DAFTAR TINDAKAN – TINDAKAN YANG PERLU INFORMED

CONSENT

Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa tindakan
kedokteran dan kedokteran gigi yang wajib diberikaninformed consent. Tindakan tersebut yaitu:

A. Semua Tindakan Pembedahan dan Tindakan Invasive

B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam )
C. Semua Tindakan Pemberian Produk Darah & Komponen Darah
D. Semua Tindakan/PENGOBATAN Yang Berisiko Tinggi.

A.Tindakan Pembedahan dan Tindakan Invasiveyang memerlukan informed

consentantara lain:

N KSM/INSTALASI/UNIT
o
1 KSM Bedah Saraf
TINDAKAN
1. Amygdala Hypocampectomy (Epilepsi)
2. Anterior Temporomesial Lobectomi (Epilepsi)
3. Biopsi Saraf Tepi/Otot
4. Blok Saraf Perifer I
5. Cingulotomy (Psichiatric)
6. Corpus Callosotomi (Epilepsi)
7. Debrimen Rekonstruksi Vulnus Kulit Kepala
8. Dekompresi Saraf Tepi
9. Dekompresi Tulang Durameter
10. Dekortikasi Sinus Frontalis
11. Denervasi Facet
12. DREZ Lession (Pain)
13. Eksisi Ensefalokel/Mielokel
14. Eksisi Kista Jinak Kulit Kepala
15. Eksisi Osteoma/Osteositosis
16. Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan
17. Dura
18. Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
19. Dura
20. Extirpasi Tumor Jinak Saraf Kulit Kepala
21. Fusi Stabilisasi Corpus Vertebra
22. Graft/Transposisi Saraf Tepi
23. Hemisferektomi (Epilepsi)
24. Hemisferoktomi (Epilepsi)
25. Injeksi saraf perifer (dengan radiofrekuensi)
26. Injeksi spinal (Pain)
27. Insersi Elektrode Intradural
(Epilepsi,movement,psikiatrik)
28. Kordotomi Perkutan
29. Kordotomi Servikal Open (Pain)
30. Kordotomi Servikal Perkutan (Pain)
31. Kranioplasti dua sisi
32. Kranioplasti satu sisi
33. Kraniotomi Biopsi otak
34. Laminektomi Eksisi Tumor Spinal
35. Laminoplasti
36. Laminotomi Biopsi Mielum
37. Laminotomi Diskektomi HNP/Stenosis>1 level
38. Laminotomi Diskektomi HNP/Stenosis 1 level
39. Lesionectomy (Epilepsi)
40. Lobektomi (Epilepsi)
41. Mesencephalectomy (Pain)
42. Mikrodisekktomi HNP
43. MVD (Microvascular Decompression)
44. Neurektomi/Neurolise
45. Neuroendoskopi (Otak,Spinal)
46. Neuroplasti
47. Omaya drain
48. Pallidotomi (movement Disorder)
49. Paravertebral Blok Perkutan
50. Pemasangan Traksi Servikal
 51. Penjahitan Saraf Tepi
52. Punksi Cairan Otak
53. Reseksi Extra-Temporal (Epilepsi)
54. Revisi VP Shunt
55. Rhizotomi Selektif (Spastisitas)
56. Rhizotomy (Pain)
57. Selective Nerve Root Block
58. Selective Thalamotomi (Movement Disorder)
59. Simpatektomi Open (Pain)
60. Simpatektomi Perkutan
61. SLTH
62. Stereotactic Ablative Procedure (Psichiatric)
63. Subthalamotomy (Movement Disorder)
64. Suturektomi Kraniostenosis
65. Thalomotomy (Pain)
66. Transposisi kraniostenosis,dengan orbital
advancement
67. Transposisi kraniostenosis,tanpa orbital advancement
68. Trepanasi Cedera Kepala (<4jam)
69. Trepanasi Cedera Kepala (>4jam)
70. Trepanasi CVA Bleeding
71. Trepanasi kelainan Saraf Kranial
72. Trepanasi Kelainan Vascular Otak
73. Trepanasi Tumor Otak
74. VA Shunt
75. VP Shunt Multiple
76. VP Shunt Satu Sisi
2 KSM Bedah Kepala- 1. Aff Arch Barr Kepala Leher
Leher 2. Aff Arch Barr dan suspensi maksila
3. Biopsy Insisional dengan anastesi lokal
4. Deseksi submandibula
5. Diseksi leher radikal/radikal neck dissection
6. Eksisi gld submandibula
7. Eksisi higroma leher
 8. Eksisi kista tiroglosus
9. Eksisi luas tumor ganas bibir dengan rekontruksi
10. Flap lokal
11. Eksisi luas tumor ganas dengan rekontruksi flap jauh
12. Eksisi luas tumor ganas kulit dengan rekontruksi
13. Flap local
14. Eksisi luas tumor ganas rongga mulut dengan
15. Rekontruksi flap lokal
16. Eksisi parsial+marsupialisasi Ranula
17. Eksisi tumor ganas kulit dengan flap local atau graft
kulit
18. Eksisi tumor ganas kulit dengan flap local jauh
19. Eksisi tumor ganas kulit tanpa rekontruksi
20. Eksisi tumor jinak dengan anastesi lokal
21. Ekskokleasi epulis
22. Ekskokleasi kista folikuler
23. Ekskokleasi kista radikuler
24. Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran
<2cm
25. Ekstirpasi kista dermoid
26. Endoscopic thyroidectomy
27. Fiksasi interna fraktur maksilofasial 1-2 tempat patahan
28. Fiksasi interna fraktur nasal
29. Fiksasi interna pan-facial
30. Hemiglosektomi
31. Insisi abses dengan anastesi lokal
32. Insisi flegmon dasar mulut
33. Internal Fiksasi fraktur condylus mandibula
34. Internal Fiksasi fraktur maksilofasial 3-4 tempat
patahan
35. Internal fiksasi fraktur maksilofasial 5 tempat patahan
atau lebih
36. Laringectomi
3 KSM Bedah THT-KL 1. Adenotonsilektomi
2. Anthrostomi+Sinuskopi
3. BLM Simple (Kista,Polip,Nodul,Granulasi)
4. Biopsi Tumor
5. Bronkoskopi Rigid
6. BLM Advance (Stenosis, Subjektif/Trakea, Papiloma
Laring/Trakea)
7. Cald Well Luc
8. Cochlear Implant/Implan Baha
9. Dekompresi Nervus Fasialis
10. DCR
11. Eksisi Ekstostosis
12. Ekstirpasi Kista Branchial
13. Ekstirpasi Kista Ductus Tiroglosus
14. Ekstraksi granulasi MAE/Kolesteatosis
15. Ekstraksi Polip
16. Esofagoskopi Rigid & Fleksibel
17. Ethmoidektomi (Intranasal)
18. Ekstraksi Korpus Alienum Kavum Nasi
19. Ekstraksi Korpus Alienum Kavum Nasi Endoskopi
20. Ekstirpasi Fistel Pre Aurikuler
21. Ekstraksi Korpus Alienum MAE
22. Ekstirpasi Kelenjar Sub Mandibula
23. Ekstirpasi Angiofibroma Nasofaring
24. Eksplorasi Abses Parafaringeal
25. Ekstirpasi Tumor Jinak Kepala & Leher (Aterom
Lipoma)
26. Faringotomi
27. FESS
28. FESS Advance
29. Frontal Sinusotomi
30. Fore Head Flap
31. Fronto Etmoidektomi (Ekstranasal)
32. FOL
33. Glosektomi Total/Parsial
34. Glosektomi Total/Hemiglosektomi+RND
35. Hemiglosektomi+SOHND
36. Insisi Abses Leher Dalam
37. Inversi Grommet
38. Insisi Perikondritis
39. Irigasi Sinus Maksila
40. Insisi Abses Peritonsil
41. Imunoterapi
42. Konka Reduksi
43. Kaustik Konka Inferior
44. Laringektomi
45. Laringektomi+ND
46. Laringo Fisur/Eksplorasi Laring
47. Ligasi A. Karotis Eksternal
48. Laringoskopi Rigid
49. Laringoskopi Fleksible
50. Laringoskopi Direkta
51. Maksilektomi Total+Rekontruksi
52. Mastoidektomi Radikal
53. Mini FESS
54. Myocutaneus Flap (Pectoral Mayor)
55. Myringoplasty/Timpaniplasti
56. Mandibulekromi
57. Neurektomi Saraf Vidian
58. Osteotomi+Septum koreksi
59. Rekontruksi Fraktur Maksila Multiple
60. Rekontruksi Fraktur Maksila Sederhana
61. Rhinoplasti
62. Rinotomi Lateral+Maksilektomi Medial
63. Rekontruksi Laring Trakea
64. Reposisi Fraktur Os Nasal
65. Reposisi& Fiksasi Fraktur Mandibula
66. Septum Koreksi+Konkotomi
67. Stapedektomi
 68. Skin Pricle Test
69. Tiroidektomi Sub-Total
70. Tonsilektomi/Adenoidektomi
71. Tracheostomi
72. Turbinektomi
73. Tiroidektomi Total+ND
74. Temporal Bone Resection
75. Terapi Wicara pada Anak-Anak dan dewasa
76. Terapi Wicara Tuna Laring
4 KSM Orthopedi 1. Abdominopelvic amputation
2. Achillotenotomy Traumatologi
3. Adductor tenotomy of hip
4. Advancement of tendon
5. Advancement of tendon of hand
6. Amputation above knee
7. Amputation and disarticulation of finger- general
anaesthesia
8. Amputation and disarticulation of finger -local
anaesthesia
9. Amputation and disarticulation of thumb-general
anaesthesia
10. Amputation and disarticulation of finger- general
anaesthesia
11. Amputation and disarticulation of finger -local
anaesthesia
12. Amputation and disarticulation of thumb-general
anaesthesia
13. Amputation and disarticulation of thumb-local
anaesthesia
14. Amputation of ankle through malleoli of tibia and fibula
15. Amputation of toe-general anaesthesia
16. Amputation of toe-local anaesthesia 17 Amputation
through foot 18 Amputation through forearm
17. Amputation through hand, Amputation through
 carpals
18. Amputation through humerus, Upper arm amputation
19. Amputation, not otherwise specified
20. Ankle fusion
21. Application of external fixator device
22. Application of external fixator device, monoplanar
system
23. Application of external fixator device, ring system
24. Application of hybrid external fixator device
25. Arthrocentesis
26. Arthrodesis of elbow
27. Arthrodesis of hip
28. Arthrodesis of knee
29. Arthrodesis of other specified joints
30. Arthrodesis of shoulder
31. Arthrodesis of unspecified joint
32. Arthroplasty of carpocarpal or carpometacarpal joint
with implant
33. Arthroplasty of carpocarpal or carpometacarpal joint
without implant
34. Arthroplasty of metacarpophalangeal and
interphalangeal joint with implant
35. Arthroplasty of metacarpophalangeal and
interphalangeal joint without implant
36. Arthroscopy
37. Arthrotomy for removal of prosthesis without
replacement
38. Aspiration of bursa
39. Aspiration of bursa of hand
40. Aspiration of other soft tissue
41. Aspiration of other soft tissue of hand
42. Atlas-axis spinal fusion
43. Biopsy of bone
44. Biopsy of joint structure
45. Biopsy of spinal cord or spinal meninges
46. Bone graft
47. Bone marrow or hematopoietic stem cell transplant
(all procedures included in this clas
48. Bunionectomy with soft tissue correction and
arthrodesis
49. Bunionectomy with soft tissue correction and
osteotomy of the first metatarsal
50. Bursectomy
51. Bursectomy of hand
52. Bursotomy
53. Bursotomy of hand
54. Carporadial fusion
55. Closed reduction of dislocation -General anaesthesia
56. Closed reduction of dislocation of ankle
57. Closed reduction of dislocation of elbow
58. Closed reduction of dislocation of foot and toe-
general anaesthesia
59. Closed reduction of dislocation of foot and toe-local
anaesthesia
60. Closed reduction of dislocation of hand and finger-
general anaesthesia
61. Closed reduction of dislocation of hand and finger-
local anaesthesia
62. Closed reduction of dislocation of hip
63. Closed reduction of dislocation of knee
64. Closed reduction of dislocation of other specified sites-
general anaesthesia
65. Closed reduction of dislocation of other specified sites-
local anaesthesia
66. Closed reduction of dislocation of other specified sites-
local anaesthesia
67. Closed reduction of dislocation of shoulder
68. Closed reduction of dislocation of wrist
69. Closed reduction of dislocation-Local anaesthesia
70. Closed reduction of fracture with internal fixation -
Carpal and metacarpal
71. Closed reduction of fracture with internal fixation -
Femur (Including : MIPO, interlocking nail, TEN)
72. Closed reduction of fracture with internal fixation -
Humerus (including : Interlocking nail, TEN, MIPO)
73. Closed reduction of fracture with internal fixation -
Intrarticular Major Bone
74. Closed reduction of fracture with internal fixation -
Phalang of foot
75. Closed reduction of fracture with internal fixation -
Phalang of hand
76. Closed reduction of fracture with internal fixation -
Radius and ulna (MIPO, TEN)
77. Closed reduction of fracture with internal fixation -
Tarsal and metatarsal 84 Excision of bone for graft 85
Excision of intervertebral disc 86 Excision of lesion of
muscle 87 Excision of lesion of muscle of hand 88
Excision of lesion of other soft tissue
78. Dorsal and dorsolumbar fusion of the anterior column,
anterior technique
79. Dorsal and dorsolumbar fusion of the posterior column,
posterior technique
80. Excision of bone for graft
81. Excision of intervertebral disc
82. Excision of lesion of muscle
83. Excision of lesion of muscle of hand
84. Excision of lesion of other soft tissue
85. Excision of lesion of tendon sheath
86. Excision of lesion of tendon sheath of hand,
Ganglionectomy of tendon sheath (wrist)-General
anaesthesia
87. Excision of lesion of tendon sheath of hand,
 Ganglionectomy of tendon sheath (wrist)-Local
Anaestesi 99 Excision of muscle or fascia for graft 100
Excision of muscle or fascia of hand for graft
88. Excision of other lesion of soft tissue of hand
89. Excision of semilunar cartilage of knee
90. Excision of tendon for graft
91. Excision of tendon of hand for graft
92. Excision or correction of bunionette, That with
osteotomy
93. Excision or destruction of intervertebral disc,
unspecified
94. Exploration of tendon sheath
95. Exploration of tendon sheath of hand
96. Exploratory thoracotomy
97. Fasciotomy
98. Fasciotomy of hand
99. Finger reattachment
100. Five-in-one repair of knee
101. Foot reattachment
102. Forearm, wrist, or hand reattachment
103. Fusion or refusion of 2-3 vertebrae
104. Fusion or refusion of 4- 8 vertebrae
105. Fusion or refusion of 9 or more vertebrae
106. Graft of muscle or fascia
107. Hip bearing surface, ceramic-on-ceramic
108. Hip bearing surface, ceramic-on-polyethylene, Hip
bearing surface, oxidized zirconium-on-polyethylene
109. Hip bearing surface, metal-on-metal
110. Hip bearing surface, metal-on-polyethylene
111. Implantation of internal limb lengthening device with
kinetic distraction
112. Implantation of other internal limb lengthening device
113. Implantation or replacement of peripheral
neurostimulator lead (s)
114. Implantation or replacement of spinal neurostimulator
lead(s)
115. Incision and drainage of palmar or thenar space
116. Injection of anesthetic into peripheral nerve for
analgesia
117. Injection of anesthetic into spinal canal for analgesia
Injection of destructive agent into spinal canal
118. Injection of locally-acting therapeutic substance into
other soft tissue
119. Injection of other agent into spinal canal, Intrathecal
injection of steroid, Subarachnoid perfusion of
refrigerated saline
120. Injection of therapeutic substance into bursa
121. Injection of therapeutic substance into bursa of hand
122. Injection of therapeutic substance into joint or ligament
123. Injection of therapeutic substance into tendon
124. Injection of therapeutic substance into tendon of hand
125. Insertion of bone growth stimulator
126. Insertion of bone void filler
127. Insertion of catheter into spinal canal for infusion of
therapeutic or palliative substances, Insertion of
catheter into epidural, subarachnoid, or subdural
space of spine with intermittent or continuous infusion
of drug (with creation of any reservoir)
128. Insertion of interbody spinal fusion device
129. Insertion of other spinal devices
130. Insertion of partial spinal disc prosthesis, cervical
131. Insertion of partial spinal disc prosthesis, lumbosacral
132. Insertion of recombinant bone morphogenetic protein
133. Insertion of spinal disc prosthesis, not otherwise
specified, Replacement of spinal disc, NOS
134. Insertion of spinal disc prosthesis, thoracic
135. Insertion of sternal fixation device with rigid plates
136. Insertion of total spinal disc prosthesis, cervical
137. Insertion of total spinal disc prosthesis, lumbosacral
Insertion or replacement of (cement) spacer
138. Insertion or replacement of facet replacement
device(s)
139. Insertion or replacement of interspinous process
device(s)
140. Insertion or replacement of pedicle-based dynamic
stabilization device(s)
141. Insertion or replacement of skeletal muscle stimulator
142. Internal fixation of bone without fracture reduction
143. Interphalangeal fusion
144. Interthoracoscapular amputation, Forequarter
amputation
145. Intra-operative neurophysiologic monitoring –
Neuromonitoring
146. Intervertebral chemonucleolysis
147. Limb lengthening procedures
148. Limb shortening procedures
149. Local excision of lesion or tissue of bone
150. Lower leg or ankle reattachment
151. Lower limb amputation, not otherwise specified
152. Lumbar and lumbosacral fusion of the anterior column,
anterior technique
153. Lumbar and lumbosacral fusion of the anterior column,
posterior technique
154. Lumbar and lumbosacral fusion of the posterior
column, posterior technique
155. Lysis of adhesions of hand
156. Lysis of adhesions of muscle, tendon, fascia, and
bursa
157. Lysis of adhesions of spinal cord and nerve roots
158. Metacarpocarpal fusion
159. Metacarpophalangeal fusion
160. Metatarsophalangeal fusion
161. Midtarsal fusion
162. Muscle transfer or transplantation
163. Myotomy
164. Myotomy of hand
165. Neurectasis
166. Open biopsy of cranial or peripheral nerve or ganglion
167. Open biopsy of soft tissue
168. Open reduction of dislocation of ankle - Neglected
dislocation
169. Open reduction of dislocation of elbow -Fresh
dislocation
170. Open reduction of dislocation of hand and finger
-Fresh dislocation
171. Open reduction of dislocation of hip - Fresh dislocation
172. Open reduction of dislocation of hip - Neglected
dislocation
173. Open reduction of dislocation of knee - Neglected
dislocation
174. Open reduction of dislocation of knee -Fresh
dislocation
175. Open reduction of dislocation of other specified sites
176. Open reduction of dislocation of shoulder -Fresh
dislocation
177. Open reduction of dislocation of shoulder -Neglected
dislocation
178. Open reduction of dislocation of unspecified site-Fresh
dislocation
179. Open reduction of dislocation of unspecified site-
Neglected dislocation
180. Open reduction of dislocation of wrist -Fresh
dislocation
181. Open reduction of fracture with internal fixation- radius
and ulna-Simple fracture
182. Open reduction of fracture with internal fixation-
 unspecified site (Periarticular Major Bone )
183. Open reduction of fracture with internal fixation-
carpals and metacarpals - plate & screws Hand NOS
-Plate & Screw
184. Open reduction of fracture with internal fixation-
carpals and metacarpals - plate & screws Hand NOS
-Plate & Screw
185. Open reduction of fracture with internal fixation-
carpals and metacarpals - simple implants (K-wire)
Hand NOS -implant sederhana (K-wire)
186. Open reduction of fracture with internal fixation-femur-
Comminutive or Segmental
187. Open reduction of fracture with internal fixation-femur-
Simple fracture
188. Open reduction of fracture with internal fixation-
humerus - Simple fracture
189. Open reduction of fracture with internal fixation-
humerus - Comminutive or Segmental
190. Open reduction of fracture with internal fixation- other
specified bone (Intraartikular Major Bone )
191. Open reduction of fracture with internal fixation-
phalanges of foot - simple implants (K-wire)
192. Open reduction of fracture with internal fixation-
phalanges of foot-Plate & Screws
193. Open reduction of fracture with internal fixation-
phalanges of hand- Plate & Screws
194. Open reduction of fracture with internal fixation-
phalanges of hand- simple implants
195. Open reduction of fracture with internal fixation-
tarsals and metatarsals- Plate & Screws
196. Open reduction of fracture with internal fixation-
tarsals and metatarsals- simple implants
197. Open reduction of fracture with internal fixation-tibia
and fibula -Simple fracture
198. Open reduction of fracture with internal fixation-tibia
and fibula-Comminutive or Segmental
199. Open reduction of fracture without internal fixation
200. Open reduction of separated epiphysis
201. Osteoclasis (correction of bone deformity)
202. Other (peripheral) vascular shunt or bypass
203. Other amputation below knee
204. Other anastomosis of cranial or peripheral nerve
205. Other and unspecified repair of the anulus fibrosus
206. Other arthrotomy
207. Other bunionectomy
208. Other bunionectomy with soft tissue correction
209. Other cervical fusion of the anterior column, anterior
technique
210. Other cervical fusion of the posterior column, posterior
technique
211. Other change in hand muscle or tendon length
212. Other change in muscle or tendon length
213. Other destruction of intervertebral disc
214. Other diagnostic procedures on joint structures
215. Other diagnostic procedures on muscle, tendon,
fascia, and bursa, including that of hand
216. Other division of bone
217. Other excision of joint
218. Other excision of soft tissue
219. Other excision of soft tissue of hand
220. Other excision or avulsion of cranial and peripheral
nerves
221. Other excision, fusion and repair of toes
222. Other exploration and decompression of spinal canal,
Decompression
223. Other fasciectomy
224. Other fasciectomy of hand
225. Other fusion of foot
226. Other hand muscle transfer or transplantation
227. Other hand muscle transposition
228. Other hand tendon transfer or transplantation
229. Other hand tendon transposition
230. Other incision of bone without division
231. Other incision of soft tissue
232. Other incision of soft tissue of hand
233. Other injection of locally-acting therapeutic substance
into soft tissue of hand
234. Other local excision or destruction of lesion of joint
235. Other muscle transposition
236. Other myectomy
237. Other myectomy of hand
238. Other neuroplasty
239. Other operations on muscle, tendon, fascia, and bursa
240. Other operations on muscle, tendon, fascia, and
bursa,
241. Suture of bursa
242. Other partial ostectomy (including : Bone curretage,
marginal resection/excision)
243. Other peripheral nerve or ganglion decompression or
lysis of adhesions Peripheral nerve neurolysis NOS
244. Other plastic operations on fascia
245. Other plastic operations on hand
246. Other plastic operations on muscle
247. Other repair of ankle
248. Other repair of elbow
249. Other repair of hand, fingers and wrist
250. Other repair of joint
251. Other repair of knee
252. Other repair of shoulder
253. Other repair of the collateral ligaments
254. Other repair of the cruciate ligaments
255. Other repair or plastic operations on bone
256. Other suture of flexor tendon of hand
257. Other suture of muscle or fascia
258. Other suture of other tendon of hand
259. Other suture of tendon
260. Other tendon transposition
261. Other tenodesis of hand
262. Other tenonectomy
263. Other tenonectomy of hand
264. Other tenoplasty of hand
265. Other tenotomy
266. Other total shoulder replacement
267. Partial hip replacement
268. Partial shoulder replacement
269. Patellar stabilization
270. Percutaneous denervation of facet
271. Percutaneous vertebral augmentation
272. Percutaneous vertebroplasty
273. Peripheral nerve injection, not otherwise specified
274. Plastic operation on hand with graft of muscle or
fascia
275. Plastic operation on hand with other graft or implant
276. Pollicization operation carrying over nerves and blood
supply
277. Quadricepsplasty
278. Reattachment of muscle
279. Reattachment of muscle of hand
280. Reattachment of tendon
281. Reattachment of tendon of hand
282. Refusion of atlas-axis spine
283. Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique
284. Refusion of dorsal and dorsolumbar spine, posterior
column, posterior technique
285. Refusion of lumbar and lumbosacral spine, anterior
 column, anterior technique
286. Refusion of lumbar and lumbosacral spine, anterior
column, posterior technique
287. Refusion of lumbar and lumbosacral spine, posterior
column, posterior technique
288. Refusion of other cervical spine, anterior column,
anterior technique
289. Refusion of other cervical spine, posterior column,
posterior technique
290. Refusion of spine, not elsewhere classified
291. Refusion of spine, not otherwise specified
292. Release of carpal tunnel
293. Release of clubfoot, not elsewhere classified
294. Release of tarsal tunnel
295. Removal of (cement) spacer
296. Removal of bone growth stimulator (invasive)
297. Removal of foreign body from spinal canal
298. Removal of implanted devices from bone - carpals
and metacarpals-Plate & screw
299. Removal of implanted devices from bone - carpals
and metacarpals-simple implants (K-wire)
300. Removal of implanted devices from bone - External
fixator device (invasive)
301. Removal of implanted devices from bone - femur
302. Removal of implanted devices from bone - humerus
303. Removal of implanted devices from bone - radius and
ulna
304. Removal of implanted devices from bone - scapula,
clavicle, and thorax (ribs and sternum)
305. Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) - Plate
& Screw
306. Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) -
 simple implants (K-wire)
307. Removal of implanted devices from bone -patella
308. Removal of implanted devices from bone- tarsals and
metatarsals- simple implants (K-wire)
309. Removal of implanted devices from bone- tibia and
fibula
310. Removal of implanted devices from bone-other
(Pelvic bone and Vertebraae)
311. Removal of implanted devices from bone-tarsals and
metatarsals - Plate & Screw
312. Removal of internal limb lengthening device
313. Removal of pedicle screw(s) used in spinal fusion
314. Removal of peripheral neurostimulator lead(s)
315. Removal of skeletal muscle stimulator
316. Removal of spinal neurostimulator lead(s)
317. Reopening of laminectomy site 334 Repair of claw
toe
318. Repair of cleft hand
319. Repair of hammer toe
320. Repair of hip, not elsewhere classified
321. Repair of macrodactyly
322. Repair of mallet finger
323. Repair of old traumatic injury of cranial and peripheral
nerves
324. Repair of recurrent dislocation of shoulder
325. Repair of the anulus fibrosus with graft or prosthesis
326. Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae,
Removal of bony spicules from spinal canal
327. Replacement of joint of foot and toe
328. Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum
329. Resurfacing hip, partial, femoral head
330. Revision of total knee replacement, tibial insert (liner),
 Replacement of tibial insert(liner)
331. Revision or replacement of artificial spinal disc
prosthesis, cervical
332. Revision or replacement of artificial spinal disc
prosthesis, lumbosacral
333. Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified
334. Revision or replacement of artificial spinal disc
prosthesis, thoracic
335. Rotator cuff repair
336. Separation of equal conjoined twins
337. Separation of unequal conjoined twins
338. Sequestrectomy
339. Spinal fusion, not otherwise specified
340. Subtalar fusion
341. Subtalar joint arthroereisis
342. Suture of Artery
343. Suture of capsule or ligament of ankle and foot
344. Suture of capsule or ligament of other lower extremity
345. Suture of capsule or ligament of upper extremity
346. Suture of cranial and peripheral nerves
347. Suture of muscle or fascia of hand
348. Suture of tendon sheath
349. Suture of tendon sheath of hand
350. Suture of Vein
351. Synovectomy
352. Tarsometatarsal fusion
353. Tendon graft
354. Tendon pulley reconstruction
355. Tendon pulley reconstruction
356. Tendon transfer or transplantation
357. Tenotomy of hand
358. Thigh reattachment
359. Thumb reattachment
 360. Toe reattachment
361. Total ankle replacement
362. Total elbow replacement
363. Total ostectomy
364. Total wrist replacement
365. Transplant from cadaver
366. Transposition of cranial and peripheral nerves - Nerve
transplantation
367. Triad knee repair
368. Triple arthrodesis
369. Unspecified operation on bone injury
370. Upper arm reattachment
371. Upper limb amputation, not otherwise specified
372. Wedge osteotomy
5 KSM BEDAH THORAKS 1. Biopsi Terbuka Bronkhus
DAN 2. Biopsi Terbuka Diafragma
KARDIOVASKULAR 3. Biopsi Terbuka Mediastinum
4. Biopsi Terbuka Paru
5. Biopsi Terbuka Pleura
6. Biopsi Terbuka Pleura dengan VATS
7. Biopsi Terbuka Tumor Dinding Thoraks
8. Debridement Mediastinum (Sternotomi)
9. Eksisi Pada Bronkhus
10. Eksisi Pada Paru (Lung Volume Reduction) 1
11. Eksisi Pada Paru dengan VATS
12. Eksisi Tumor Dinding Dada dengan Rekonstruksi
Dinding Dada
13. Eksisi Tumor Mediastinum (Thymoma, Teratoma,
Neurogenic dsb)
14. Ekstraksi Corpus Alienum di Regio Toraks
15. Ekstraksi Corpus Alienum di Regio Toraks dengan
VATS
16. Evakuasi Efusi Pleura/Empyema secara
Torakoskopik (VATS)
17. Fiksasi Costae (Clipp, Wire) (diluar Clipp)
18. Fiksasi Sternum (Wire, Plate) (diluar wire/plate)
19. Lobektomi Parsial (Reseksi Paru segmental)
20. Lobektomi Parsial (Reseksi Paru segmental) dengan
VATS
21. Lumbal Simpatektomi
22. Mediastinostomy
23. Pemasangan thorak drain/water sealed drainage
(WSD) (diluar alat)
24. Pleural window (Eloeser Flap)
25. Pleurektomi
26. Pleurodesis (Pleurosklerosis)
27. Plikase Bulae / Bleb Emfisematous
28. Plikasi diafragma
29. Pneumonectomy
30. Pneumonectomy dengan VATS
31. Pulmonary Decortication
32. Pulmonary Decortication dengan VATS
33. Pulmonary Lobectomy/Bilobectomy
34. Pulmonary Lobectomy/Bilobectomy dengan VATS
35. Redo Torakotomi
36. Rekonstruksi Sternum&Dinding Dada
37. Repair deformitas Pectus
38. Repair Fistula Bronkopleural
39. Repair Laserasi Diafragma
40. Revisi Thoraks drain/water sealed drainage (WSD)
(diluar alat)
41. Thoracal Symphatectomy dengan Video Assissted
Thoracoscopic Surgery (VATS)
42. Thoracocentesis
43. Thymectomy
44. Thymectomy dengan VATS
45. Torakoplasti (Air Plumbage/Muscle Plumbage)
46. Torakotomi / sternotomi Eksplorasi
47. Torakotomi Eksplorasi pada Trauma jantung/Repair
Laserasi Jantung
48. Bedah Kardio (Jantung)
49. Aortic Valve Repair (AVR)
50. Aortic Valve Repair (AVR) dengan Bioprosthesis
Valve
51. Aortic Valve Repair (AVR) dengan Mechanical Valve
52. Atrial septal Defect (ASD) Closure
53. Bidirectional Cavo-Pulmonary Shunt (BCPS)
54. Biopsi Jantung
55. Biopsi Perikardium
56. Blalock-Taussing Shunt (BT Shunt)
57. Coronary Artery Bypass Graft (CABG)
58. Eksisi Cardiac Myxoma
59. Fontan Operation (Atrium-Pulmonary Artery Conduit)
60. Internal Resusitasi/Cardiac Massage (Operasi
Terbuka)
61. Ligasi Patent Ductus Arteriosus (PDA)
62. Mitral valve repair (MVr)
63. Mitral Valve Repair (MVR) dengan Bioprosthesis
Valve
64. Mitral Valve Replacement (MVR) dengan Mechanical
Valve
65. Operasi Redo Open Heart (Valve Replacement)
66. Operasi Reopen oleh Karena sebab Perdarahan,
Tamponade Jantung
67. Pemasangan IABP
68. Pemasangan Pace Maker Permanen (diluar alat)
69. Pericardiocentesis
70. Perikardiektomi
71. Perikardiotomi/Pericardial Window
72. Pulmonal Valve Repair (PVR)
73. Pulmonal Valve Repair (PVR) dengan Bioprosthesis
Valve
74. Pulmonal Valve Repair (PVR) dengan Mechanical
Valve
75. Pulmonary Artery Banding (PA)
76. Rastelli Procedure (right Ventricle-Pulonary Artery
Conduit)
77. Repair (Eksisi) Aneurisma Jantung
78. Repair Aorta Torakalis (38.34)
79. Repair Atrioventricular Septal Defect (35.54)
80. Repair Total Anomalous Pulmoanry Venous
Connection (TAPVC) (35.82)
81. Repair Transposition of Great Arteries (TGA) (35.84)
82. Repair Trunkus Arteriosus (35.83) 83 Revisi/Aff Pace
Maker Permanen (diluar alat) (37.89)
83. Septostomi Terbuka Septum Atrium (35.41)
84. Total Koreksi Tetralogy of Fallot (TOF) (35.81)
85. Tricuspid Valve Repair (TVR) (35.14)
86. Tricuspid Valve Repair (TVR) dengan Bioprosthesis
Valve (35.27)
87. Tricuspid Valve Repair (TVR) dengan Mechanical
Valve (35.28)
88. Ventricle Septal Defect (VSD) Closure (35.5)
89. Amputasi Above Knee (AK) (84.17)
90. Amputasi Below Knee (BK) (84.14)
91. Arterial Pungsi, Kanulasi, Sectie (38.91)
92. Arteriovenous Shuntt (AV Shunt) Brakiosefalika
(39.42)
93. Arteriovenous Shuntt (AV Shunt) Radiosefalika
(39.27)
94. Bedah Varises Insisi Babcock (38.5)
95. Biopsi Pembuluh Darah (Perifer) (38.21)
96. Debriment-Nekrotomi Luka Gangren (86.22)
97. Disartikulasi Sendi Ekstremitas (84.13)
98. Eksisi Biopsi :
1) Eksisi Tumor Pembuluh Darah Perifer
 (Hemangioma) Tumor Pembuluh
2) Eksplorasi Vaskular (Trauma/Non trauma) Darah
3) Embolektomi/Trombektomi Aorta
4) Embolektomi/Trombektomi Pembuluh Darah
Arteri Abdominal
5) Embolektomi/Trombektomi Pembuluh Darah
Arteri Ekstremitas Bawah
6) Embolektomi/Trombektomi Pembuluh Darah
Ekstremitas Atas (diluar alat)
7) Embolektomi/Trombektomi Pembuluh Darah
Ekstremitas Bawah(diluar alat)
8) Embolektomi/Trombektomi Pembuluh Darah
Regio servikal (Karotis, Jugular) (diluar alat) 9
Evakuasi Hematom di Ekstremitas (Pasca Pungsi
HD/ Traumatik)
9) Fasciotomy
10) Ligasi Vaskular Ekstremitas
11) Mutilasi Digiti Ekstermitas
12) Pasang Double Lumen Hemodialisis (HD) (diluar
alat)
13) Pasang Implantable Central Venous Access
(diluar alat: porth-a-cath, celsite)
14) Pemasangan Central Venous Catheter (CVC)
(diluar alat)
15) Pemasangan Intra Aortic Baloon Pump (IABP)
(diluar alat)
16) Pemasangan Peritoneal Dyalisis (PD) Catheter
(diluar alat)
17) Pembedahan Teleangiectasis
18) Repair Aneurisma (True/false) Ekstremitas
Superior (diluar graft)
19) Repair Aneurisma Aorta Abdominalis (Diluar
Protesa)
20) Repair Pembuluh Darah Regio Servikal (Karotis,
 Jugular)
21) Repair Ruptur Pembuluh Arteri Abdominal
22) Revisi Arteriovenous Shunt
23) Skleroterapi Vena (Varises, Hemangioma)
24) Stripping Varises Ekstremitas Inferior
25) Vascular Shunting (Splenorenal Shunt, De Palma
Shunt)
26) Vena Punctie, Kanulasi, Sectie

6 KSM BEDAH 1. Abdominal pull through (sfingter saving procedure)

DIGESTIVE 2. Abdominoperineal resection (miles) dengan penyulit
mayor
3. Abdominoperineal resection (miles) dengan penyulit
minor
4. Abdominoperineal resection (miles) tanpa penyulit
5. Abdominoplasty
6. Apendektomi
7. Apendektomi dgn penyulit major
8. Apendektomi dgn penyulit minor
9. Apendektomi laparoskopik
10. Bilio-difgestif anastomosis tanpa penyulit
11. Biliodigestif dengan penyulit mayor
12. Biliodigestif dengan penyulit minor
13. Biopsi insisional, local anastesi
14. Biopsi rectum
15. Eksisi hemoroid eksterna
16. Eksplorasi duktus bilier & cholangiografi intra operatif
17. Esofagotomi
18. Fistulotomi
19. Fistulotomi dgn penyulit mayor
20. Fistulotomi dgn penyulit minor
21. Gastrostomi
22. Hemikolektomi dengan penyulit mayor
23. Hemikolektomi dengan penyulit minor
24. Hemikolektomi tanpa penyulit
25. Hemoroid stapling (diluar alat)
26. Hemoroidektomi
27. Herniotomi
28. Herniotomi dgn penyulit mayor
29. Herniotomi dgn penyulit minor
30. Herniotomi laparoskopik
31. Jejunostomi / ileostomi
32. Laparotomi dengan penyulit minor
33. Laparotomi tanpa penyulit
34. Ligasi hemoroid (diluar alat)
35. Pankreatiko-duodenektomi cephalis (Whipple)
dengan penyulit mayor
36. Peritoneal dreanse (CAPD)
37. Peritoneal lavase
38. Polipektomi
39. Potong kolostomi
40. Prosedur Heller
41. Rektopexy
42. Repair fistel usus
43. Repair fistel vesicorectal
44. Repair hernia cicatricalis
45. Repair hernia cicatricalis dgn penyulit mayor (diluar
alat)
46. Repair hernia cicatricalis dgn penyulit minor (diluar
alat)
47. Repair Hernia Diafragmatika (diluar alat)
48. Reseksi anterior dengan penyulit mayor
49. Reseksi anterior dengan penyulit minor
50. Reseksi anterior tanpa penyulit
51. Reseksi esofagus-colon / ileum transposisi
52. Reseksi esofagus-end to end
53. Reseksi esofagus-esofago-gastrectomy
54. Reseksi hati
 55. Second look laparoscopy
56. Splenektomi / splenoraphy traumatika
57. Splenektomi non trauma
58. Terminal esofagus proksimal gastrektomi (TEPG)
59. Total gastrektomi
60. Total pantreaktomi
61. Total prokto-kolektomi
62. Tutup burst abdomen (tanpa alat)
63. Tutup burst abdomen dengan penyulit mayor
64. Tutup burst abdomen dengan penyulit minor
65. Tutup kolostomi / ileostomi
66. Tutup kolostomi / ileostomi dengan penyulit mayor
67. Tutup kolostomi / ileostomi dengan penyulit minor
68. Repair Aorta Torakalis (38.34)
69. Repair Atrioventricular Septal Defect (35.54)

7 KSM BEDAH UROLOGI 1. Adrenalektomi

2. Adrenalektomi (Abdominotorakal)
3. Anastomosis end to end Ureter 4 Augmentasi Buli
4. Biopsi Ginjal perkutan
5. Biopsi Ginjal Terbuka
6. Biopsi Penis
7. Biopsi Prostat
8. Biopsi Testis
9. Bladder Neck Rekonstruksi
10. Buried Penis
11. Businasi/Dilatasi Uretra
12. Cabut DJ Stent
13. Defooring Kista Ginjal per Laparoskopi
14. Deroofing/Unroofing Kista
15. Diseksi Kelenjar Getah Bening Inguinal
16. Diseksi Kelenjar Getah Bening pelvis
17. Diseksi Kelenjar Getah Bening Pelvis per
Laparoskopi
18. Divertikulektomi Buli
19. Divertikulum Uretra
20. Dorsumsisi
21. Drainase Periureter
22. Eksisi Chordae/Chordektomi
23. Eksisi Fibroma/Rekonstruksi Penis
24. Eksisi Plaque (Peyronie Disease)
25. Eksisi Webbed Penis
26. Eksplorasi testis (Microsurgery)
27. Ekstraksi Batu
28. Ekstrofi Buli Rekonstruksi
29. Epispadia
30. Evakuasi Bekuan Darah (Clot)
31. Extended Pyelolithotomy
32. Fistulektomi/Repair Fistel Uretra
33. Funikokelektomi
34. Ganti Nefrostomy
35. Hidrokel per Inguinal/Ligasi Tinggi
36. Hidrokel per Skrotal
37. Hipospadia Subkoronal
38. Holmium YaG Laser (Sewa)
39. Ileal Conduit (Bricker)
40. Insersi DJ Stent
41. Insisi Abses Perineum
42. Insisi Abses Skrotum
43. Insisi Posterior Urethral Valve
44. Johanson
45. Johanson I
46. Johanson II
47. Kalibrasi Uretra
48. Kauterisasi
49. Koreksi Horseshoe Kidney
50. Koreksi Priapismus
51. Laparoskopi Adrenalektomi
52. Laparotomi Eksplorasi
53. Ligasi V.Spermatika Interna (Microsurgery)
54. Limfadenektomi Ilioinguinal
55. Limfadenektomi Retroperitoneal/RPLND
56. Litholapaksi
57. Lithotripsi
58. Masase Prostat
59. Meatoplasti
60. Meatotomi
61. MMK/Sling Uretra
62. Nefrektomi
63. Nefrektomi Donor Transplant
64. Nefrektomi Parsial
65. Nefrektomi per Laparoskopi
66. Nefrektomi Radial
67. Nefropeksi/Renopeksi
68. Nefrostomi Perkutan/Temporer
69. Nefrostomi Terbuka/Permanen
70. Nefroureterektomi
71. Neobladder
72. Operasi Priapismus (prosedur Winter)
73. Operasi Repair Buli Trauma
74. Operasi Sistokel
75. Operasi Trauma Ginjal
76. Operasi Urakhus/Reseksi urakhus
77. Orkhidektomi
78. Orkhidektomi extended
79. Orkhidektomi Ligasi Tinggi
80. Orkhidektomi Subkapsuler
81. Orkhidopeksi (Torsio Testis)
82. Orkhidopeksi (UDT)
83. Orkhidopeksi per Laparoskopi
84. Pasang Kateter
85. Pasang Kateter dengan Mandrain
86. Pasang Kateter Tenckhoff untuk CAPD
87. PCNL/PNL
88. Penektomi Parsial
89. Penektomi Total/Amputasi Penis
90. PER (Primary Endoscopic Realignment)
91. Pielokalikotomi
92. Pielolitotomi
93. Pieloplasti
94. Pieloplasti per Laparoskopi
95. Prostatektomi Radikal
96. Prostatektomi Retropubik
97. Prostatektomi Terbuka
98. Prostatektomi Terbuka dan Sectio Alta
99. Psoas Hitch/Boari Flap
100. Punksi dan sklerosing Kista Ginjal
101. Railroading Rupture Uretra
102. Reimplantasi Ureter Bilateral
103. Reimplantasi Ureter Unilateral/Ureteroneosistostomi
104. Rekontruksi Renovaskuler
105. Repair Fistel Enterovesika
106. Repair Fistel Vesikokutan
107. Repair Fistel Vesikorektal
108. Repair Fistel Vesikovagina
109. Repair Fistel Vesikovagina Kompleks
110. Reparasi Penis
111. Reseksi-anastomosis Uretra
112. RPG
113. Sectio Alta/Vesikolithotomi
114. Sirkumsisi
115. Sistektomi Parsial/Sistoplasti Reduksi
116. Sistektomi Per Laparoskopi
117. Sistektomi Total/Radikal
118. Sistoskopi
119. Sistoskopi ODS
 120. Sistostomi perkutan
121. Sistostomi Terbuka
122. Skrotoplasti
123. Spermatokelektomi
124. Tailoring Ureter
125. Transplan Resipien
126. Transuretero-ureterostomi
127. TUR Prostat/TUIP/BNI
128. TUR Tumor Buli
129. TVP/TMP
130. Ureterokutaneostomi
131. Ureterolisis
132. Ureterolithotomi
133. Ureterolithotomi Distal
134. Ureterolithotomi Proksimal
135. Ureterosigmoidostomi (Caffey)
136. Ureterostomi
137. Ureterouretostomi
138. Uretroplasti Hipospadia
139. Uretroskopi/Uretrosistoskopi
140. Uretrotomi Interna (Sachse)
141. URS/Lithotripsi
142. Varikokelektomi (Palomo)
143. Vasektomi (anestesi lokal)
144. Vasektomi (narkose)
145. Vasoepididimostomi
146. Vasografi
147. Vasovasostomi
8 KSM ILMU KESEHATAN 1. Angkat Jahitan
MATA 2. Angkat Jahitan dengan GA
3. Anterior Chamber Tap/Parasintesis
4. Aspirasi Massa Lensa
5. Blefaroplasty (2 Kelopak Mata)
6. Claw Lens
7. Cryopexy Kornea
8. Cyclo Cryo
9. Dacryocystorinostomi (Without Silicon Tube)
10. Dekompresi Orbital/Lateral Orbitotomi
11. Disisi Aspirasi & IOL
12. ECCE
13. ECCE & IOL
14. Eksenterasi
15. Eksisi Hordeolum / Chalazion
16. Ekstirpasi Corpus Alienum di Kornea
17. Ekstirpasi Pterygium + Graft Konjungtiva
18. Ekstripasi Corpus Alienum di Bilik Mata Depan
19. Enukleasi/Eviscerasi (DFG/Bonegraft)
20. Evakuasi Silikon Oil
21. Fornix Repair
22. ICCE
23. ICCE & IOL
24. Injeksi Intra Vitreal
25. Injeksi Periokuler Terapetik
26. IOL Explant
27. Iridectomi
28. Jahit Kelopak Mata Full Thickness & Lid Margin
29. Jahit Kornea
30. Keratoplasti (Corneal Transplantation)
31. Konjungtival Flap/Amnion Graft
32. Piggy Back IOL
33. Pneumoretinopexy
34. Repair Canalis Lacrimalis (Without Silicon Tube)
35. Repair Coloboma Palpebra (Skin/Mucosal Graft)
36. Reposisi IOL
37. Reposisi Iris
38. Resesi & Reseksi 2 Otot
39. Resesi & Reseksi 3 Otot
40. Resesi & Reseksi 4 Otot
 41. Resesi/Reseksi 1 Otot
42. Sekunder Implant (Posterior Chamber)
43. Sekunder Implant Claw Lens / Fiksasi Sulcus
44. SICS
45. SICS & IOL
46. Simpel Vitrektomi
47. Skleral Buckle
48. Socket Repair (Contracted Socket)
49. Trabekulektomi
50. Trabekuletomi & Ollogen
51. Trabulektomi & Goniotomi pada Pediatric Glaucoma
52. Tube Shunt (Express)
53. Viscocanulostomy 54 Vitrektomi +++
54. Vitrektomi Lengkap & Skleral Buckle
55. Wide Eksisi Tumor Kelopak Mata
56. Wide Eksisi Tumor Kelopak Mata + Flap + graft.
9 Divisi Onkologi 1. Aspirasi Kista Mamma Single dan Multiple
2. Biopsi Core Lokal Anestesi
3. Biopsi Eksisi Lokal
4. Biopsi Eksisi Narkose
5. Biopsi Insisi Lokal
6. Biopsi Narkose
7. Breast Conserving Surgery (BCS)
8. Breast Conserving Surgery + LD Flap
9. Debridement Mamma
10. Diseksi Axilla
11. Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi
12. Eksisi Fibroadenoma Multiple Narkose
13. Eksisi Tumor Metastase Loco-regional
14. Eksplorasi Duktus Mama
15. Eksplorasi Duktus Mama+VC
16. Insisi Absces Mastitis Lokal
17. LD Flap + Eksisi Tumor
18. Mastectomy + Tram Flap
19. Modified Radical Mastectomy + Flap/Single Grafting
20. Modified Radical Mastectomy Single
21. Quadrantectomy / Partial Mastectomy
22. Simple Mastektomy + Flap/Skin Grafting
23. Simple Mastektomy Single
24. Tram Flap + Eksisi Tumor
25. Operasi Tumor Kulit
26. Biopsi Insisi Tumor Kulit Lokal
27. Biopsi Eksisi Tumor Kulit Narcose
28. Eksisi Tumor Jinak ≤ 3cm
29. Eksisi Tumor Jinak + Flap/Skin Graft
30. Eksisi Tumor Jinak Kulit >3cm
31. Wide Eksisi + Diseksi KGB
32. Wide Eksisi Tumor Ganas Kulit
33. Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft
34. Operasi Soft Tissue Tumor
35. Amputasi + Diseksi KGB
36. Amputasi Jari + Flap / Skin Graft
37. Amputasi Tungkai / Lengan
38. Biopsi Core soft Tissue
39. Biopsi Insisi Tumor Sof Tissue dengan Narcose
40. Biopsi Insisi Tumor Soft Tissue Lokal Anestesi
41. Eksisi Tumor Jinak > 3cm
42. Eksisi Tumor Jinak Ø<3cm
43. Wide Eksisi + Compartement Procedure
44. Wide Eksisi + Diseksi KGB
45. Wide Eksisi Tumor Ganas
46. Wide Eksisi Tumor Jinak + Flap/Skin Graft
47. Operasi Tindakan Tertentu
48. Advancement Flap
49. Aspirasi Effusi Pleura
50. Aspirasi Paru + Pleurodhesis
51. Delto Pectoral Flap (DP Flap)
52. Diseksi Axilla
 53. Diseksi Inguinal
54. Diseksi Para Aorta
55. Eksisi Tumor Lidah
56. Eksisi Tumor Sub Mandibula/Sub Mental
57. Insersi Chest Tube
58. Ismulobectomy
59. Kemoterapi Perinfus
60. Latissimus Dorsi Flap (LD Flap)
61. Maksilektomi Total
62. Mastopexy Skin Grafting
63. Modifikasi RND
64. Operasi Compartement Otot
65. Ovariectomy Bilateral
66. Reseksi Mandibula
67. Rotation Flap
68. Sub Total Thyroidectomy
69. Superficial Parotidectomy
70. Thoraco Abdominal Flap (TA-Flap)
71. Total Thyyroidectomy
72. Transversus-Rectus AbdominisFlap (Tram Flap)
73. Parotidectomy
1 DIVISI BEDAH ANAK 1. Abdominal pull through (sfingter saving procedure)
0 2. Adhesiolisis
3. Appendektomi dgn penyulit
4. Appendektomi laparoskopik
5. Appendektomi tanpa penyulit 6 Biliodigesif dengan
penyulit mayor
6. Biliodigestif anastomosis tanpa penyulit atau penyulit
minor
7. Biopsi rectum
8. By pass usus dengan penyulit mayor / minor
9. Divertikulektomy
10. Drainase abses dengan general anasthesia
11. Drainase abses local anasthesia
12. Eksisi hygroma colli
13. Eksisi kista brachialis
14. Eksisi kista duktus tiroglossus
15. Eksisi neoplasma Jinak ( lipoma, atheroma dll )
16. Eksisi sinus/granuloma umbilikalis
17. Eksisi soft tissue tumor dengan penyulit
18. Eksisi soft tissue tumor tanpa penyulit
19. Eksisi teratoma dengan penyulit dan rekonstruksi
20. Eksisi teratoma tanpa penyulit
21. Eksisi tumor jinak wajah
22. Eksisi urachus
23. Ekstirpasi fistel pre aurikulae
24. Ekstirpasiranula
25. Endoskopik diagnostik
26. Endoskopik terapeutik
27. Gastrostomi
28. Hemikolektomi
29. Herniotomi elektif tanpa penyulit
30. Herniotomi laparoskopik
31. Hernitomi dgn penyulit / komplikasi
32. Hidrokolektomi
33. Intraoperatif kolangiografi
34. Intraoperatif kolangiografi laparoskopik
35. Jejenostomi / ileostomi dengan penyulit mayor
36. Jejenostomi / ileostomi dengan penyulit minor
37. Jejenostomi / ileostomi tanpa penyulit
38. Koledokotomi dengan penyulit mayor
39. Kolesistektomi
40. Kolesistektomi laparoskopik
41. Kolostomi / sigmoidostomi (46.11)
42. Ligasihemoroid (49.4)
43. Operasi kelainan umbilikal lain (54.3)
44. Orchidopexy (62.5)
45. Orchidopexy laparoskopik (62.5 + 61.6)
46. Other Repair of Abdominal Wall (Repair Omphacele)
(954.72)
47. Polipektomi (48.36)
48. Posterosagital anorectoplasty
49. Posterosagital anorectoplasty urethro vaginoplasty
(70.79)
50. Potong kolostomi (46.14)
51. Potong Stump (84.3)
52. Prosedur Heller (44.6)
53. Prosedur Kasai (51.37)
54. Repair atresia
55. LADD Operation (54.95)
56. Laparoskopik diagnostik (61.6) (49.79) esofagus
(42.5)
57. Repair defek diafragma (53.8)
58. Repair ekstrofia buli (57.8)
59. Repair hernia diafragma (53.7/53.8)
60. Repair of Gastrochisis (54.71)
61. RPLND (40.59)
62. Separasi conjoined twin (84.9)
63. Sirkumsisi dengan general anesthesia (64.0)
64. Sirkumsisi dengan local anesthesia (64.0) 6668
65. Transnasal endorectal pullthrough laparascopic
assisted (48.42)
66. Transplantasi organ
67. Tutup burst abdomen dengan penyulit (54.61)
68. Tutup Splenektomi (41.5)
69. Splenorenal shunt (39.1)
70. Burst abdomen tanpa penyulit (54.61)
71. Tutup ileostomi dengan penyulit (46.5)
72. Tutup kolostomi / ileostomi (46.5)
73. Tutup Stoma (46.5)
74. Urethroplasty / chordectomy (64.42)
75. Vena Sectie Aksilaris (38.94)
 76. Vena sectie Femoralis / saphena magna (38.94)
77. Wound repair (86.8)
1 KSM BEDAH PLASTIK 1. Abdominoplasty
1 2. Aff archbar, Lokal Anastesi
3. Aff Suspensi, Lokal Anastesi
4. Amputasi above elbow
5. Amputasi bellow elbow
6. Amputasi digital
7. Amputasi jari >1
8. Amputasi jari single
9. Augmentasi mamae
10. Blefaroplasty (2 kelopak mata)
11. Blefaroplasty pada kasus sulit
12. Blefaroptosis + Muskulocutan flap
13. Bone rekonstruksi facial cleft
14. Cheilonasoraphy
15. Chordectomy
16. Chordectomy+urethroplasty
17. Closed Reduction Fr. Nasal
18. Comisuroplasty
19. Bone rekonstruksi facial cleft Eks mamma aberan
bilateral
20. Eksisi neoplasma jinak (lipoma, atheroma dll)
21. Eksisi luas + Deltopectoral flap
22. Eksisi luas + Fore head flap
23. Eksisi luas Eksisi luas + rekonstruksi dengan bedah
mikrovaskular
24. Eksisi malformasi lymphatik / vaskuler
25. Ekstraksi ateroma / keloid
26. Ekstraksi korpus alienum
27. Elevasi ear rim cartilago
28. Excise hemangioma + rekonstruksi
29. Excise intra keloid
30. Excise polydactyly
31. Excise reduksi lymedema
32. Facial sling dengan allograft
33. Fasciotomy burn injury
34. Fasciotomy with complication
35. Flap lokal sederhana
36. Fr. Condylus mandibula open red
37. Fr. Maksila suspensi (IOID)
38. Fr. Nasal open reduction
39. Fraktur Prosesus alveolaris dengan inter dental
wiring (IDW) (per rahang)
40. Fraktur Prosesus alveolaris luas dengan IDW (per
rahang)
41. Fraktur rahang reduksi terbuka & inter oseus wiring
(IOW)
42. LD flap
43. Le fort I osteotomy
44. Liposuction
45. Lobuloplasti
46. Malarplasty
47. Mamma aberan unilateral
48. Mandibular distraksi
49. Mandibular rekonstruksi dengan costochondral graft
52 Mastopexi
50. Mentoplasty
51. Microsurgery
52. Multiple facial fraktur + implant
53. Muskulokutaneus flap
54. Myokutaneus flap/pectoralis mayor flap
55. Nasal repair dan rekonstruksi
56. Neo vagina
57. Operasi bedah mikro
58. Orif fraktur zygoma
59. Orif fraktur hand
60. Orif fraktur mandibula
61. Orif fraktur maxilla
62. Orif maksila plating
63. Orif mandibula plating
64. Orif mandibula wiring
65. Orif orbital wall
66. Orif orbital wall
67. Orif zygoma wiring
68. Osteotomy craniosynostosis reconstruction
69. Osteotomy facial rekonstruksi
70. Osteotomy genioplasti tanpa tarif bahan
71. Osteotomy maksila Le fort I
72. Osteotomy maksila Le fort II
73. Palatoplasti bilateral komplit
74. Palatoplasti bilateral tak komplit
75. Palatoplasti unilateral komplit
76. Palatoplasti unilateral tak komplit
77. Palatoraphy
78. Pasang archbar
79. Pasang back slab/fore slab
80. Pasang cast/gips tanpa reposisi
81. Recheiloraphy
82. Rekonstruksi dengan alloplastic material
83. Rekonstruksi facial cleft
84. Rekonstruksi nasal
85. Rekonstruksi palpebra
86. Released buried penis
87. Released syndactyly kompleks
88. Repair canalis lacrimalis (without silicon tube)
89. Repair coloboma palpebra (skin/mucosal graft)
90. Repair ductus nasolacrimalis
91. Repair fingertip injury
92. Repair fistel urethra
93. Replantation
94. Reposisi fraktur nasal sederhana
 95. Reposisi fraktur os nasalis (complicated)
96. Reseksi mandibula + bone graft
97. Rhinoplasty
98. Rotation flap
99. Sagital Split osteotomi mandibula
100. Simple bone grafting
101. Simple skin grafting
102. Skin flap
103. Skin graft >5 cm
104. Skin graft sedang 5 cm
105. Skin grafting kecil
106. Skin grafting luas
107. Skin grafting sedang
108. Skin grafting with complication
109. Tendon reconstruction
110. Tendon transfer
111. Tendon transfer with complication
112. Tennoraphy
113. Tennoraphy with complication
114. TMJ arthroplasty
115. TMJ arthrostomy
116. Tram flap
117. Wound Dressing
118. Wound Repair
1 KSMOBGYN 1. Cauter serviks
2 2. Cordosentesis
3. Debulking tumor ovarium
4. Eksplorasi vagina
5. Embryotomi
6. Extirpasi + kuret polip endoserviks
7. Extirpasi geboren mioma
8. Extirpasi geboren mioma+kuiretasi
9. Histeroctomy pada mola / chorio Ca
10. Histeroctomy radikal
11. Kistektomi
12. Konisasi serviks
13. Kuret abortus incompletes
14. Lap op: myomektomi
15. Laparoskopi (Kistektomi Ovarium, Salphingektomi,
Adhesiolisis)
16. Laparoskopi Histerektomi
17. Laparoskopi steril
18. Laparoskopik Diagnostik
19. Laparotomi dengan penyulit mayor
20. Laparotomi dengan penyulit minor
21. Laparotomi tanpa penyulit
22. LEEP
23. Micro kuretase DUB
24. Mikrokuret
25. Miomectomy
26. Neovagina
27. Operasi Ca vagina
28. Operasi kanker corpus uteri
29. Operasi tumor ganas ovarium
30. Operative histeroscopy/Ablasi endometrium
31. Overectomi
32. Painless labor
33. Persalinan normal
34. Persalinan normal dengan penyulit
35. Persalinan pervaginam tindakan operatif
36. Persalinan sungsang
37. Rekanalisasi
38. Rekanalisasi tuba
39. Salfingektomi unilateral
40. Salvingoovarectomi unilateral
41. Secound look surgery Ca ovarium
42. Seksio sesaria
43. Seksio sesaria dengan penyulit penyulit
 44. Sirklase serviks
45. Seksio sesaria dengan penyulit penyulit
46. Sirklase serviks
47. Supra vaginal hyterectomy
48. Surgical staging
49. TAH+BSO dengan Penyulit
50. TAH+BSO dengan Penyulit Pemasangan Tampon
Abdomen
51. Total abdominal hysterectomy+bilateral salfingektomi
52. Tubektomi klinik 53 Tutup burst abdomen

1 KSM BEDAH GIGI

3 danMULUT 1. Augmentasi Tulang Per Regio (Belum Termasuk
Bahan)
2. Debriment Mukosa dan Pengelolaan Luka Sayat
3. Dislokasi Sendi Mandibula
4. Eksisi Epulis Per Rahang
5. Eksisi Kelenjar Ludah Submandibula
6. Eksisi Kista Odontogenik Keratosis + Ostektomi
7. Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil
8. Eksisi Parsial + Marsupialisasi Ranula
9. Eksisi Plunging Ranula
10. Eksisional Biopsi Neoplasma Jinak
11. Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi
12. Enukleasi Kista radikuler Per Rahang + Extraksi Gigi
Penyebab
13. Extirpasi Kista Dermoid
14. Extirpasi Sialolith
15. Extraksi Corpus Alienum dengan Teknik Lindorf
16. Extraksi Gigi Anak dengan Kelainan Jantung Per
Rahang
17. Extraksi Gigi Anak Per Rahang
18. Extraksi Gigi Dewasa Per Rahang
19. Fissure Sealant pada Autis
 20. Fraktur Dento alveolar Dengan arch Bar
21. Fraktur Dento alveolar Dengan Bracket (belum
termasuk bahan)
22. Fraktur Dento Alveolar dengan Eyelet
23. Fraktur Maksila dengan Suspensi Wiring
24. Fraktur Nasal close Reduksi
25. Fraktur Nasal Open Reduksi
26. Fraktur Rahang Reduksi Tertutup dengan
Intermaksila Fiksasi
27. Frenektomi Per Rahang
28. Genioplasty
29. Gingivektomi Per Rahang
30. Hemi Maksilektomi Tanpa Rekonstruksi
31. Insisi Abses / Phlegmon
32. Insisional Biopsi Neoplasma Jinak
33. Mandibular Distraksi
34. Odontektomi Per Gigi
35. ORIF Maksila + Zygoma + Mandibula (belum
termasuk implant)
36. ORIF Maksila Plating (belum termasuk implant)
37. ORIF Mandibula Plating (belum termasuk implant)
38. ORIF Zygoma Plating (belum termasuk implant)
39. Osteotomi Maksila le Fort I
40. Osteotomi Maksila le Fort II
41. Pelepasan Arch Bar (Intermaksila Fiksasi)

1 DIVISI 1. Intubasi Endotrakea

4 GAWATDARURAT 2. Krikotirotomi
3. Kanulasi vena perifer
4. Vena sectie
5. Pungsi lumbal
6. Pungsi Pleura

1 KSM 1. Diagnostik Kateterisasi Jantung

5 PENYAKITJANTUNG 2. PTMC PEMBULUH
 3. PTCA/Stenting DARAH
4. Pacemaker Temporer & Permanen
5. IABP 6 Perikardiosintesis
6. Pemasangan Swan Ganz Kateter
7. Pemasangan Amplatzer/ADO/Coilling
8. CVC
9. Pelepasan Arch Bar (Intermaksila Fiksasi)

1 KSM PENYAKIT DALAM

6 A. Endoscopy
B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam),
tindakan yang memerlukan informed consent
tersebut antara lain:
a. Semua tindakan anestesi dan sedasi di dalam
kamar operasi
b. Semua tindakan anestesi dan sedasi di ICU
c. Tindakan Anestesi di ICU
d. Pemasangan intubasi ventilator
e. Pemasangan vena central
f. Pemasangan CRRT
g. Pemasangan Swan Ganz (Kateter Arteri
Pulmonal)
h. Pemasangan Intra Arterial Catheher (Kateter
Intra Arterial)
i. Pemasangan Percutaneous Dilatational
Tracheostomy
j. Pemasangan Drain Intra Thorakal/Punksi
Thorax
k. Pemasangan IABP Pemasangan Drain Intra
Abdominal
l. Pemasangan Gemo Cardioversi Bronchoskopi-
FOB TEE
C. Tindakan Pemberian Produk Darah dan Komponen
Darah,tindakan yang memerlukan informed consent
 tersebut antara lain: Transfusi darah:
a. Plasma sel
b. PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin f. lain – lain
D. Semua Tindakan Yang Berisiko Tinggi :

1 KSM Anak 1. Chest tube

7 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 Pungsi Pleura
12. Pemasangan kateter urine
13. Pemasangan keteter rectal
14. Pemasangan orogastrik tube
15. Pemasangan nasogastrik tube

1 THT-KL 1. Pemeriksaan Audiometri

8 2. Pemeriksaan Timpanometri
3. Pemeriksaan Audiometri Tutur
4. Pemeriksaan Sisi&Tore Decay
5. Pemeriksaan Pendengaran Pada Anak
6. Pemeriksaan Brainstem Evoked Response Audiometry

1 KSM Patologi Anatomi FNAB (Fine Needle Aspiration Biopsy)

9
2 Radiologi 1. Inst. Radiotherapi
0 2. Tindakan Radiotherapi
2 KSM Neurologi 1. Cerebral Angiografi
1 2. AVM & Embolisasi
3. Aneurisma Coiling
4. Embolisasi pre operasi
5. Diagnosis DSA
6. Lumbal Punksi
7. Pain Intervention
8. Injeksi Triger point
9. Injeksi Triger Fringer
10. Injeksi CTS
11. Sub Optical Functional
12. Injeksi botox
13. EMG
2 KSM Patologi Klinik Phlebotomi
2
2 KSM Gigi dan Mulut 1. Scaling
2 2. Curettage/root planning (jika diperlukan anestesi)
3. Gingivektomi
4. Frenektomi
5. Flap operasi (bone graft/membrance/GTR/interseptif)
6. Implant
7. Vital pulpektomi dan Partial Nekrose
8. Cauter
9. Retraksi Gingiva pada prep.crown
2 Poli Andrologi Suntik Intra Cavernosal Penis
3
2 KSM Kardiologi dan 1. Dobutamin Stress Ekhokardiografi
4 Kedokteran Vaskular 2. Transophegal Ekhokardiografi
3. Treadmill Tes
4. Exercise Stress Ekhokardiografi
2 KSM Pulmonologi dan 1. Bronchoscopy/FOB
5 Ilmu Kedokteran 2. Tindakan kemotherapi
Respirasi 3. Thoracoscopy
4. Contra Ventil/WSD
5. Punctie Pleura
6. FNAB
7. Scalene Biopsy

2 KSM Radiologi
6 2. Tindakan Radiologi pada pasien dengan kelainan
2 KSM Neurologi
7 2. AVM&Embolisasi
2 Instalasi Hemodialisis
8
2 KSM Rehabilitasi Medik Elektromiografi dan Kecepatan Hantar Saraf
9
8. Reposisi
9. Pleurodesis
10. AFF WSD
11. Perawatan Luka WSD
12. USG Thorax Marker
1. Tindakan Radiologi Injectee contrast
cardiovaskuler
3. Tindakan Radiologi pada pasien dengan alergi berat
4. Tindakan Radiologi pada pasien dengan KU yang
menurun
5. Tindakan Radiologi yang memerlukan FNAB Guiding
MSCT pada pasien dengan kelainan yang
berdekatan dengan organ vital
6. Tindakan Radiologi pada Ibu hamil yang memerlukan
foto
1. Cerebral Angiografi
3. Aneurisma Coiling
4. Embolisasi pre operasi
5. Diagnosis DSA
6. Lumbal Punksi
7. Pain Intervention
8. Injeksi Triger point
9. Injeksi Triger Fringer
10. Injeksi CTS
11. Sub Optical Functional
12. Injeksi botox
13. EMG
14. Neuro endovaskuler: Coiling,Embolisasi,DSA
Setiap kali melakukan tindakan Hemodialisis