84.57)
167 Other arthrotomy (80.10-80.19) Arthrostomy 
168 Arthroscopy (80.20-80.29) 
Biopsy of joint structure (80.30-80.39). aspiration 

169 biopsy
Division of joint capsule, ligament or cartilage (80.40- 

80.49)
Goldner clubfoot release, Heyman-Herndon(strong)

correction of metatarsus varus
Release of : adherent or constrictive joint capsule,joint

170 ligament
Excision, desctruction and other repair of 

171 intervertebral disc
Excision or desctruction, unspecified. Unspecified as 

172 to excision or desctruction
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.
Code also any : concurrent spinal fusion (81.00-

81.09)
173 Repair of the anulusfibrousus (80.53-80.54)
Excision of semilunar cartilage of knee, excision of 

174 meniscus knee
Synovectomy , complete or partial resection of 

175 synovial merabrane(80.70-80.79)
Other local excision or desctruction of lesion of joint 

176 (80.80-80.89)
177 Other excision of joint (80.90-80.99) 
178 Repair and plastic operations on joint structures 

Spinal fusion 
Includes : arthrodesis of spine with : bone graft,

internal fixation,
Code also any insertion of interbody spinal fusion

device (84.51
Any insertion of recombinant bone morphogenetic

protein (84.52)

for graft (77.70-77.79)
180 Spinal fusion, not otherwise specified 
Dorsal and dorsolumbar fusion, posterior technique 
Arthrodesis of thoracic or thoracolumbar region :

posterior (interbody) technique, posterolateral
181 technique
Lumbar and lumbosacral fusion,anterior 

technique,anterior lumbar interbody fusion (ALIF)
Arthrodesis of lumbar or lumbosacral region anterior

182 (Interbody) technique, anterolateral technique
Lumbar and lumbosacral fusion, lateral transverse 

183 process technique
M DS
Lumbar and lumbosacral fusion, posterior technique 
Arthrodesis of lumbar or lumbosacral region :
Posterior (interbody) technique, posterolateral

technique
Posterior lumbar interbody fusion (PLIF)
Arthrodesis and arthroereisis of foot and ankle, 

includes :
Arthrodesis of foot and ankle with : bone graft,

185 external fixation device
186 Ankle fusion, tibiotalar fusion 
Triple arthrodesis. Talus to calcaneus and calcaneus 

187 to cuboid and navicular
188 Subtalar fusion 
189 Midtarsal fusion 

190 Tarsometatarsal fusion 
191 Metatarsophalangeal fusion 
192 Other fusion of foot 
193 Subtalar joint arthroereisis 
Arthrodesis of other joint 
Includes :
Arthrodesis with : bone graft, external fixation device,

194 excision of bone ends and compression
195 Arthrodesis of unspecified joint 
196 Arthrodesis of hip 
197 Arthrodesis of knee 
198 Arthrodesis of shoulder 
199 Arthrodesis of elbow 
200 Carporadial fusion 
201 Metacarpophalangeal fusion 
202 Interphalangeal fusion 
203 Arthrodesis of other specified joints 
Refusion of spine, includes : arthrodesis of spine with 

: bone graft , internal fixation, correction of
pseudarthrosis of spine, code also any insertion of
interbody spinal fusion device (84.51), any insertion of
recombinant bone morphogenetic protein (84.52)

graft (77.70-77.79)
205 Refusion of spine, not otherwise specified 
Refusion of dorsal and dorsolumbar spine, anterior 

technique. Arthrodesis of thoracic or thoracolumbar
region : anterior (intrerbody) technique, anterrolateral
206 technique
Refusion of lumbar and lumbosacral spine, posterior 

technique, arthrodesis of lumbar of lumbosacral
region : posterior (interbody) technique, posterolateral
technique
Posterior lumbar interbody fusion (PLIF),
208 Refusion of spine, not elsewhere classified 
Other repair of joint of lower exteremity 

209
Includes : arthroplasty of lower extremity
with:external traction of fixation, graft of bone (chips)
or cartilage, internal fixation device
M DS
210 
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
211 
Total hip replacement.
Replacement of both femoral head and acetabulum by

prosthesis
Total reconstruction of hip
Code also any type of bearing surface, if known (

00.74-00.77)
212 
Partial hip replacement. Bipolar endoprosthesis. Code
also any type of bearing surface, if known (00.74-
00.77)
213 
Total knee replacement Bicompartmental,
tricompartmental, unicompartmental (hemijoint)
214 
Other procedures on spine Note : number of vertebrae
Teh vertebral spine consists of 25 vertebrae in the

following order and number :
Cervical : C1 (atlas), C2 (axis), C3, C4,C5,C6,C7
Thoracic or Dorsal :T1,T2,T3.T4,T5,T6,T7,T8,

T9,T10,T11,T12. Lumbar and sacral :L1,L2,L3,L4,
L5,S1. Coders should report only one code from the
series 81.62 or 81.63 or 81.64 to show the total
number of vertebrae fused on the patient.
Code also the level and approach of fusion or refusion

(81.00-81.08),81.30-81.39)
217 Fusion or refusion of 9 or more vertebrae 
218 Suture of capsule or ligament of other lower extremity 
Operations on msucle, tendon, and fascia of hand 
Includes : operations on : aponeurosis, synovial

219 membrane (tendon sheath), tendon sheath
220 Incision of muscle, tendon, fascia, and bursa of hand 
Exploration of tendon sheath of hand, incision of 

tendon sheath of hand: Removal of rice bodies in
221 tendon sheath of hand
222 Myotomy of hand 
223 Bursotomy of hand 
224 Incision and drainage of palmar or thenar space 
225 Advancement of tendon of hand 
226 Recession of tendon of hand 
227 Reattachment of tendon of hand 
228 Reattachment of muscle of hand 
229 Other change in hand muscle or tendon length 
230 Other hand tendon transfer or transplantation 
231 Other hand tendon transposition 
232 Other hand muscle transfer or transplantation 
233 Other hand muscle transposition 
Reconstruction of thumb . includes : digital transfer to 

act as thumb
Code also any ampuattion for digital transfer

234 (84.01,84.11)
Policization operation carrying over nerves and blood 

235 supply
Other reconstruction of thumb. “Cooked-hat” 

procedure (skin fla and bone)
236 Grafts : bone to thumb skin (pedicle)to thumb
M DS
237 Plastic operation on hand with graft or implant 

Tendon pulley reconstruction. Reconstruction for 
238 apponenspalsty
Plastic operation on hand with graft of muscle or 

239 fascia
Plastic operation on hand with other graft or implant. 

240 Tendon graft to hand
241 Other plastic operation on hand 
242 Transfer of finger, except thumb 
243 Repair of cleft hand 
244 Repair of macrodactyly 
245 Repair of mallet finger. 
246 Other tenodesis of hand. Tendon fixation of hand NOS 
247 Other tenoplasty of hand. Myeotenoplasty of hand 
Other plastic operations on hand. Plication of fascia. 

248 Repair of fascial hernia
Other operations on muscle, tendon and fascia of 

249 hand
Lysis of adhesions of hand 
Freeing of adhesions of fascia, muscle, and tendon of

250 hand
251 Aspiration of bursa of hand 
252 Aspiration of other soft tissue of hand 
253 Injection of therapeutic substance into bursa of hand 
254 Injection of therapeutic substance into tendon of hand 
Other injection of locally-acting therapeutic substance 

255 into soft tissue of hand
Other operations on muscle, tendon, and fascia of 

256 hand
Fasciotomy. Division of fascia, division of iliotibial 

band, fascia stripping, release of Volkmann’s
257 contracture by fasciotomy
Other division of soft tissue. Division of muscle, 

muscle release, Myotomy for thoracic outlet
decompression, myotomy with division, Scalenotomy,
258 transection of muscle
Diagnostic procedures on muscle, tendon, fascia, and 

259 bursa, including that of hand
260 Excision of lesion of muscle, tendon, fascia, and bursa 
261 Excision of lesion of tendon sheath 

262 Excision of ganglion of tendon sheath, except of hand 
Excision of lesion of muscle 
Excision of : heterotopic bone,
Muscle scar for release of Volkmann’s contracture,

263 myositis ossificans
Excision of lesion of other soft tissue. Excision of 

264 Baker’s Cyst
265 Other excision of muscle, tendon, and fascia 
267 Excision of tendon for graft 
268 Other fascietomy 
Other myectomy. Debridement of muscle NOS. 

269 Scalenectomy
270 Other excision of soft tissue 
271 Bursectomy 
272 Suture of muscle,tendon, and afscia 
273 Suture of tendon sheath 
M DS
274 Delayed suture of tendon 
275 Rotator cuff repair 
Other suture of tendon. Archillorrhaphy, 

276 aponeurorrhapy
Other suture of muscle or fascia. Repair of diastasis 

277 recti
278 Reconstruction of muscle and tendon 
279 Advancement of tendon 
280 Recession of tendon 
281 Reattachment of tendon 
282 Reattachment of muscle 
283 Tendon transfer or transplantation 
284 Other tendon transposition 
Muscle transfer or transplantation. 
Release of Volkmann’s contracture by muscle

285 transplantation
286 Other muscle transposition 

287 Other plastic operations on muscle,tendon and fascia 
288 Tendon graft 
289 Graft of muscle or fascia 
290 Tendon pulley reconstruction 
Release of clubfoot, not elsewhere classified. Evans 

291 operation on clubfoot
Other change in muscle or tendon length 
Hamstring lengthening, heel cord shortening, Plastic

292 achillotenotomy, Tendon plication
293 Quadricepsplasty 
Other plastic operations on muscle. Musculoplasty, 

294 myoplasty
Other plastic operations on tendon. 
295 Myotenoplasty, Tendon fixation, tenodesis, Tenoplasty
Other plastic operations on fascia 
296 Fascia lengthing, Fascioplasty, Plication of fascia
297 Other operations on muscle, tendon, fascia and bursa 
Lysis of adhesions of muscle, tendon, fascia and 

298 bursa
Insertion or replacement of skeletal muscle, 

stimulator
Implantation, insertion, placement, or replacement of

299 skeletal muscle : electrodes, stimulator
300 Removal of skeletal muscle stimulator 
301 Aspiration of bursa 
302 Aspiration of other soft tissue 
303 Injection of therapeutic substance into bursa 
304 Injection of therapeutic substance into tendon 
Injection of locally-acting therapeutic substance into 

305 other soft tissue
Other operations on muscle, tendon, fascia and 

306 bursa. Suture of bursa
307 Other procedures on muscoloskeletal system 
308 Amputation of upper limb 

M DS
309 
Upper limb amputation, not otherwise specified
Amputation of upper limb
Closed flap amputation of upper limb NOS
Kineplastic amputation of upper limb NOS
Open or guillotine amputation of upper limb NOS
Revision of current traumatic amputation of upper

limb NOS
310 Amputation and disarticulation of finger 
311 Amputation and disarticulation of thumb 
Amputation through hand. Amputation through 

312 carpals
314 Amputation through forearm. Forearm amputation 
Interthocoscapular amputation. Forequarter 

316 amputation
317 Amputation of lower limb 
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

318 limb NOS
Amputation of toe. Amputation through 

metatarsophalangel joint.
Disarticulation of toe.
Metatarsal head amputation
Ray amputation of foot (disarticulation of the

metatarsal head of the toe
Extending across the forefoot just proximal to the

319 metatarsophalangeal crease)
Amputation through foot. Amputation of forefoot. 
Amputation through middle of foot. Chopart’s

amputation.
Midtarsal amputation. Transmetatrsal amputation

320 (amputation of the forefoot, including all the toes)
321 Disarticualtion of ankle 
Amputation of ankle through malleoli of tibia and 

322 fibula
Other amputation below knee. Amputation of leg 

323 through tibia and fibula NOS
Disarticulation of knee. Batch,Spitler, and McFaddin 

amputation.Mazet amputation. S.P. Roger’s
324 amputation
Amputation above kneee. Amputation of leg through 

femur.
Amputation of thigh. Conversion of below-knee

325 amputation
326 Disarticulation of hip. 
Abdominopelvic amputation. Hemipelvectomy, 

327 hindquarter amputation
328 Reattachment of extremity 
329 Thumb reattachment 
330 Finger reattachment 
331 Forearm, wrist, or hand reattachment 
M DS
332 Upper arm reatachment. Reattachment of arm NOS 
333 Toe attachment 
334 Foot attachment 
Lower leg ankle reattachment. Reattachment of leg 

335 NOS
336 Thigh reattachment 
337 Other reattachment 
Revision of amputation stump. 
Reamputation of stump, secondary closure of stump,

338 Trimming of stump
339 Implantation or fitting of prosthetic limb device 
Implantation or fitting of prosthetic limb device, not 

340 otherwise specified
341 Fitting of prosthetic of upper arm and shoulder 
342 Fitting of prosthetic of lower arm and hand 
343 Fitting of prosthesis of arm, not otherwise specified 

345 Implantation of prosthetic device of arm 
346 Fitting of prosthetic above knee 
347 Fitting of prosthetic below knee 
348 Fitting of prosthetic of leg, not otherwise specified 
349 Implantation of prosthetic device of leg 
Implantation of other musculoskletal devices and 

350 substances
351 
Insertion of interbody spinal fusion device
Insertion of : cages (carbon,ceramic,metal,plastic or

titanium),
Interbody fusion cage, synthetic cages or spacers,

threaded bone dowels
Code also refusion of spine (81.30-81.39).
Code also spinal fusion (81.00-81.08)
352 
Insertion of recombinant bone morphogenetic protein.

rhBMP.
That via collagen sponge,coral,ceramic and other

carriers
Code also primary procedure performed : fracture

repair (79.00-79.99), spinal fusion (81.00-81.08),
spinal refusion (81.30-81.39)
353 
Implantation of internal limb lengthening device with
kinetic distraction
M DS
354 Implantation of other internal limb lengthening 

deevice
Implangtation of internal limb lengthening device, Not

Otherwise Specified (NOS)

355 
Insertion of bone void filler
Insertion of : acrylic cement (PMMA), bone void

cement, calcium based bone void filler,
polymethylmethacrylate (PMMA)
356 
Insertion or replacement of (cement) spacer.
Insertion or replacement of joint (methylmethacrylate)

spacer.
357 
Removal of (cement) spacer. Removal of joint
(methylmethacrylate) spacer
358 Insertion of other spinal devices 
Adjunct codes for external fixator devices 
Code also any primary procedure performed :

application of external fixator device (78.10,78.12-
78.13,78.17-78.19), reduction of fracture and
359 dislocation (79.00-79.89)
Application of external fixator device, monoplanar 

360 system
Application of external fixator device, ring system. 
361 Iiizarov type,sheffield type
Application of hybird external fixator device. 

Computer (assisted) (dependent) external fixator
device.
Hybird system using both ring and monoplanar

362 devices
363 Other operations on musculoskeletal system 
364 Amputation, not otherwise specified 
365 Separation of equal conjoined twins 
Separation of unequal conjoined twins. Separation of 

366 conjoined twins NOS
Other operations on skin and subcutaneous tissue 
Includes : operations on : hair follicles, male perineun,

nails, sebaceous glands, subcutaneous fat
367 pads,sudoriferous glands, superficial fossae
368 Incision of skin and subcutaneous tissue 
369 Aspiration of skin and subcutaneous tissue 

Aspiration of : abscess of nail,skin,or subcutaneous
tissue. Hematoma of nail, skin,or subcutaneous
tissue. Seroma of nail hematoma of nail, skin, or
subcutaneous tissue. Seroma of nail, skin or
subcutaneous tissue
Injection or tattooing of skin lesion or defect, Injection 

of filling material, insertion of filling material,
370 pigmenting of skin of filling material.
Diagnostic procedures on skin and subcutaneous 

371 tissue
372 Biopsy of skin and subcutaneous tissue 
M DS
Other diagnostic procedures on skin and 

Excision or desctruction of lesion or tissue of skin and 

Other local excision or destruction of lesion or tissue 

of skin and subcutaneous tissue
Destruction of skin by : cauterization cryosurgery,

375 fulguration, laser beam. That with Z-plasty
Radical excision of skin lesion 
Wide excision of skin lesion involving underlying or

adjacentstructure
376 Code also any lymph node dissection (40.3-40.5)
Closure of skin and subcutaneous tissue of other 

377 sites.adhesive (surgical) (tissue), staples,sutures
Free skin graft, Includes : excision of skin for 

378 autogenous graft
379 Free skin graft, not otherwise specified 
380 Full-thickness skin graft to other sites 
381 Hair transplant 
382 Heterograft to skin. Pigskin graft, Porcine graft 
Homograft to skin. 
Graft to skin of : amnionic membrane from donor skin

383 from donor
384 Pedicle grafts or flaps 
385 Pedicle or flap graft, not otherwise specified 

Cutting and preparation of pedicle grafts or flaps. 
Elevation of pedicle from its bed. Flap design and
386 raising. Partial cutting of pedicle or tube. Pedicle delay
387 Advancement of pedicle graft 
388 Attachment of pedicle or flap graft to hand 
Attachment of pedicle or flap graft to other sites. 

Attachment by : advanced flap, double pedicle flap,
389 pedicle graft, rotating flap, sliding flap, tube graft
Revision of pedicle or flap graft. Debridement of 

390 pedicle or flap graft. Defatting of pedicle or flap graft


393 Other operations on skin and subcutaneous tissue 
Excision of skin for graft. Excision of skin with closure 

394 of donor site
Physical therapy, respiratory therapy, rehabilitation, 

395 and related procedures
396 Diagnostic physical therapy 
397 Functional evaluation 
398 Orthotic evaluation 
399 Prosthetic evaluation 
400 Manual testing of muscle function 
401 Range of motion testing 
Measurement. Girth measurement, measurement of 

402 skull circumference
403 Electromyography 
M DS
404 Other diagnostic physical therapy procedure 
405 Physical therapy exercises 
406 Assisting exercise 
407 Training in joint movements 
408 Mobilization of spine 
409 Mobilization of other joints 
410 Other passive musculoskeletal exercise 

411 Exercise, not elsewhere classified 
412 Other physical therapy musculoskeletal manipulation 
413 Manual and mechanical traction 
414 Ambulation and gait training 
415 Fitting of orthotic device 
Training in use of prosthetic or orthotic device. 

416 Training in cructh walking
417 Forced extension of limb 
418 Manual rupture of joint adhesions 
419 Strecthing of muscle or tendon 
420 Strecthing of fascia 
421 Other forcible correction of deformity 
422 Other physical therapy therapeutic procedures 
Combined physical therapy without mention of the 

423 components
424 Other physical therapy 
425 Skeletal traction and other traction 
Spinal traction using skull device. Traction using : 

caliper tongs, Crutchfield tongs, halo device, Vinke
426 tongs
427 Other spinal traction. Cotrel’s traction 
428 Intermittent skeletal traction 
Other skeletal traction 
Bryant’s traction, Dunlop’s traction, Lyman Smith

429 traction, Russell’s traction
430 Thomas’ splint traction 
Other skin traction of limbs 
Adhesive tape traction., Boot traction, Buck’s traction,

431 Gallows traction
Other immobilzation, pressure, and attention to 

432 wound
433 Application of plaster jacket 
Application of nek support. Aplication of : cervical

434 collar, Minerva jacket, molded neck support
435 Applcation of other cast 
436 Application of splint. Plaster splint, Tray splint 
437 Removal of other device from trunk 

Removal of external immobilization device. Removal of
438 : brace,cast, splint
439 Removal of other therapeutic device 
KETERANGAN :
M : Mandiri
DS : Dibawah Supervisi
TA : Tak Ada Alat
TK : Tak Ada Kompetensi
Demikianlah RINCIAN KEWENANGAN KLINIS ini diberikan sebagai acuan dalam

melaksanakan prosedur/tindakan, dengan ketentuan dilarang melakukan prosedur
tindakan medis diluar rincian kewenangan klinis kecuali dalam keadaan darurat
dan tidak ada sejawat lain yang memiliki kewenangan tersebut
Direktur Utama
Rumah Sakit Umum Daerah (RSUD)
Dr. A. Dadi Tjokrodipo
Bandar Lampung
dr. Hj. Indrasari Aulia, MHKEs

Nip 19600620 198910 2 002

DR Thurman HS Spot Fix

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DR Thurman HS Spot Fix

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Perihal : Proses Kredensial

Proses Penambahan Kewenangan Klinis

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Direktur RSUD A. Dadi Tjokrodipo

Demikianlah permohonan ini kami sampaikan, atas perhatiannya diucapkan terimakasih.

dr. Thurman HS, Sp. OT

Berkas yang diperlukan:

1. Foto copy STR

Lampiran : 1( satu) berkas Kepada Yth.

Perihal : Rekomendasi Surat Penugasan Klinis Direktur RSUD A. Dadi Tjokrodipo

Dengan Rincian Kewenangan Klinis di Tempat

Menindak lanjuti rekomendasi direktur utama rumah sakit No……. tanggal……………..….

Nama : dr. Thurman HS, Sp. OT

Keahlian : SPESIALISASI ORTHOPEDI DAN TRAUMATOLOGI

Demikian dan terima kasih atas perhatiannya.

Ketua Komite Medis

RSUD A Dadi Tjokrodipo

Dr.Upang Wijayanto Sp.THT

Kewenangan ini diberikan kepada:

Nama : dr. Thurman HS, Sp. OT

Kualifikasi : Dokter Spesialis Orthopedi dan Traumatologi

NO PROSEDUR TINDAKAN DISETUJUI KET

Shoulder dislocation, closed & open 

2 Orif fraktur shoulder region (glenoid, 

3 Elbow : dislocation, closed & open 

4 Orif pada fraktur aroundelbow 

5 Wrist : Dislocation, closed & open 

6 Orif fraktur around wristjoint 

8 Pemasangan eksternal support (gips, 

9 Hand (Carpal bones,metacarpals, 

11 Closed / open reduction + eksternal 

12 Close reduction + internal fiksasi 

17 Closed reduction + eksternal support 

18 Radius ulna : Fraktur & dislokasi : Orif 

20 Close reduction + eksternal support 

21 Close reduction + internal fiksasi 

22 Femur & Hip : Fraktur & dislokasi : Orif 

23 Closed reduction & internal fiksasi 

NO PROSEDUR TINDAKAN DISETUJUI KET

Knee joint : Dislokasi & cedera ligament 

26 closed reduction + eksternal support 

Tibasi & fibula, ankle & fraktur & 

29 Closed reduction & eksternal support 

30 Closed reduction & Internal fiksasi 

32 Arthodesis ankle dengan fiksasi 

33 Arthodesis knee dengan fiksasi 

Foot : ( Fraktur & dislokasi pada 

35 Closed reduction & eksternal support 

36 Closed reduction & internal fiksasi 

Spine : Dekompresi ( Laminectomy, 

40 Debridement pada spine 

41 Repair tendon pada ekstremitas atas 

42 Repair tendon pada ekstremitas bawah 

44 Arthroplasty : Total hip Arthroplasty 

45 Hemi hip Arthroplasty 

46 Total knee Arthroplasty 

50 Skin graft ( STSG, FTSG) 

51 Flap pada ekstremitas 

52 Arteri repair pada ekstremitas 

54 Nerve repair pada ekstremitas 

56 Arthroscopy knee : Debridement 

58 Orif pada fraktur pelvis 