CONTOH ;

DAFTAR TINDAKAN – TINDAKAN

YANG PERLU INFORMED CONSENT

Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa
tindakan kedokteran dan kedokteran gigi yang wajib diberikaninformed consent.
Tindakan tersebut yaitu :
A. Semua Tindakan Pembedahan dan Tindakan Invasive
B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam )
C. Semua Tindakan Pemberian Produk Darah & Komponen Darah
D. Semua Tindakan Yang Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasiveyang memerlukan informed

consentantara lain:

KSM/INSTALASI
NO TINDAKAN
/UNIT
1 KSM Bedah 1 Amygdala Hypocampectomy (Epilepsi)
Saraf 2 Anterior Temporomesial Lobectomi (Epilepsi)
3 Biopsi Saraf Tepi/Otot
4 Blok Saraf Perifer I
5 Cingulotomy (Psichiatric)
6 Corpus Callosotomi (Epilepsi)
7 Debrimen Rekonstruksi Vulnus Kulit Kepala
8 Dekompresi Saraf Tepi
9 Dekompresi Tulang Durameter
10 Dekortikasi Sinus Frontalis
11 Denervasi Facet
12 DREZ Lession (Pain)
13 Eksisi Ensefalokel/Mielokel
14 Eksisi Kista Jinak Kulit Kepala
15 Eksisi Osteoma/Osteositosis
 16 Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan
17 Dura
NO KSM/INSTALASI TINDAKAN
NO 18 Elevasi Kraniotomi TINDAKAN Fraktur Impresi,Tanpa Robekan
KSM/INSTALASI
/UNIT
NO
NO KSM/INSTALASI
/UNIT TINDAKAN
TINDAKAN
KSM/INSTALASI 204 Open reduction ofTINDAKAN fracture with internal fixation-
NO KSM/INSTALASI
/UNIT
KSM/INSTALASI/
KSM/INSTALASI TINDAKAN
NO /UNIT 102 humerus
Excision of- semilunar Simple fracture TINDAKANof knee
cartilage
/UNIT
UNIT 1 Abdominopelvic amputation
4 KSM /UNIT
Orthopedi 205
48 Open reduction
Pallidotomi of fracture with internal fixation-
NO KSM/INSTALASI
KSM/INSTALASI/ 28
155
103 Insertion
130 Arthrodesis
Excision
Injection of(movement
or replacement
of
tendonelbowfor
anesthetic Disorder)
TINDAKAN
graft
into
TINDAKAN of interspinous
spinal canal for process
analgesia
Dan 2
19 Dura Achillotenotomy
humerus - Comminutive or Segmental
NO /UNIT
UNIT device(s)
KSM/INSTALASI 49
29104 Paravertebral
206
131 Arthrodesis
Excision
Open
Injection reduction of Blok
tendon
of replacement
destructive Perkutan
hipofTINDAKANof hand
fracture agent forinto
with graft
internal
spinalfixation-other
canal
NO
2. Traumatologi
KSM/UNIT
Bedah 156
3
20
1
49 Insertion
Adductor
Extirpasi
Laringoskopi
Aff Arch Barr or
tenotomy
Tumor Jinak
Fleksible ofSaraf
hip of Kulit
pedicle-based
Kepala dynamic
KSM/INSTALASI/ specified bone TINDAKAN
(Intraartikular Major Bone )
50
30 Pemasangan
stabilization Traksi
device(s) Servikal
UNIT
Kepala Leher 2105
132
4
207
21
Arthrodesis
Excision
Injection
Aff Arch
Advancement
75 FusiOpen
Closed
or of
of
Barr
reduction
Stabilisasi
correction
reduction
knee
locally-acting
danof ofsuspensi
tendon
Corpus fracture
of
of bunionette,
fracture
therapeutic
Vertebra maksila
withwithinternal
That
substance
internal
with into
fixation-
fixation -
NO KSM/INSTALASI/ 50
157
182 Laringoskopi
Insertion
osteotomy
other
Open or
soft tissue
biopsy Direkta
replacement
ofMajorcranial TINDAKAN of
or peripheral skeletal nerve muscle stimulator
or ganglion
NO 51
31 Penjahitan
Arthrodesis
phalanges
Intrarticular Saraf
of foot
other Tepi- simple
specified
Bone
TINDAKAN implants
joints (K-wire)
3
5
133
22 Biopsy
Excision
Advancement
Injection Insisional
106 Graft/Transposisi or of
of destruction
other of dengan
tendon
agent ofanastesi
of
into intervertebral
handspinal lokal disc,
canal,reduction
Intrathecal
No
UNIT
KSM/INSTALASI
KSM/INSTALASI/ 183
51
158
208
76 Open
Maksilektomi
Internal
Open
Closed biopsyfixation
reduction
reduction ofSaraf
soft of tissue
Total+Rekontruksi
bone
fracture
of
TINDAKAN
Tepi
without
fracture with fracture
withinternal
internal fixation-
fixation -
/UNIT 52
32 Punksi
unspecified
Arthrodesis
injection Cairanof ofof Otak
shoulder
steroid, Subarachnoid perfusion of
UNIT 4
6
19
23
184 Deseksi
phalanges
Amputation
Phalang
Ekstraksi
Hemisferektomi
Open submandibula
Korpus
reduction of above
footfoot-Plate
Alienum knee
(Epilepsi)
of Kavum
dislocation & Screws
Nasi Endoskopi
of ankle - Neglected
52
159
20107
55 Mastoidektomi
Interphalangeal
Exploration
refrigerated
Bursotomy
Ekstirpasi Fistel of Radikal
salinetendon
fusion
offraktur
Pre hand
Aurikuler sheath
53
29
33
209
77 Reseksi
Fiksasi
Arthrodesis
Open
Closed
dislocation Extra-Temporal
interna
reduction of
reduction unspecified
of nasal
fracture
of (Epilepsi)
fracture joint
withwithinternal
internal fixation-
fixation -
5
7
134
24
21 Diseksi
Amputation
Injection
Hemisferoktomi
Ekstraksi leher
Korpusof ofand radikal/radikal
disarticulation
therapeutic
(Epilepsi)
Alienum MAE neck
substance dissection
of finger-
into bursa general
53
160
30108
185 Mini
Fiksasi FESS
Interthoracoscapular
Exploration
phalanges
Phalang
Open
56 Ekstirpasi interna
reduction
Carporadial of
of hand hand-
tendon
pan-facial
of Plate
amputation,
sheath & Screws
of hand
Forequarter
dislocation of elbow -Fresh dislocation
54
34
22
6
Revisi
anaesthesia
Arthroplasty
Eksisi
VP
gld
Shunt
Kelenjar offusion
submandibulacarpocarpal
Sub Mandibulaor carpometacarpal joint
210
3178
135
25 amputation
Open
Hemiglosektomi
Closed
Injection
Injeksi reduction
saraf reduction
of therapeutic
perifer of fracture
of fracture
(dengan with
substance withinternal
internal
into bursa
radiofrekuensi) fixation-
fixation -
of hand
54
23
8 109
186
57 Myocutaneus
Ekstirpasi
with
Exploratory
Open implant
Amputation
Closed Angiofibroma
reduction and
reduction Flap
thoracotomy
of (Pectoral
Nasofaring
disarticulation
dislocation
of dislocation Mayor)
of of -General
hand finger
and finger -local -Fresh
55
161
32
24 Rhizotomi
Intra-operative
phalanges
Radius
Insisi
Eksplorasiabses and
AbsesSelektif
of
dengan hand-
ulna (Spastisitas)
neurophysiologic
simple
(MIPO,
Parafaringealanastesi TEN)implants
lokal monitoring -
7
35
136
26 Eksisi
anaesthesia
Arthroplasty
dislocation
Injection
Injeksi higroma
spinal of
of therapeutic
(Pain) leher
carpocarpal or carpometacarpal
substance into joint or joint
55
211
33
2579 anaesthesia
Myringoplasty/Timpaniplasti
Neuromonitoring
110 Insisi
Fasciotomy
Open
Closed
Ekstirpasi reduction
flegmon reduction
Tumor dasar
Jinak ofKepala
fracture
of fracture
mulut with
& Leher withinternal
internal
(Aterom fixation-
fixation
Lipoma) -
56
187
9 Rhizotomy
without
Open
Amputation
ligament implant
reduction (Pain)
andofdisarticulation
dislocation of hip of of- Fresh dislocation
thumb-general
8
26
3458
162 Closed
Insersi
Eksisi
Intervertebral
tarsals
TarsalFiksasi
Faringotomi
Internal andreduction
Elektrode
kista tiroglosus
metatarsals- of
Intradural
chemonucleolysis
metatarsal dislocation
fraktur condylus mandibulaPlate & ankle
Screws
27
56
36111 Mandibulekromi
137
27 anaesthesia
Arthroplasty
Fasciotomy
Injection
FESS of
of metacarpophalangeal
of therapeutichand substance into and tendon
57
212
188
3584 (Epilepsi,movement,psikiatrik)
Selective
Open
Open
Internal reduction
Excision FiksasiNerve
reductionof boneofRoot
of
dislocation
fraktur for Block
fracture
graft
maksilofasial with
of hipinternal
- Neglected
3-4 fixation-
tempat
9
10
2859
163 Closed
Eksisi luas
interphalangeal
Limb
Amputation
FESS reduction
lengthening
Advance tumor
and joint of
ganas dislocation
procedures
with
disarticulation bibir
implant dengan
of of elbow
finger- rekontruksi
general
57
138
36
28 dislocation
Neurektomi
tarsals
112 patahan and
Finger reattachment
Injection
Kordotomi of Saraf
metatarsals-
therapeutic
Perkutan Vidian simple
substance into implants tendon of
58
37
2985
189 Selective
anaesthesia
Arthroplasty
Excision
Frontal
Open Sinusotomi
reduction Thalamotomi
of of metacarpophalangeal
intervertebral
of procedures
dislocation (Movement
disc
of knee Disorder)
and
10
37
30
60 Internal
164
213 Closed
flap
Limb
Open
hand lokal reduction
shortening
reduction
fiksasi frakturof of dislocation
fracture
maksilofasial with of5- foot
internalNeglected
tempat and toe-
fixation-tibia
patahan
58
11
29113 Fore Head
Osteotomi+Septum
interphalangeal
Amputation
Five-in-one
Kordotomi
dislocation Flapand repair
Servikal joint koreksi
without
disarticulation
of
Open knee (Pain) implant
of finger -local
59 Simpatektomi
86 atau
139 and fibula
general
Excision
Insertion -Simple
anaesthesia
of Open
lesion fracture
(Pain)
of muscle
38
11
38
165
190
31 Eksisi
Local
Open
Fronto
lebih
anaesthesia
Arthroscopy luasof
excision
reduction
Etmoidektomi
bone
tumor growth
ganas
of (Ekstranasal)
of lesion
dislocation or stimulator
dengan
tissue
of knee rekontruksi
of-Fresh
bone dislocation flap jauh
68
214
39
30114
61 Rekontruksi
Open
Foot
Closed
Laringectomi
Kordotomi reduction
reattachment Fraktur
reduction
Servikal of Maksila
fracture
of dislocation
Perkutan Multiple
with
(Pain) internal
of foot and fixation-tibia
toe-local
60
1287
140 Simpatektomi
Amputation
Excision
Insertion of
of and Perkutan
lesion
bone disarticulation
of
void muscle
filler ofofhand
thumb-general
12
39
166 Eksisi
and fibula-Comminutive
Arthrotomy
Lower luas
leg ortumor
1115 Adenotonsilektomi
anaesthesia for ankleremovalganas ofkulit
reattachment orprosthesis
Segmental
dengan rekontruksi
without
3.
191
32
69 Open
FOL
Rekontruksi reduction
anaesthesia Fraktur of dislocation
Maksila of other specified
Sederhana sites
KSM 31 Forearm,
Kranioplasti wrist,
dua or
sisi hand reattachment
61
215
88
141 SLTH
replacement
Open
Excision
Insertion reduction
262 Anthrostomi+Sinuskopi
Closed of
of lesion
catheter
reduction of fracture
of other
into
of dislocation without
soft
spinal tissue
canal internal
for fixation
infusion of
13
167
192
33 flap
Open lokal
Amputation
Lower
Glosektomi limb
reduction amputation,
andofdisarticulation
Total/Parsial dislocation not of of of
otherwise hand
thumb-local
shoulder
and finger-
specified
-Fresh
Bedah THT-KL 70
40
3116 Rhinoplasti
Aspiration
Fusion
therapeutic of bursa
oranaesthesia
refusion
or palliative of 2-3substances,
vertebrae Insertion of
32
62
1489 BLM
216 Simple
Kranioplasti
general
Stereotactic
anaesthesia
Open
Dorsal
dislocation
Eksisi
reduction
luas and (Kista,Polip,Nodul,Granulasi)
satu
Ablative
tumor
sisi
of separated
dorsolumbarganas
Procedure fusion
rongga
epiphysis
(Psichiatric)
of the dengan
mulut anterior
168
4
3463 Lumbar
catheter
Biopsi
Closed
Glosektomi Tumor and
into lumbosacral
reduction epidural,
Total/Hemiglosektomi+RND of fusion
subarachnoid,
dislocation of ofthehand anterior
or subdural
andand finger-
71
14
41
193
33117 Rinotomi
Amputation
Aspiration
Open
Fusion
column,
Kraniotomi Lateral+Maksilektomi
reduction
or of of bursa
anterior
refusion
Biopsi ankle
of of through
dislocationhand
technique
otak 4- 8 of Medial
malleoli
shoulder
vertebrae of tibia
-Neglected
63
217
5 Subthalamotomy
column,
Osteoclasis
space
Bronkoskopi
dislocation ofanterior
spine (correction
Rigid technique
with (Movement of
intermittent bone Disorder)
deformity)
or continuous
15
35
local
rekontruksi
fibula anaesthesia
90 Hemiglosektomi+SOHND
Dorsal andflap lokal
dorsolumbar fusion of the posterior
72
42
169
34
6118
194 Rekontruksi
Aspiration
Lumbar
BLMinfusion
Fusion
Laminektomi
Open Advance and
or
reductionofof Laring
drug
lumbosacral
other
refusion
Eksisi
(Stenosis,
of Trakea
(withsoft 9creation
tissue
fusion
of dislocation
Tumor
dislocation or more
Spinal ofofany
thereservoir)
vertebrae
Subjektif/Trakea,
of unspecified anterior
Papiloma
64
1564 Amputation
218 Closed reduction
Suturektomi
Other
column, ofKraniostenosis
posterior toe-general of
technique anaesthesia of hip site-Fresh
16
142
36 Eksisi
column,
Insertion
dislocation
Insisi Abses parsial+marsupialisasi
posterior
of
Leher interbody
Dalam technique spinal Ranula
fusion device
73
4391
119 Reposisi
Aspiration
Graft
Excision ofFraktur of other
muscle bone Osor for Nasal
soft
fascia tissue of hand
graft
35
65
1665 Laring/Trakea)
170
219
195
Laminoplasti
Closed
Thalomotomy
Amputation
Lumbar
Other
Open reduction
(peripheral)
and
reduction oflumbosacral
(Pain)
toe-local
of of dislocation
vascular
dislocation anaesthesia
fusion
ofshunt ofofor
the
unspecified kneebypass
posterior
17
143
7
37 Eksisi
Insertion
Cald
Inversi Well tumor
Grommet Lucof ganas
other kulit
spinal dengan
devices flap localsite- atau graft
74
44
3692
120 Reposisi
column,
Atlas-axis
Hip
Excision
bearing
Neglected
Laminotomi &
posterior
Fiksasi
spinal
of surface, technique
Fraktur
fusion
intervertebral
dislocation
Biopsi Mielum Mandibula
ceramic-on-ceramic
disc of other specified
66
1766
220 Closed
Transposisi
Amputation
Other amputation
8 Cochlear reduction
through of
kraniostenosis,dengan
Implant/Implan below dislocation
footBaha knee orbital
18
171
196
144
38 Kulit
Lysis
Open
Insertion
Insisi of adhesions
reduction
Perikondritis of partial of
of dislocation handdisc
spinal of wrist -Fresh dislocation
prosthesis, cervical
75
45
37
993
121 Septum
advancement
Biopsy
Hip
Excision
bearingKoreksi+Konkotomi
of
sites-general
Laminotomi
Dekompresi bone
of surface,
lesion
Diskektomi
Nervus anaesthesiaof ceramic-on-polyethylene,
muscle
FasialisHNP/Stenosis>1 level Hip
18
221 Amputation
Other anastomosis through forearm of cranial or peripheral nerve
67
19
172
197
145
67 DCRTransposisi
Eksisi
Lysis
Open
bearing
Insertion
Closed oftumoradhesions
reduction of kraniostenosis,tanpa
surface, ganasof
partial ofkulit
fracture
oxidized muscle,
spinal dengan
with
disc tendon,
flap
internalorbital local
fascia,
fixation-
zirconium-on-polyethylene
prosthesis, jauhand
radius
of reduction
10
39
76 Irigasi Sinus Maksila dislocation of other specified
46
3894 Stapedektomi
Biopsy
Excision
Laminotomi
and ulna-Simple
advancement
bursa
joint
of structure
lesion
Diskektomi fracture of muscle
HNP/Stenosis of hand 1 level
19
222
11122 Amputation
lumbosacral
Other
Hip and
bearing
sites-local
Eksisi Ekstostosis unspecified
through
surface,
anaesthesia hand, repairAmputation
metal-on-metal of the anulus
through fibrosus
20
198
40 Eksisi
Open
Insisi Abses tumor
reduction ganas
Peritonsil of kulit tanpa
fracture with rekontruksi
internal fixation-
NO KSM/INSTALASI 68
77
173
47
146
39
1295
68 Skin
Trepanasi
carpals
Lysis
Biopsy Pricle
Insertionofofadhesions
Excision
Lesionectomy
Closed Test
Cedera
spinal
of
ofrecombinant
reduction lesion cord
(Epilepsi)Kepala
ofoforspinal
TINDAKAN
of (<4jam)
spinal
other bone
dislocation cord
soft and
meninges
morphogenetic
tissue
of nerve
other roots
specified
123 Ekstirpasi
223 Other
Hip
unspecified Kista
arthrotomy
bearing site Branchial
surface,
(Periarticular metal-on-polyethylene
Major Bone )
/UNIT 21
20
13 Eksisi
Amputation
protein tumor
sites-local through
jinak
anaesthesia dengan
humerus, anastesi Upper lokalarm amputation
41
69
78
4896 Ekstirpasi
174
199
40 Imunoterapi
Tiroidektomi
Trepanasi
Metacarpocarpal
Bone
Excision
Open
Lobektomi graft
reductionKista
Cedera
of Ductus
Sub-Total
lesion
(Epilepsi) of fusion
Kepala Tiroglosus
of tendon
fracture (>4jam)
with sheathfixation-carpals
internal
147
224
124
231
1469 Insertion
Other
Implantation
Other
Closed
Ekstraksi bunionectomy
of
diagnostic spinal
reduction
granulasi of internaldisc
procedures
of prosthesis,
limbonlengthening
dislocation
MAE/Kolesteatosis joint not
ofstructures
shoulderotherwise
device with
22
21
42 Ekskokleasi
Amputation,
and
Konka metacarpals
Reduksi epulis
not -otherwise
plate & screws specified
70
79
175
49
41
1597
232 Tonsilektomi/Adenoidektomi
Trepanasi
Metacarpophalangeal
specified,
Bone
kinetic
Excision
Other marrow
diagnostic
Mesencephalectomy
Ekstraksi
Hand NOS PolipCVA
Replacement
distraction
of or
lesionBleeding
-Plate & Screw hematopoietic
of
procedures fusion
tendon
(Pain) of spinal
on stem
sheath
muscle,disc, cell
of NOStransplant
hand,
tendon, fascia, and
225
70 Other
Closed bunionectomy
reduction of with soft tissue
dislocation of correction
wrist
23
22
148
16
200
43 Ekskokleasi
Ankle
(all
Insertion
Open procedures
125 Esofagoskopi
bursa,
Kaustik fusion
Implantation
Ganglionectomy
reduction ofInferior
including
Konka kista
spinal
ofofincluded
Rigid folikuler
other of
&disc
fracture
that tendonprosthesis,
in
internal
ofFleksibel
hand with this class
sheath
limb
internal thoracic
lengthening
(wrist)-General
fixation-carpals
71
80
176
42 Tracheostomi
Trepanasi
Metatarsophalangeal
Mikrodisekktomi kelainan HNP Saraf
fusion Kranial
50
226
233
17 Bunionectomy
device
Other
andanaesthesia
Other cervical
metacarpals
71 Ethmoidektomi division
Closed reduction ofwith
fusion
- plate
bone
(Intranasal) soft of
&
offixationtissue
the
screws anterior
dislocation-Local correction column, and anterior
24
23
149
44 Ekskokleasi
Application
Insertion
Laringektomi ofofkista
sternal
external radikuler fixator device
device with anaesthesia
rigid plates
72
81
177
43
234
18 Turbinektomi
Trepanasi
arthrodesis
Midtarsal
technique
98 Ekstraksi
126 Implantation
Excision
Hand
MVDOther NOS fusion
(Microvascular
excision Kelainan
of lesion
-Plate
Korpus orofAlienum
&joint Vascular
replacement
of
Screw tendon
Decompression)
Kavum Otak
of
sheath
peripheral
Nasiof hand,
25
24
51
150
227 Ekstirpasi/eksisi
Application
Bunionectomy
neurostimulator
Insertion
Other
Ganglionectomy
72 Laringektomi+ND
201
235
45 Closed
Open
Other cervical
reduction of of total
reduction
excision external
with
fusion
ofor tumor
lead
spinal
softof soft
tendon
(s)
of
oftissue
fracture fixator
jinak
tissue
disc
the
fracture posterior
jaringan
sheath
prosthesis,
device,
correction (wrist)-Local
with internal
with internal lunak
monoplanar
column,
cervical
and ukuran -
fixation
fixation-carpals
73
82
178
44 Tiroidektomi
Trepanasi
Muscle transfer
Neurektomi/Neurolise Tumor
Total+ND Otak
transplantation
<2cm
system
osteotomy
127 andposterior
Anaestesi
metacarpals
Implantation
Carpal andtechnique
of metacarpal
the first metatarsal
or -replacement
simple implants (K-wire)
of spinal
152
46 Insertion
Hand
Laringo NOS of total spinal
-implant
Fisur/Eksplorasi sederhana
Laring disc prosthesis,
(K-wire) lumbosacral
74
26
83
25
52
179
228
4599 Temporal
VA
Ekstirpasi
Application
Bursectomy
Myotomy
neurostimulator
Other
Excision
Shunt
73 Neuroendoskopi change
Bone
Closed reduction kista
ofof muscle
external
Resection
indermoid
lead(s)
hand of fracture withgraft
or
(Otak,Spinal) fixator
muscle
fascia device,
for
or tendon ringlength
internal system
fixation -
202
153
128 Open
Incision
Insertionreduction
andor of
replacement
drainagefracture of with
palmar
of internal
(cement)or fixation-femur-
thenar
spacer space
47
75
27
84
26
53
180
229
46 Femur
100 Ligasi
Terapi
VP A.Wicara
Endoscopic
Application
Bursectomy
Myotomy
Other
Excision
Shunt
Neuroplasti
Comminutive (Including
Karotis
changeof Eksternal
Multiple
ofof
hand
thyroidectomy
of
ormuscle
pada
hybrid
hand
in muscle
Segmental : MIPO,
Anak-Anak
external
or fascia or interlocking
tendon
fixator
of
dan hand dewasa
length
device
fornail,
graftTEN)
2874 Fiksasi
154
129
203 Closed
Injection
Insertion
Open reductionreduction
interna
of
or anesthetic
replacement
fraktur
of of fracture
fracture maksilofasial
into withreplacement
ofperipheral
with facet
internal internal
1-2 nerve fixation
tempat
fixation-femur- for -
48
76
85
27
54101 Laringoskopi
181
230 Terapi
VP
Arthrocentesis
Bursotomy
Neurectasis
Other
Excision
Shunt Wicara Rigid
destruction
Satu
of otherTunaSisi of
lesion
Laring
intervertebral
of soft tissuedisc of hand
47 Omaya
patahan
analgesia
device(s)
Humerus
Simple drain
fracture (including : Interlocking nail, TEN, MIPO)
 236 Other excision of soft tissue of hand
237 Other excision or avulsion of cranial and peripheral nerves
238 Other excision, fusion and repair of toes
239 Other exploration and decompression of spinal canal,
Decompression
KSM/INSTALASI 240 Other fasciectomy TINDAKAN
NO
/UNIT 241 Other fasciectomy of hand
242 fusion of foot
Other peripheral nerve or ganglion decompression or
259
243 Otherofhand
lysis musclePeripheral
adhesions transfer ornerve
transplantation
neurolysis NOS
244
260 hand muscle
Other plastic transposition
operations on fascia
245
261 hand tendon
Other plastic transfer
operations or transplantation
on hand
246
262 Other hand tendon transposition
Other plastic operations on muscle
247
263 Other
Other incision
repair ofofankle
bone without division
248
264 Other incision of soft tissue
Other repair of elbow
249 Other incision of soft tissue of hand
265 Other repair of hand, fingers and wrist
250 Other injection of locally-acting therapeutic substance into
266 Other repair of joint
267 soft
Othertissue
repairofof
hand
knee
251
268 Other local excision
Other repair of shoulder or destruction of lesion of joint
252
269 Other muscle transposition
Other repair of the collateral ligaments
253 Other myectomy
270 Other repair of the cruciate ligaments
254 Other myectomy of hand
271 Other
255 Other repair or plastic operations on bone
neuroplasty
272
256 Other operations
Other suture of flexor tendon tendon,
on muscle, of hand fascia, and bursa
273
257 Other suture of muscle or fascia
Other operations on muscle, tendon, fascia, and bursa,
274 Other suture of other tendon of hand
Suture of bursa
275 Other suture of tendon
258 Other partial ostectomy (including : Bone curretage,
276 Other tendon transposition
277 marginal resection/excision)
Other tenodesis of hand
278 Other tenonectomy
279 Other tenonectomy of hand
280 Other tenoplasty of hand
NO KSM/INSTALASI TINDAKAN
281 Other tenotomy
/UNIT
282 Other totalof shoulder
300 Refusion dorsal replacement
and dorsolumbar spine, posterior
283 Partial hip replacement
column, posterior technique
284
301 Partial shoulder
Refusion replacement
of lumbar and lumbosacral spine, anterior
285 Patellar stabilization
column, anterior technique
286
302 Percutaneous
Refusion denervation
of lumbar of facet
and lumbosacral spine, anterior
287 Percutaneous vertebral
column, posterior technique augmentation
288
303 Percutaneous
Refusion vertebroplasty
of lumbar and lumbosacral spine, posterior
289 Peripheral nerve injection,
column, posterior technique not otherwise specified
290
304 Plastic operation
Refusion of other oncervical
hand with graft anterior
spine, of musclecolumn,
or fascia
291 Plastic operation
anterior technique on hand with other graft or implant
292
305 Pollicization
Refusion of operation carrying
other cervical overposterior
spine, nerves and blood
column,
supply
posterior technique
293 Quadricepsplasty
306 Refusion of spine, not elsewhere classified
294 Reattachment of muscle
307 Refusion of spine, not otherwise specified
295 Reattachment of muscle of hand
296 Reattachment of tendon
297 Reattachment of tendon of hand
298 Refusion of atlas-axis spine
299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique
 308 Release of carpal tunnel
309 Release of clubfoot, not elsewhere classified
310 Release of tarsal tunnel
311 Removal of (cement) spacer
312 Removal of bone growth stimulator (invasive)
313 Removal of foreign body from spinal canal
314 Removal of implanted devices from bone - carpals
and metacarpals-Plate & screw
315 Removal of implanted devices from bone - carpals
and metacarpals-simple implants (K-wire)
316 Removal of implanted devices from bone - External
fixator device (invasive) (
317 Removal of implanted devices from bone - femur
318 Removal of implanted devices from bone - humerus
319 Removal of implanted devices from bone - radius and
ulna
320 Removal of implanted devices from bone - scapula,
clavicle, and thorax (ribs and sternum)
321 Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) - Plate
& Screw
322 Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) -
simple implants (K-wire)
323 Removal of implanted devices from bone -patella
324 Removal of implanted devices from bone- tarsals and
metatarsals- simple implants (K-wire)
325 Removal of implanted devices from bone- tibia and
fibula
326 Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)

KSM/INSTALA TINDAKAN
NO
SI/UNIT
327 Removal of implanted devices from bone-tarsals and
metatarsals - Plate & Screw
328
Removal of internal limb lengthening device
329
Removal of pedicle screw(s) used in spinal fusion
330
Removal of peripheral neurostimulator lead(s)
331
Removal of skeletal muscle stimulator
332 Removal of spinal neurostimulator lead(s)
333
Reopening of laminectomy site
334
Repair of claw toe
335
Repair of cleft hand
336
Repair of hammer toe
337
Repair of hip, not elsewhere classified
338
Repair of macrodactyly
339
Repair of mallet finger
340 Repair of old traumatic injury of cranial and peripheral
nerves
341
Repair of recurrent dislocation of shoulder
342
Repair of the anulus fibrosus with graft or prosthesis
343 Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae,
Removal of bony spicules from spinal canal
344
Replacement of joint of foot and toe
345 Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
346
Resurfacing hip, partial, femoral head
347 Revision of total knee replacement, tibial insert (liner),
Replacement of tibial insert(liner)
348 Revision or replacement of artificial spinal disc
prosthesis, cervical
349 Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
350 Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
351 Revision or replacement of artificial spinal disc
prosthesis, thoracic
352
Rotator cuff repair
353
Separation of equal conjoined twins
354
Separation of unequal conjoined twins
355
Sequestrectomy
356
Spinal fusion, not otherwise specified
357 Subtalar fusion
358 Subtalar joint arthroereisis
 359 Suture of Artery
360 Suture of capsule or ligament of ankle and foot

NO KSM/INSTALASI
KSM/INSTALASI TINDAKAN
TINDAKAN
NO /UNIT
/UNIT
5 KSM BEDAH 1 361 Biopsi Terbuka Bronkhus
Suture of capsule or ligament of other lower
THORAKS 2 Biopsi Terbuka Diafragma
NO KSM/INSTALASI extremity TINDAKAN
DAN 3 Biopsi Terbuka Mediastinum
/UNIT
KARDIOVASKULAR 4 362 BiopsiSuture
Terbukaof capsule
Paru or ligament of upper extremity
5 363
40 Biopsi
Suture
Terbuka
Revisi
of cranial
Thoraks Pleura and peripheral nerves
drain/water sealed drainage (WSD) (diluar
364
6 Biopsi alat)Terbuka Pleuraor
Suture of muscle fascia VATS
dengan of hand
365
7 41 BiopsiSuture
Thoracal
Terbukaof tendon
Tumorsheath
Symphatectomy Dinding dengan Video Assissted
Thoraks
366 Suture of
Thoracoscopic
8 Debridement tendon sheath
Surgery (VATS)
Mediastinum of hand
(Sternotomi)
367
42 Suture of
Thoracocentesis
9 Eksisi Pada Bronkhus Vein
NO KSM/INSTALASI/ 1043368EksisiSynovectomy
Thymectomy
Pada Paru (Lung TINDAKAN
Volume Reduction)
UNIT 369
44 Tarsometatarsal
Thymectomy
11 Eksisi Pada Paru dengan dengan fusion
VATS VATS
370
45
1276 Eksisi Tendon
Torakoplasti
Tumor graft
(Air
Dinding Plumbage/Muscle
Dada denganPlumbage)
Rekonstruksi
Rastelli Procedure (right Ventricle-Pulonary ArteryDinding
371
46 Dada Tendon
Torakotomi pulley
/ reconstruction
sternotomi Eksplorasi
Conduit)
372
47
1377 EksisiTendon
Torakotomi
Tumor pulley reconstruction
Eksplorasi
Mediastinum pada Trauma jantung/Repair
Repair (Eksisi)
Laserasi Jantung Aneurisma (Thymoma,
Jantung Teratoma,
373 Tendon
Neurogenic transfer
dsb) or transplantation
7848 Repair
Bedah Aorta
Kardio Torakalis (38.34)
14 374 Tenotomy
Ekstraksi Corpus of(Jantung)
hand
Alienum di Regio Toraks
7949 Repair
AorticAtrioventricular
Valve Repair (AVR) Septal Defect (35.54)
15 375 Thigh
Ekstraksi reattachment
Corpus AlienumPulmoanry
di Regio Toraks dengan VATS
80 Repair
50 Aortic Total
Valve Anomalous Venous
Repair (AVR) dengan Bioprosthesis Connection
Valve
16376 Thumb
Evakuasi
(TAPVC)
reattachment
Efusi
(35.82) Pleura/Empyema secara Torakoskopik
51
378 Aortic Valve
Toe reattachmentRepair (AVR) dengan Mechanical Valve
81 (VATS)
Repair Transposition of Great Arteries (TGA) (35.84)
52 Atrial
379 Totalseptal
ankleDefect (ASD)
replacement Closure
17
82 Fiksasi
Repair Costae (Clipp,
TrunkusCavo-Pulmonary Wire)
Arteriosus (35.83) (diluar Clipp)
53
380 Bidirectional
Total elbow replacement Shunt (BCPS)
18
83 Fiksasi Sternum (Wire, Permanen
Plate) (diluar wire/plate)
54 Revisi/Aff
381 Biopsi Pace Maker
Total Jantung
ostectomy
(diluar alat) (37.89)
19
84 Lobektomi
Septostomi Parsial (Reseksi Paru
Terbuka Septum Atrium (35.41) segmental)
55
382 Biopsi
Total Perikardium
wrist replacement
20
85 Lobektomi Parsial (Reseksi Paru(TOF)
segmental)
(35.81)dengan
56 Total
383
Koreksi Tetralogy
Blalock-Taussing
Transplant fromShunt
of(BT
cadaver
Fallot
Shunt)
86 VATS
Tricuspid Valve Repair (TVR) (35.14)
57
384 Coronary Artery
Transposition Bypass
of cranialGraftand(CABG)
peripheral nerves -
21
87 Lumbal
Tricuspid Simpatektomi
Valve Repair (TVR) dengan Bioprosthesis Valve
58 Eksisi Cardiac Myxoma
Nerve transplantation
22 Mediastinostomy
(35.27)
59 Fontan Operation (Atrium-Pulmonary Artery Conduit)
23
88389 Triad kneethorak
Pemasangan repair drain/water sealedMechanical
drainage (WSD)
60 Tricuspid
Internal Valve Repair
Resusitasi/Cardiac (TVR) dengan
Massage Valve
(Operasi Terbuka)
390(diluar alat)arthrodesis
Triple
(35.28)
61 Ligasi Patent Ductus Arteriosus (PDA)
24
89391Pleural
Ventriclewindow
Septal(Eloeser
Unspecified operation Flap)
Defect (VSD) on bone injury
Closure (35.5)
62 Mitral valve repair (MVr)
25
90392Pleurektomi
Upper Above
Amputasi arm reattachment
Knee (AK) (84.17)
63 Mitral Valve Repair (MVR) dengan Bioprosthesis Valve
26
91393Pleurodesis
Upper Below
Amputasi (Pleurosklerosis)
limb amputation,
Knee (BK) not otherwise specified
(84.14)
64 Mitral Valve Replacement (MVR) dengan Mechanical
27
92394Plikase
Wedge
Arterial Bulae / Bleb Emfisematous
osteotomy
Valve Pungsi, Kanulasi, Sectie (38.91)
28
93 Plikasi diafragma
65 Arteriovenous
Operasi RedoShuntt (AV Shunt)
Open Heart (Valve Brakiosefalika
Replacement) (39.42)
29
94 Pneumonectomy
66 Arteriovenous
Operasi Reopen Shuntt
oleh(AV
KarenaShunt) Radiosefalika
sebab Perdarahan,(39.27)
30
95 Pneumonectomy
Bedah Varises
Tamponade Jantung dengan
Insisi BabcockVATS (38.5)
31
9667 Pulmonary
Biopsi Decortication
Pembuluh
Pemasangan Darah (Perifer) (38.21)
IABP
32
9768 Pulmonary
Pemasangan Decortication
Debriment-Nekrotomi Pace MakerLukadengan
Gangren
Permanen VATS (86.22)alat)
(diluar
33
98 Pulmonary
69 Disartikulasi Lobectomy/Bilobectomy
Sendi Ekstremitas (84.13)
Pericardiocentesis
6 Eksisi Biopsi 341 Pulmonary
Eksisi Tumor
70 Perikardiektomi Lobectomy/Bilobectomy
Pembuluh dengan VATS
Darah Perifer (Hemangioma)
3571 Redo Torakotomi
Perikardiotomi/Pericardial Window
3672 Rekonstruksi
Pulmonal Valve Sternum&Dinding
Repair (PVR) Dada
3773 repair deformitas
Pulmonal Valve Pectus
Repair (PVR) dengan Bioprosthesis Valve
3874 Repair
Pulmonal
FistulaValve Repair (PVR) dengan Mechanical Valve
Bronkopleural
39 75Repair
Pulmonary
Laserasi Artery Banding (PA)
Diafragma
 Tumor Pembuluh 2 Eksplorasi Vaskular (Trauma/Non trauma)
Darah 3 Embolektomi/Trombektomi Aorta
NO KSM/INSTALASI 4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal
TINDAKAN
NO
NO KSM/INSTALASI
/UNIT 5 Embolektomi/Trombektomi TINDAKAN
Pembuluh Darah Arteri Ekstremitas
10
NO
11 Divisi
/UNIT
Onkologi
KSM/INSTALASI
DIVISI BEDAH Bawah
Aspirasi
OperasiKista
176 Abdominal pullMamma
Trauma GinjalSingle
TINDAKAN
through dan
(sfingter Multiple
saving procedure)
NO KSM/INSTALASI TINDAKAN
/UNIT
ANAK 6120
277Embolektomi/Trombektomi
Biopsi
Sistostomi
Core Lokal
perkutan
Operasi Urakhus/Reseksi
Adhesiolisis Pembuluh
Anestesi Darah
urakhus Ekstremitas Atas
/UNIT
KSM/INSTALASI (diluar alat) TINDAKAN
NO KSM/INSTALASI 121
44
3
60 Biopsi
LDSistostomi
flap
78 Fistulotomi
32
19 Total Eksisi
Orkhidektomi Terbuka
Lokal
pantreaktomi
Hernitomi dgn
dgn TINDAKAN
penyulit
penyulit / mayor
komplikasi
NO /UNIT
KSM/INSTALASI 761 Repair of Gastrochisis
3 Embolektomi/Trombektomi
Appendektomi dgn (54.71)
TINDAKAN
penyulit
Pembuluh Darah Ekstremitas
NO
NO /UNIT
KSM/INSTALASI
KSM/INSTALASI 122
45
4
79 Le
61
20 Biopsi
Skrotoplasti
fortprokto-kolektomi
Total Eksisi
I osteotomy
Orkhidektomi
Fistulotomi
Pasang Narkose
dgn
Double extended
TINDAKAN
penyulit
Lumen
TINDAKAN minor
Hemodialisis (HD) (diluar
/UNIT 33
62
13 Hidrokolektomi
Bawah(diluar
RPLND alat)
(40.59)
/UNIT
/UNIT 123
34
46
5
4
62
80
21 Funikokelektomi
Biopsi
Liposuction
Spermatokelektomi
Tutup Insisi
Appendektomi
Orkhidektomi
burst
Gastrostomi
alat) Lokal
laparoskopik
abdomen
8 47Embolektomi/Trombektomi Ligasi Tinggi
(tanpa alat)
Pembuluh Darah Regio servikal
Operasi Tindakan Tertentu
124
35
47
6
34
63
22
63
13 Ganti
Biopsi
Lobuloplasti
Tailoring
81(Karotis,
18 Tutup Nefrostomy
Narkose
Intraoperatif
Orkhidektomi
Ekstripasi
burst
Hemikolektomi
Separasi
Pasang
Bone Ureter
kolangiografi
Corpus
abdomen
Subkapsuler
conjoined
Implantable
rekonstruksi
Jugular) dengan
(diluar Alienum
dengan
twin
facial
alat) cleftdi
penyulit
(84.9)
Central penyulit
Bilik
mayor
Venous Mata
mayor
Depan
Access (diluar
5 Appendektomi tanpa penyulit
14
48
125
36
48
7
64
82
19
923
14 Advancement
Hidrokel
Breast
Malarplasty
Transplan
Tutup Conserving
Hemikolektomi
alat:
Evakuasi
Bone per
Orkhidopeksi
porth-a-cath,
Hematom
rekonstruksi Flap
Resipien
Inguinal/Ligasi
Enukleasi/Eviscerasi
burst abdomen
(Torsio
dengan
di Surgery
dengan
Testis)(BCS)
Tinggi
(DFG/Bonegraft)
celsite) penyulit
Ekstremitas
facial cleft penyulit
minor
(Pasca minor
Pungsi HD/
35
64 Intraoperatif
Sirkumsisi kolangiografi
dengan general laparoskopik
anesthesia
6
126
37
49
8
65
83
20
24 Biliodigesif
Hidrokel
Breast
Mamma
Tutup
Orkhidopeksi
Evakuasi dengan
Transuretero-ureterostomi
Conserving
aberan
per
kolostomi
Hemikolektomi
Traumatik)
Pemasangan Skrotal
Silikon
(UDT)
/ penyulit
unilateral
Surgery
ileostomi
tanpa
Central Oil penyulit
Venous +mayor
LD Flap (64.0)
Catheter (CVC) (diluar
49
15 Aspirasi Effusi
Cheilonasoraphy Pleura
36
127
38
50
9
66 Jejenostomi
Hipospadia
Debriment
Mandibular
TUR / ileostomi
Prostat/TUIP/BNI
Mamma
distraksi
Subkoronal dengan penyulit mayor
7 Biliodigestif anastomosis tanpa penyulit ataumayor
10 84
21
25
65 Tutup
Orkhidopeksi
Fornix
Fasciotomy
Hemoroid
alat) kolostomi
Sirkumsisi Repair per
stapling
dengan / ileostomi
Laparoskopi
(diluar
local dengan
alat)
anesthesia penyulit
(64.0) penyulit
11 50
128
39
10
51
67
85
22
26 Aspirasi
Holmium
Diseksi
Mandibular
TUR
Tutup
Pasang
ICCE
Ligasi TumorParu
Axilla
YaG
kolostomi
Vaskular
Hemoroidektomi
Pemasangan Kateter +/ Pleurodhesis
rekonstruksi
Buli
Laser (Sewa)
ileostomi
Ekstremitas dengan
dengancostochondral
penyulit minorgraft
16
37
16
66 Chordectomy
minor
Jejenostomi
Splenektomi ileostomi dengan penyulit minor (diluar
Intra
/(41.5) Aortic Baloon Pump (IABP)
NO KSM/INSTALASI 12129
40
52
11
68
23
27 Ileal
Eksisi
Mastopexi
TVP/TMP
86Mutilasi
Repair Conduit
Pasang
ICCE Fibroadenoma
Aorta
& IOL
Digiti
Herniotomi
alat) (Bricker)
Kateter
Torakalis
Ekstermitas dengan Lokal
TINDAKAN
(38.34)Anestesi Single Satu Sisi
Mandrain
8
51
17 Biopsi
Delto rectum
Pectoral Flap (DP Flap)
Chordectomy+urethroplasty
/UNIT 38
130
41
12
53
69
87
24
28
67 Jejenostomi
Insersi
Eksisi
Mentoplasty
Ureterokutaneostomi
Repair
Pasang
InjeksiFibroadenoma
Herniotomi
Pemasangan
SplenorenalDJ Stent/ Vitreal
ileostomi
Atrioventricular
Intra
Kateter
dgnshunt Tenckhoff
penyulit
Peritoneal (39.1) tanpa
Multiple
Septal
mayor
Dyalisis penyulit
Narkose
untuk
Defect CAPD
(PD) (35.54)
Catheter
8 KSM BEDAH 17
9
52
131
42
13
54
88
1
25
29 ByDiseksi
pass
Insisi
Eksisi
Microsurgery
Ureterolisis
Rekonstruksi
Abses
Tumor
Adrenalektomi
PCNL/PNL
Injeksi
Herniotomi usus
Axilla dengan
Perineum
Periokuler
dgn Metastase
palpebra penyulit
Terapetik
penyulit Loco-regional
minor mayor / minor
18
39 (diluar
Closed alat)
KoledokotomiReduction dengan Fr. Nasal penyulit mayor
UROLOGI 68
132
43
14
55
89
2
26
30 Transnasal
Insisi
Eksplorasi
Multiple
Ureterolithotomi
Released
Abses
Adrenalektomi
Penektomi
IOL facial
Explant
Herniotomi endorectal
Duktus
buried
Skrotum
fraktur
Parsial penis
Mama pullthrough
+ implant
(Abdominotorakal)
laparoskopik laparascopic
18
10
53 Pembedahan
Divertikulektomy
Diseksi Inguinal Teleangiectasis
19
40
133
44
15
56
90
3
27 assisted
Comisuroplasty
Kolesistektomi
Insisi
Eksplorasi
Released (48.42)
Muskulokutaneus
Ureterolithotomi
Posterior
Anastomosis
Penektomi
Iridectomi Duktus
syndactylyUrethral
Distal
flap
Total/AmputasiMama+VC kompleks
Valve
31
19 Jejunostomi
Repair Aneurisma / end
ileostomito end
(True/false) Ureter Penis Ekstremitas Superior
69
11
54
134
45
16
57
91
4
28 Transplantasi
Drainase
Diseksi
Johanson
Insisi
Myokutaneus
Augmentasi
PER
Jahit Para
abses
Ureterolithotomi
RepairAbscescanalis
(Primary
Kelopak organ
Aorta
dengan
Mastitis
Buliflap/pectoralis
lacrimalis
Mata Proksimal
Endoscopic Lokal
Full general
(without
mayor
Thickness anasthesia
Realignment)silicon
flap
& Lid tube)
Margin
32
20
41 Laparotomi
(diluar
Eks graft)
mamma dengan
aberan
Kolesistektomi laparoskopik penyulit
bilateral minor
135
46
17
58
92
5
29
33
20
70
12
55 Johanson
LD
Nasal
Ureterosigmoidostomi
Repair
Flap
Biopsi repair
Laparotomi
Repair
Tutup
Drainase +coloboma
Pielokalikotomi
Jahit Kornea
Ginjal
Eksisiburst I
Eksisi
Aneurisma
Tumor
abses dan
perkutan
tanpa
abdomen Tumor
rekonstruksi
Lidah palpebra
penyulit
localAorta (Caffey)
dengan (skin/mucosal
Abdominalis
anasthesia penyulit(Diluar graft)
(54.61)Protesa)
21
42
136
47
18
59
93
6
30
34
21 Eksisi
Kolostomi
Johanson
Biopsi
Ligasi
Repair neoplasma
Mastectomy
Neo
Ureterostomi
Repair
vagina /
ductus
Pielolitotomi
Keratoplasti
Ginjal
hemoroid sigmoidostomi
II +Terbuka
Pembuluh Tram jinak
nasolacrimalis
(Corneal
(diluar
Darah Flap (lipoma, (46.11)
Transplantation)
alat) atheroma
Regio Servikal (Karotis, dll)
71
13
56
137
48
19
60
94
7
31 Tutup
Eksisi
Eksisi
Kalibrasi
Modified
Operasi burst
hygroma
Tumor
Ureterouretostomi
Repair
Biopsi
Pieloplasti
Konjungtivalbedah abdomen
fingertip
PenisRadical
Uretra Sub
colli
mikro
injury
Mastectomy
Flap/Amnion tanpaGraft
Mandibula/Sub penyulit (54.61) Grafting
Mental
+ Flap/Single
35
22
43 Jugular)
Pankreatiko-duodenektomi
Eksisi
LADD luas
Operation+ Deltopectoral
(54.95) cephalis
flap (Whipple)
138
49
20
61
95
8
32
22
72
14
57 Kauterisasi
Modified
Orif
Uretroplasti
Repair
Biopsi
dengan
Repair
Tutup
Eksisifraktur
Pieloplasti
Piggy
Insersi fistel
Radical
Prostat
Back zygoma
penyulit
ileostomi
Ruptur
kistaChest perHipospadia
urethra
IOL Mastectomy
Laparoskopi
mayor
Pembuluh
brachialisdengan
Tube ArteriSingle
penyulit Abdominal
(46.5)
23
44
139
50
21
62
96
9
33
36
23 Eksisi
Koreksi
Biopsi luas
Laparoskopik
Quadrantectomy
Orif fraktur +
Horseshoe
Prostatektomi
Pneumoretinopexy
Peritoneal
Revisi Testis handFore
dreanse
Arteriovenous diagnostik
Uretroskopi/Uretrosistoskopi
Replantation / head
Partial
Radikal Kidney
(CAPD)
Shunt flap
(61.6)
Mastectomy
73
15
58
140
51
22
63
97 Tutup
Eksisi
Koreksi
Simple
Orif kolostomi
Ismulobectomy
kista
Uretrotomi
Reposisi
fraktur duktus
Mastektomy
Priapismus
fraktur
mandibula
Interna / nasal
ileostomi
tiroglossus (46.5)Grafting
10
34
37
24
45 Bladder
Prostatektomi
Repair
Peritoneal
Skleroterapi
Eksisi Neck
Canalis
lavase
Vena
luas + Muskulocutan
Ligasihemoroid (49.4) Flap/Skin
Rekonstruksi
Retropubik(Sachse)
+
Lacrimalis
(Varises, sederhana(Without
Hemangioma)
flap Silicon Tube)
141
52
23
64
98
11
35
38
74
25
16
59 Laparoskopi
Simple
Orif
URS/Lithotripsi
Reposisi
Buriedfraktur
Polipektomi
Tutup
Stripping
Eksisi Mastektomy
Prostatektomi
Repair Penis
Stoma
Kemoterapi fraktur
maxilla
ColobomaAdrenalektomi
Varises
neoplasma os
Terbuka
(46.5)
Perinfus Single
nasalis
Palpebra
Ekstremitas
Jinak ( lipoma, (complicated)
(Skin/Mucosal
Inferior
atheroma Graft)
dll )
25
46
142
53
24
65
99
12
36
39 Eksisi
Operasi luas
Laparotomi
Tram
Orif
Varikokelektomi
Reseksi
maksila
Flap ++Eksplorasi
kelainan rekonstruksi
mandibula
Businasi/Dilatasi
Prostatektomi
Reposisi
Potong IOL
kolostomiplating
Eksisi umbilikal
(Palomo)
Terbuka Tumor
Uretra + bone dan dengan
laingraft
Sectio bedah
(54.3) AltaDe Palma
26 Vascular Shunting (Splenorenal Shunt,
75
17
60 Urethroplasty
mikrovaskular
Eksisi
Latissimus
sinus/granuloma / chordectomy
Dorsi Flap (LD
umbilikalis (64.42)
Flap)
143
54
25
66
100
13
37
40
47 Ligasi
Operasi
Orif
Vasektomi
Rhinoplasty
Cabut mandibula
Psoas V.Spermatika
Reposisi
Shunt)
Prosedur DJ
Orchidopexy Tumor (anestesi
Hitch/Boari
Stent
Iris
Heller (62.5)plating
Kulit Interna
Flap lokal) (Microsurgery)
26
144
55
26
67
101
14
76
38 Eksisi
Defooring
Vena
Punksi
Resesi malformasi
Limfadenektomi
Biopsi
Orif
Vasektomi
Rotation
mandibula
Insisi
Sectie&flap
dan (narkose)
Tumor
Kista
Reseksi wiring
Aksilaris lymphatik
Ilioinguinal
sklerosing
Ginjal Kulit
2 Otot
(38.94)
per Lokal
Kista / Ginjal
vaskuler
Laparoskopi
27
41
18
61 Rektopexy
Eksisi Punctie,
Maksilektomi
soft tissue Kanulasi,
Totaltumor Sectie
dengan penyulit
7 KSM BEDAH 48
145
56
68
102
15
39
42
1
27 Orchidopexy
Limfadenektomi
Biopsi
Orif
Vasoepididimostomi
Sagital
orbital
Eksisi
Split
Deroofing/Unroofing
Railroading
Resesi
Abdominal
Repair
Ekstraksi &ateroma
fistel laparoskopik
wall
Tumor
Reseksi
pull osteotomi
Rupture
usus Retroperitoneal/RPLND
through/ Kulit
3keloid
Kista
Otot
Uretra (62.5 +
mandibula
Narcose
(sfingter 61.6) procedure)
saving
77
19
62 Vena
Eksisi sectie
Mastopexy
soft Femoralis
tissue tumor / tanpa
saphena magna (38.94)
penyulit
DIGESTIVE 146
57
28
69
103
103
16
40
43
2
49 Litholapaksi
Eksisi
Orif
Vasografi
Simple
orbital
Diseksi Tumor
Reimplantasi
Resesi bone
Abdominoperineal
Repair
Ekstraksi
Other fistel
Repair wall
Kelenjar
&korpus Jinak
ofgrafting
Reseksi Ureter
Getah
vesicorectal 4≤ Otot
3cm
Bilateral
resection
alienum
Abdominal Bening Wall Inguinal
(miles) dengan
(Repair penyulit
Omphacele)
147
58
78
70
104
104
17
41
44
29
20
63 Lithotripsi
Eksisi
Wound
Orif
Vasovasostomi
Simple
mayor zygoma
Diseksi Tumor
repair
Reimplantasiskin
Resesi/Reseksi
Repair
Elevasi
Eksisi
(954.72)
ModifikasiKelenjar
hernia
ear
teratoma wiring
rim grafting
Jinak
(86.8)
Ureter
Getah
1
cicatricalis
cartilago+
Otot Flap/Skin
Bening
RNDdengan penyulit dan rekonstruksi Graft
pelvis
9 KSM ILMU 59
71
105
18
3
45
30
501
42 Masase
Eksisi
Osteotomy
Unilateral/Ureteroneosistostomi
Angkat
Skin flap
Tumor
Sekunder
Repair
Excise
Polipektomi Prostat
Jahitan
Abdominoperineal
Diseksi craniosynostosis
Kelenjar
hernia Jinak
Implant
hemangioma Getah Kulit
resection
cicatricalis
(48.36) (Posterior >3cm
Bening reconstruction
dgn(miles)
+ rekonstruksi Chamber)
Pelvis
penyulit dengan
per
mayorpenyulit
(diluar
12 KSM BEDAH 1
21
64 Abdominoplasty
Eksisi
Operasiteratoma
Compartement tanpa penyulit
Otot
KESEHATAN 105
60
31
72
106
2
43 minor
Laparoskopi
Meatoplasti
Wide
Osteotomy
Rekontruksi
Angkat
Skin
alat) Eksisi
graft
Sekunder
Excise Jahitan
>5
facial
+ Renovaskuler
Diseksi
Implant
intra Lokal cm dengan
rekonstruksi
keloidAnastesi Claw KGB GA
Lens / Fiksasi Sulcus
PLASTIK 2
51 Aff archbar,
Posterosagital anorectoplasty (49.79)
MATA 106
19
61
73
107
4
463
44
32
22
65 Abdominoperineal
Divertikulektomi
Meatotomi
Wide
Osteotomy
Repair
Anterior
Skin
Repair
SICS
Excise
Eksisi Eksisi
graftFistel
Chamber
hernia sedang
genioplasti
Tumor
polydactyly Enterovesika
Buli resection
cicatricalisGanas
5Tap/Parasintesis
cm tanpadgnKulit (miles)
tarif bahan
penyulit tanpa
minorpenyulit
(diluar
3 Aff Suspensi,jinak
Ovariectomy
tumor Bilateral
Lokal wajah
Anastesi
107
20
62
33
74
108
54
45
52 Abdominoplasty
alat)
Divertikulum
MMK/Sling
Wide
Osteotomy
Repair
Aspirasi
Skin
SICS
Excise Eksisi
grafting
& Fistel
Massa
IOL Uretra
maksila
Tumor
Uretra
kecil
Vesikokutan
reduksi anorectoplasty
Posterosagital Lensa
lymedema Ganas
Le fort Kulit+Flap
I / Skin Graft
urethro vaginoplasty
23
66
4
108
47
21
63
109
75
65
46 Eksisi
Reseksi
Amputasi
Operasi
Osteotomy
Repair urachus
Apendektomi
Repair
Dorsumsisi
Nefrektomi
Blefaroplasty
Skin
Simpel Mandibula
above
grafting
Hernia
Soft
Fistel
maksila (2elbow
Tissue
Vitrektomi luas
Diafragmatika
Vesikorektal
Kelopak
Le
Tumor fort Mata)
II (diluar alat)
34 Facial
(70.79) sling dengan allograft
109
48
22
64
35
110
76
76
47
24
53
67
5 Apendektomi
Reseksi
Drainase
Nefrektomi
Amputasi
Palatoplasti
Repair
Claw
Skin
Skleralgrafting
Fasciotomy
Ekstirpasi
Potong
Rotation
Amputasi Lens
Fistel
anterior
Periureter
+ Donor
Buckle
kolostomi
FlapDiseksi
bilateral
dgn
burn
fistel
bellow sedang
Vesikovagina
predengan
penyulit
Transplant
injury KGB
(46.14)
elbow komplit
aurikulae penyulit
major mayor
110
49
23
65
111
77
87
48
36 Apendektomi
Reseksi
Eksisi
Nefrektomi
Amputasi
Palatoplasti
Repair
Cryopexy
Skin
Socket grafting
Chordae/Chordektomi
Fasciotomy Fistel
anterior
Jari
Kornea
Parsial
Repair bilateral
dgn
with +with
Vesikovagina
Flap
dengan
penyulit
complication
(Contracted tak
/ Skin
complication komplit
penyulit
minor
Graft
Kompleks
Socket) minor
25
54
68
6
111
112
50
24
66
78
98
49 Ekstirpasiranula
Potong
Skin
Amputasi
Eksisi Grafting
Apendektomi
Reseksi
Nefrektomi
Palatoplasti
Reparasi
Cyclo
Tendon Stump
digital (84.3)
Fibroma/Rekonstruksi
Cryo
anterior
reconstruction
TrabekulektomiTungkai
Penis
per
unilateral
laparoskopik
Laparoskopi
tanpa
/ Lengan komplit
penyulit Penis
37 Flap lokal sederhana
112
113
10
51
25
67
38
799
50
26
55
69
7 Bilio-difgestif
Reseksi
Eksisi
Nefrektomi
Biopsi
Palatoplasti
Reseksi-anastomosis
Dacryocystorinostomi
Tendon Plaque
Coreesofagus-colon
Trabekuletomi
Endoskopik
Prosedur
Fr.
SubCondylus
Amputasi transfer
TotalHellerRadial
unilateral
soft
anastomosis
(Peyronie
&Tissue
Thyroidectomy
jari diagnostik
mandibula Ollogen
>1(44.6) open red takUretra
(Without
Disease)
/ komplit
ileum
tanpa transposisi
Silicon
penyulitTube)
113
114
52
26
68
80
11
10
51
39 Biliodigestif
Reseksi
Eksisi
Nefropeksi/Renopeksi
Biopsi
Palatoraphy
RPG
Dekompresi
Tendon Webbed
Insisi
Trabulektomi
Fr. Maksila esofagus-end
transfer
dengan
Tumor
Orbital/Lateral
suspensi &PeniswithSof
penyulit
Goniotomi complication
to
(IOID)Tissue
end mayor
Orbitotomi
pada dengan Narcose
Pediatric
27
56
70
8
114
115
12
53
27
69
40
8111 Endoskopik
Prosedur
Superficial
Amputasi
Biliodigestif
Reseksi
Eksplorasi
Nefrostomi
Biopsi
Pasang
Sectio
Disisi
Glaucoma
Tennoraphy
InsisiKasai
jari
Aspirasi terapeutik
Parotidectomy
single(51.37)
Alta/Vesikolithotomi
archbar
esofagus-esofago-gastrectomy
testis
Perkutan/Temporer
dengan
Tumor & (Microsurgery)
IOLSoft
penyulit Tissue minorLokal Anestesi
Fr. Nasal open reduction
115
116
13
54
70
82
12
52
28
57
71
41
9 Biopsi
Reseksi
Ekstraksi
Nefrostomi
Eksisi
Pasang
Sirkumsisi
ECCE
Tube
Tennoraphy
Tumor
insisional,
Gastrostomi
Repair
Thoraco
Fraktur
Augmentasi Shunt
back
hati
Batu
atresia Terbuka/Permanen
(Express)
Jinak
slab/fore
with
Abdominal
Prosesus mamae local
esofagus complication
> 3cm anastesi
Flap
alveolaris slab(42.5)
(TA-Flap)
dengan inter dental
71
115
117
14
55
29
42
83
13
53 Biopsi
Second
Ekstrofi
Nefroureterektomi
Eksisi
Pasang
Sistektomi
ECCE
Viscocanulostomy
TMJ arthroplasty
Tumor
rectum
Buli
&
look
cast/gips
IOL Parsial/Sistoplasti
Rekonstruksi
laparoscopy
Jinak
wiring (IDW) (per rahang) tanpa
Ø<3cm reposisi Reduksi
29
58
72
10 Hemikolektomi
Repair
Total Parotidectomy
defek diafragma
Blefaroplasty (2 kelopak (53.8)
mata)
72
116
118
15
56
30
43
84
14
54
42 Eksisi
Splenektomi
Epispadia
Neobladder
Wide
Recheiloraphy
Sistektomi
Eksenterasi
Vitrektomi
TMJ
Fraktur Eksisi
arthrostomy
hemoroid
Prosesus +++
+
Per
/ Compartement
splenoraphy
Laparoskopi
eksterna
alveolaristraumatika luasProcedure
dengan IDW (per
73
117
119
16
57
31
44
85
15
55
30
59
73
11 Eksplorasi
Splenektomi
Evakuasi
Operasi
Wide
Rekonstruksi
Sistektomi
Eksisi
Vitrektomi
Tram Eksisi
Herniotomi
Repair
rahang)
Total flap
Hordeolum
Priapismus
Bekuan
duktus
Lengkap
+
Total/Radikal
non
Thyyroidectomy
ekstrofia
Blefaroplasty dengan
elektifDiseksi
pada trauma
buliDarah
bilier
/ (prosedur
tanpa Chalazion
&alloplastic
KGB
(57.8)
kasus Skleral
&penyulit
(Clot)
cholangiografi
sulit Winter)
Buckle
material intra operatif
74
118
120
17
58
32
45
86
16
56
43 Esofagotomi
Terminal
Extended
Operasi
Wide
Rekonstruksi
Sistoskopi
Ekstirpasi
Wide
Wound
Fraktur Eksisi
Eksisi
Repair
Dressing
esofagus
Pyelolithotomy
rahang Corpus
Tumor
Tumor
facialBuliproksimal
reduksi Ganas
Alienum
cleft
Trauma
Kelopakterbuka digastrektomi
Mata
Kornea
& inter oseus (TEPG)wiring
31
60
12
74 Herniotomi
Repair
Blefaroptosis
Transversus-Rectus
hernia laparoskopik
diafragma Abdominis
(53.7/53.8) Flap (Tram Flap)
75
119
121
18
59
33
46
87
17
57 Fistulotomi
Total
Fistulektomi/Repair
Operasi
Wide
(IOW)
Rekonstruksi
Sistoskopi
Ekstirpasi
Wide
Wound gastrektomi
Eksisi
Eksisi
Sistokel
Repair
Pterygium
ODS
Tumor
Tumor
nasal Jinak Fistel
Kelopak
+ Graft+Uretra
Flap/Skin
Mata
Konjungtiva
+ Flap
Graft+ graft
 KSM/INSTALASI/ TINDAKAN
NO
UNIT
13
NO KSM
KSM/INSTALASI 1 Cauter serviks TINDAKAN
OBGYN
/UNIT 2 Cordosentesis
14
NO KSM
KSM/INSTALASI 13 Augmentasi
Debulking tumorTulang Per Regio (Belum Termasuk
ovarium
TINDAKAN
/UNIT Bahan)
GIGI dan 24
30
EksplorasiMukosa
Debriment vagina dan Pengelolaan Luka Sayat
Hemi Maksilektomi Tanpa Rekonstruksi
MULUT 35 Dislokasi
EmbryotomiSendi Mandibula
NO KSM/INSTALASI 31
4 Insisi
EksisiAbses
Epulis/ Per TINDAKAN
Phlegmon
Rahang
/UNIT 6 Extirpasi + kuret polip endoserviks
32
5
32 Insisional
Eksisi
Painless BiopsiLudah
Kelenjar
labor Neoplasma Jinak
Submandibula
7 Extirpasi geboren mioma
33
6
33 Mandibular
Eksisi Distraksi
Kistanormal
Persalinan Odontogenik Keratosis + Ostektomi
8 Extirpasi geboren mioma+kuiretasi
34
7
34 Odontektomi
Eksisi Neoplasma
Persalinan Per Gigi
normal Jinak
dengan Extra Oral Ukuran Kecil
penyulit
9 Histeroctomy pada mola / chorio Ca
35
8
35 ORIF
Eksisi Maksila
Parsial
Persalinan ++ Marsupialisasi
Zygomatindakan
pervaginam + Mandibula
Ranula (belum
operatif
10 Histeroctomy
termasuk implant) radikal
9
36 Eksisi Plunging
Persalinan sungsangRanula
3611 ORIF Maksila
Kistektomi Plating (belum termasuk implant)
10
37 Eksisional
Rekanalisasi Biopsi Neoplasma Jinak
3712 ORIF Mandibula
Konisasi serviksPlating (belum termasuk implant)
11
38 Enukleasi
Rekanalisasi Kista tubaDentigerous + Extraksi Gigi Impaksi
3813 ORIF
KuretZygoma
abortusPlating (belum termasuk implant)
incompletes
12
39 Enukleasi
SalfingektomiKista radikuler
unilateral Per Rahang + Extraksi Gigi
3914 Osteotomi
Lap op:
Penyebab Maksila
myomektomi le Fort I
40
13
40 Salvingoovarectomi
Extirpasi
Osteotomi Kista
Maksila leunilateral
Dermoid Fort Ovarium,
II
15 Laparoskopi (Kistektomi Salphingektomi,
41
14
41 Adhesiolisis)
Secound
Extirpasi look surgery
Sialolith Ca ovarium
Pelepasan Arch Bar (Intermaksila Fiksasi)
16 Laparoskopi Histerektomi
15 15
42
1 Extraksi
Seksio Corpus Alienum dengan Teknik Lindorf
Intubasisesaria
Endotrakea
DIVISI PEDIATRI 17 Laparoskopi steril
GAWAT 16
43
2 Extraksi Gigi Anak
Seksio sesaria
Krikotirotomi dengandengan Kelainan
penyulit Jantung Per
penyulit
DARURAT 318 Rahang
Laparoskopik
Kanulasi Diagnostik
vena perifer
44
17 Sirklase
Extraksi serviks
Gigi Anak Per Rahang
ILMU 4 Vena sectie
19 Laparotomi dengan penyulit mayor
KESEHATAN 45
5
18 Seksio
Extraksisesaria
Pungsi lumbal denganPer
Gigi Dewasa penyulit
Rahang penyulit
ANAK 620 Laparotomi
Pungsiv Pleura dengan penyulit minor
46
19 Sirklase serviks
Fissure Sealant pada Autis
16 121
47
Laparotomi
Diagnostik
Supra
tanpa penyulit
Kateterisasi Jantung
KSM PENYAKIT 20 Frakturvaginal hyterectomy
Dento alveolar Dengan arch Bar
JANTUNG & 222
48
LEEP
PTMC
Surgical staging
PEMBULUH 21
323 Fraktur Dento
PTCA/Stenting alveolar Dengan Bracket (belum
Micro
termasuk kuretase DUB
DARAH 49
4 TAH+BSObahan)
Pacemaker dengan Penyulit
Temporer&Permanen
22
524 fraktur Dento
Mikrokuret
IABP Alveolar dengan Eyelet
50 TAH+BSO dengan Penyulit Pemasangan Tampon
23 Fraktur Maksila dengan Suspensi Wiring
625 Miomectomy
Abdomen
Perikardiosintesis
51
24 Total abdominal
Fraktur Nasal close hysterectomy+bilateral
Reduksi salfingektomi
726 Neovagina
Pemasangan Swan Ganz Kateter
52
25 Tubektomi
Fraktur Nasalklinik
Open Reduksi
827 Operasi
Pemasangan Ca vagina
Amplatzer/ADO/Coilling
53
26 Tutup
Frakturburst
Rahangabdomen
928 Operasi
CVC kankerReduksi Tertutup dengan
corpus uteri
Intermaksila Fiksasi
29
27
10 Operasi tumor
Frenektomi
Pelepasan ganas
Per Rahang
Arch ovarium Fiksasi)
Bar (Intermaksila
17 30 Genioplasty
28 Operative histeroscopy/Ablasi endometrium
KSM PENYAKIT Endoscopy
DALAM 29
31 Gingivektomi
Overectomi Per Rahang
 B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang
memerlukan informed consenttersebut antara lain:
a. Semua tindakan anestesi dan sedasi di dalam kamar operasi
b. Semua tindakan anestesi dan sedasi di ICU

Tindakan Anestesi di ICU

Pemasangan intubasi ventilator

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

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

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

D. Semua Tindakan Yang Berisiko Tinggi :

KSM /
No NAMA TINDAKAN
INSTALASI
1 KSM Anak 1 Chest tube
2 Tindakan kemotherapi
 3 Pemasangan Ventilator
4 Intubasi Endotrakea
5 Pemasangan Laryngeal mask
6 Krikotirotomi
7 Infus intraosseus
8 Kanulasi vena perifer
9 Vena sectie
10 Pengambilan darah intra vena dan intra arteri
11 Pungsi lumbal
12 Pungsiv Pleura
13 Pemasangan kateter urine
14 Pemasangan keteter rectal
15 Pemasangan orogastrik tube
16 Pemasangan nasogastrik tube
1 Pemeriksaan Audiometri
2 Pemeriksaan Timpanometri
3 Pemeriksaan Audiometri Tutur
2 THT-KL 4 Pemeriksaan Sisi&Tore Decay
5 Pemeriksaan Pendengaran Pada Anak
6 Pemeriksaan Brainstem Evoked Response
Audiometry
KSM Patologi
3 FNAB (Fine Needle Aspiration Biopsy)
Anatomi
Inst.
4 Tindakan Radiotherapi
Radiotherapi
1 Cerebral Angiografi
2 AVM&Embolisasi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA
KSM 6 Lumbal Punksi
5 7 Pain Intervention
Neurologi 8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
KSM Patologi
6 Phlebotomi
Klinik
7 KSM Gigi dan 1 Scaling
2 Curettage/root planning (jika diperlukan anestesi)
Mulut
3 Gingivektomi
 4 Frenektomi
5 Flap operasi (bone graft/membrance/GTR/interseptif)
6 Implant
7 Vital pulpektomi dan Partial Nekrose
8 Cauter
9 Retraksi Gingiva pada prep.crown
Poli
8 Suntik Intra Cavernosal Penis
Andrologi
1 Dobutamin Stress Ekhokardiografi
KSM
Kardiologi 2 Transophegal Ekhokardiografi
dan 3 Treadmill Tes
9 4 Exercise Stress Ekhokardiografi
Kedokteran
Vaskular
1 Bronchoscopy/FOB
2 Tindakan kemotherapi
3 Thoracoscopy
4 Contra Ventil/WSD
KSM
5 Punctie Pleura
Pulmonologi
6 FNAB
dan Ilmu
10 7 Scalene Biopsy
Kedokteran
8 Reposisi
Respirasi
9 Pleurodesis
10 AFF WSD
11 Perawatan Luka WSD
12 USG Thorax Marker
1 Tindakan Radiologi Injectee contrast
2 Tindakan Radiologi pada pasien dengan kelainan
cardiovaskuler
3 Tindakan Radiologi pada pasien dengan alergi
berat
KSM 4 Tindakan Radiologi pada pasien dengan KU yang
11 Radiologi menurun
5 Tindakan Radiologi yang memerlukan FNAB
Guiding MSCT pada pasien dengan kelainan yang
berdekatan dengan organ vital
6 Tindakan Radiologi pada Ibu hamil yang
memerlukan foto
KSM 1 Cerebral Angiografi
12 2 AVM&Embolisasi
Neurologi
3 Aneurisma Coiling
4 Embolisasi pre operasi
5 Diagnosis DSA
6 Lumbal Punksi
 7 Pain Intervention
8 Injeksi Triger point
9 Injeksi Triger Fringer
10 Injeksi CTS
11 Sub Optical Functional
12 Injeksi botox
13 EMG
14 Neuro endovaskuler: Coiling,Embolisasi,DSA
Instalasi
13 Setiap kali melakukan tindakan Hemodialisis
Hemodialisis

14 KSM
Rehabilitasi Elektromiografi dan Kecepatan Hantar Saraf
Medik

1 Psycho Analisa

2 Psycho Therapy Dalam

3 Pemeriksaan Calon Pimpinan Publik

4 Aborsi Provocatus Medicinalis

16 IRNA Jiwa
5 Tindakan terapi elektroconfusi

6 Pemeriksaan kandungan zat narkotika

7 Restraint / Fiksasi : mekanik dan psikotropika

8 Pemeriksaan sengketa/ konflik dalam keluarga

15 Semua injeksi dengan obat risiko tinggi