KEPUTUSAN DIREKTUR UTAMA RUMAH SAKIT KHUSUS IBU & ANAK

ANDINATERNATE
NOMOR : 101/005/SKPTN/RSIAA/2022
TENTANG

KEBIJAKAN JENIS TINDAKAN KEDOKTERAN YANG HARUS DISERTAI DENGAN

PERSETUJUAN TINDAKAN KEDOKTERAN (INFORMED CONSENT)
DI RSUD Dr. CHASAN BOESOIRIE

DIREKTUR UTAMA RUMAH SAKIT KHUSUS IBU & ANAK ANDINA

TERNATE,
Menimbang : a. bahwa dalam rangka untuk meningkatkan pelayanan bagi pasien dan
memberikan kepastian dan perlindungan bagi tenaga medis dalam
melakukan tindakan kedokteran di Rumah Sakit Khusus Ibu & Anak
AnDina, maka dipandang perlu ditetapkan jenis tindakan kedokteran
yang harus disertai dengan persetujuan tindakan kedokteran (Informed
Consent) dalam proses pelayanan di Rumah Sakit Khusus Ibu & Anak
AnDina sesuai dengan Undang -
Undang dan peraturan yang berlaku;
b. bahwa untuk maksud tersebut pada butir a di atas telah ditetapkan Surat
Keputusan Direktur Utama Rumah Sakit Khusus Ibu & Anak AnDina Nomor :
tentang
Kebijakan Jenis Tindakan Medik yang Harus Disertai dengan Persetujuan
Tindakan Medik (Informed Consent) di Rumah Sakit Khusus Ibu & Anak
AnDina;
c. bahwa kebijakan sebagai mana butir b perlu dilakukan revisi dan
ditetapkan dengan Surat Keputusan Direktur Utama Rumah Sakit Khusus
Ibu & Anak AnDina

Mengingat : 1. Undang - Undang RI No. 29 Tahun 2004 tentang Praktik Kedokteran;

2. Undang - Undang RI No. 36 Tahun 2009 tanggal 13 Oktober 2009
tentang Kesehatan;
3. Undang - Undang RI No. 44 Tahun 2009, tentang Rumah Sakit;
4. Peraturan Pemerintah RI Nomor 23 tahun 2005; tentang Pengelolaan
Keuangan Badan Layanan Umum;
5. Peraturan Menteri Kesehatan RI Nomor : tentang Organisasi dan Tata
Kerja Rumah Sakit Khusus Ibu & Anak AnDina;
6. Peraturan Menteri Kesehatan RI Nomor : 290/Menkes/Per/III/2008
tentang Persetujuan Tindakan Kedokteran;
7. Peraturan Menteri Kesehatan RI Nomor : 269/Menkes/PER/111/2008
tentang Rekam Medis;
8. Keputusan Menteri Kesehatan RI Nomor : tentang Penetapan Kelas
Rumah Sakit Khusus Ibu & Anak AnDina sebagai Rumah Sakit Umum
Kelas A;
9. Keputusan Menteri Kesehatan RI Nomor : 1243/MENKES/SK/VIII/2005
tanggal 11 Agustus 2005 tentang Penetapan 13 (tiga belas) eks Rumah
Sakit Perusahaan Jawatan (PERJAN) menjadi unit pelaksana tehnis
(UPT) Departemen Kesehatan dengan menerapkan pola pengelolaan
Keuangan Badan Layanan Umum;
10. Keputusan Menteri Kesehatan RI Nomor : 085/MenKes/SK/II/2012
tanggal 25 Februari 2012 tentang Pengangkatan, Pemindahan dan
Pemberhentian Dalam dan Dari Jabatan Struktural di lingkungan
Kementerian Kesehatan RI.
11. Keputusan Menteri Kesehatan RI Nomor : tentang Ijin Operasional
Tetap Rumah Sakit Khusus Ibu & Anak AnDina.
 MEMUTUSKAN

Menetapkan : KEPUTUSAN DIREKTUR UTAMA RSUD Dr. CHASAN BOESOIRIE

TENTANG KEBIJAKAN JENIS TINDAKAN KEDOKTERAN YANG
HARUS DISERTAI DENGAN PERSETUJUAN TINDAKAN
KEDOKTERAB (INFORMED CONSENT) DI RUMAH SAKIT KHUSUS IBU &
ANAK ANDINA TERNATE,

KESATU : Memberlakukan Kebijakan Jenis Tindakan Kedokteran Yang Harus Disertai

Dengan Persetujuan Tindakan Kedokterab (Informed Consent) di Rumah Sakit
Khusus Ibu & Anak AnDina,sebagaimana tersebut dalam lampiran Surat
Keputusan ini;
KEDUA : Kepada seluruh staf dan satuan kerja di lingkungan Rumah Sakit Khusus Ibu &
Anak AnDina,agar dalam melaksanakan tugas pelayanan penanganan kematian
batang otak agar selalu mengacu pada Pedoman Penanganan Kematian Batang
Otak tersebut;

KETIGA : Dengan diberlakukannya Surat Keputusan ini, maka Surat Keputusan Direktur
Utama Rumah Sakit Khusus Ibu & Anak AnDina,Nomor : tentang Kebijakan Jenis
Tindakan Medik Yang Harus Disertai Dengan Persetujuan Tindakan Medik
(Informed Consent) di Rumah Sakit Khusus Ibu & Anak AnDina,dinyatakan tidak
berlaku;
KEEMPAT : Segala biaya yang timbul diberlakukannya Surat Keputusan ini dibebankan
pada Anggaran Biaya Rumah Sakit Khusus Ibu & Anak AnDina,.

KELIMA : Keputusan ini berlaku selama 3 (tiga) tahun terhitung mulai tanggal ditetapkan,
dengan ketentuan bahwa apabila di kemudian hari ternyata terdapat kekeliruan
dalam penetapannya, akan dilakukan perbaikan kembali sebagaimana mestinya.

Ditetapkan di : Ternate
pada tanggal : 01/082022

Tembusan:
1. Direktur
2. Ketua Komite / SMF
3. Kepala lnstalasi / Unit
4. Kepala Bagian / Bidang
RSIAA TERNATE.
Lampiran Surat Keputusan Direktur Utama RSIAA TERNATE
nomor : 101/005/SKPTN/RSIAA/2022
tanggal : 01/08/2022
tentang : Kebijakan Jenis Tindakan Kedokteran Yang Harus Disertai Dengan Persetujuan
Tindakan Kedokterab (Informed Consent) Di RSIAA TERNATE

KEBIJAKAN JENIS TINDAKAN KEDOKTERAN YANG HARUS DISERTAI

DENGAN PERSETUJUAN TINDAKAN KEDOKTERAN (INFORMED CONSENT)
DI RUMAH SAKIT KHUSUS IBU & ANAK ANDINATERNATE

I. Pengertian
Tindakan kedokteran adalah suatu tindakan medis berupa preventif, diagnostik, terapeutik,
atau rehabilitatif yang dilakukan oleh dokter atau dokter gigi terhadap pasien. Jenis tindakan
kedokteran yang harus disertai dengan persetujuan tindakan kedokteran (informed consent)
adalah jenis-jenis tindakan kedokteran yang dalam pelaksanaannya wajib disertai dengan
adanya bukti persetujuan tertulis (bukti formal) yang diberikan oleh pasien atau keluarga yang
berkompeten.

II. Tujuan
1. Agar pasien dan/atau keluarga mengetahui mengenai Tindakan Kedokteran yang akan
dilakukan terhadap diri pasien.

2. Agar pasien dan/atau keluarga mendapatkan hak untuk menentukan keputusan yang terbaik
bagi pasien setelah mendapatkan penjelasan medis.

3. Untuk mendapatkan alat bukti yang sah bagi pasien, dokter dan rumah sakit dalam
pemberian tindakan kedokteran kepada pasien.

III. Kebijakan
1. Setiap pasien yang akan menjalani tindakan kedokteran di RSIAA TERNATE, maka
pasien dan atau keluarga yang berkompeten wajib diberikan penjelasan medis terlebih
dahulu oleh dokter penanggungjawab pasien (DPJP) atau dapat didelegasikan kepada
residen yang kompeten terhadap tindakan tersebut.

2. Pasien atau keluarga yang bertanggungawab setelah mendapatkan penjelasan kedokteran

maka diberikan waktu yang cukup untuk memahami penjelasan tersebut, sebelum
menentukan untuk memberikan persetujuan atau menolak tindakan kedokteran yang akan
diberikan kepadanya.
3. Persetujuan atau penolakan tindakan kedokteran dapat diberikan secara tertulis maupun
tidak tertulis dengan lisan atau isyarat bahasa tubuh.
4. Persetujuan atau penolakan tindakan kedokteran yang memiliki resiko tinggi / mengancam
jiwa wajib diberikan secara tertulis.

5. Jenis-jenis tindakan kedokteran yang harus disertai dengan persetujuan tindakan

kedokteran tertulis terdapat dalam lampiran surat keputusan ini dan jadi satu kesatuan
yang tidak terpisahkan.

6. Instalasi Catatan Medik bertanggungjawab menyiapkan lembar persetujuan atau penolakan

tindakan medik.

7. Lembar persetujuan atau penolakan tindakan kedokteran setelah ditandatangani oleh

pasien dan atau keluarga dan dokter yang memberikan penjelasan maka wajib dimasukkan
dalam berkas rekam medis.
 Lampiran Surat Keputusan Direktur Utama RSIAA TERNATE
nomor : 101/005/SKPTN/RSIAA/2022
tanggal : 01/08/2022
tentang : Kebijakan Jenis Tindakan Kedokteran Yang Harus Disertai Dengan Persetujuan
Tindakan Kedokteran (Informed Consent) Di RSIAA TERNATE

Tindakan Dengan Informed Consent

Kategori Tindakan
NO JENIS TINDAKAN
1 {Aorto}coronarv bypass of four or more coronary arteries
2 (Aorto)coronary bypass of three coronary arteries
3 Attachment of oedicle or flap araft to lio and mouth
4 Bilateral luna transolantation
5 BIOPSY of diaphraam
6 Bronchoscoov throuah artificial stoma
7 Closure of salivary fistula
8 Combined heart-luna transplantation
9 Comolete sialoadenectomy
10 Construction of auricle of ear
11 Division of glossopharvngeal nerve
12 Division of Penile adhesions
13 Drainaae of face and floor of mouth
14 Endolvmohatic shunt
15 Ethmoidectomv
16 Excision of lesion of middle ear
17 Excision of lesion or tissue of cum
18 Excision of luna and bronchus
19 Excision of maier lesion of eyelid, partial·thickness
20 Excision of oreauricular sinus
21 Excision of tonsil taa
22 Excision or destruction of lesion of external ear
24 Excision or destruction of lesion or tissue of tongue
25 Excision or destruction of other lesion of external ear
26 Extension or deepening of buccolabial or lingual sulcus
27 Fenestration of Inner ear (lnltlal)
28 lmolantation or replacement of cochlear prosthetic device
30 Incision of chest wall and pleura
31 Incision of external auditory canal
32 I nclslon of luna
33 Incision of mastoid
34 Incision of mouth
35 Incision of multiple nasal sinuses
36 Incision of Denis
37 Incision of salivarv aland or duct
38 Includes: incidental resection of hyold bone
39 Insertion of oalatal imolant
40 Insertion of removable brfdae
41 lnteratrial transposition of venous return
42 Labial frenectomv
43 Liaatlon of adrenal vessels
44 Mvrinaoolastv
45 Noninvasive oroarammed electrical stimulation {NI PS)
46 Partial alossectomv
47 Partial sialoadenectomy
48 Pericardlocentesis
49 Permanent tracheostomv
50 Radical dissection of thoracic structures
51 Radical excision of lesion of external ear
52 Radical excision of cerlaortlc lvmoh nodes
53 Removal of orosthesis of fallopian tube
54 Removal of tvmoanostomv tube
55 Repair and Dlastic ooerations on trachea
56 Reoalr of adrenal aland
57 Reoair of cleft lio
58 Repair of endocardlal cushion defect with prosthesis
59 Reoair of oval and round windows
60 Reoalr of uvula
61 Reoalr of ventricular seotal defect with technique prosthesis, closed
62 Replacement of larvnaeal or tracheal stent
63 Revision of staeedectomv
64 Root canal therapy with apicoectomv
65 Scarification of pleura
66 Sphenoidectomv
67 Stapedectomy
68 Suture of laceration of external ear
69 Suture of laceration of gum
70 Thyroid tissue reimplantation
71 Trachecscoov throuch artificial stoma
72 Type 111 tympanoplasty
73 Umbilical vein catheterization
74 Unilateral adrenalectomy
75 Unilateral lung transplantation
76 (Aorto)coronary bvoass of one coronary artery
77 (Aorto)coronary bypass of two coronary arteries
78 06.01 Aspiration of thvrold field
79 06.02 Reopenina of wound of thyroid field
80 06.11 Closed roercutaneousl rneedle] biopsy of thvroid gland
81 06.12 Open biopsy of thyroid gland
82 06.13 Bloosv of parathvrold gland
83 06.19 Other diagnostic procedures on thyroid and parathyroid glands
84 Abdominal - coronary artery bvoass
85 abdominal artery to coronarv arterv
86 Abdominal proctopexv
87 abdominal wall
88 Abdominoperineal resection of rectum
89 abscess
90 acetabular and femoral components (total)
92 acetabular comeonent only
95 acetabular liner
96 acetabular liner and/or femoral head only
99 Adenoidectomv without tonsillectomy
100 adjuct vascular system procedure
101 adrenal gland
102 Adrenalotomv (with drainage)
103 Allotransolantation of cells of Islets of Langerhans
104 Alveoloplasty
105 alveolus. alveolar bone
106 Amputation of cervix
107 Amputation of penis
108 Anal cerclaae
109 Anal flstulotomyoAnal flstulectomy
110 Anastomosis of gallbladder to hepatic ducts
111 Anastomosis of gallbladder to Intestine
112 Anastomosis of gallbladder to pancreas
113 Anastomosis of aallbladder to stomach
114 Anastomosis of hepatic duct to aastrolntestinal tract
115 Anastomosis of kidney
116 Anastomosis of pancreas
117 Anastomosis of small intestine to rectal stump
118 Anastomosis to anus
119 Angioplasty or atherectomy of other non-coronary vessells)
120 ankle (total)
121 Annuloplastv
122 antecubital fossa
123 Anterior resection of rectum with svnchronous colostomv
124 Antestemal esophaaeal anastomosis with Interposition of colon
125 Antestemal esophageal anastomosis with Interposition of small bowel
126 Antestemal esophagoesophagostomy
127 Antestemal esoohaaoaastrostomv
128 anus NEC
129 Aorta-Iliac-femoral bypass
130 Aorta-renal bvoass
131 Aorta-subclavlan-carotid bypass
132 aortic
133 aortic
134 aortic branches to heart muscle
135 Aortocoronarv bypass for heart revascularization
136 Apicoectomv
137 Aocendectomv
138 Aooendlcostomy
139 aooendlx
140 aooendix
141 Acolication of orthodontic aooliance
142 Arterial catheterizatlon
143 Arteriovenostomy for renal dialvsis
144 artery
145 artery
146 artificial
147 Artificial pneumothorax for collapse of luna
148 Artificial rupture of membranes
149 Aspiration and lavage of nasal sinus
150 Aspiration biopsy of ovarv
151 Aspiration biopsy of thyroid
152 Aspiration of fallopian tube
153 Aspiration of ovary
154 Aspiration of spermatocele
155 Aspiration of testis
156 aspiration of the thyroid field
157 Aspiration or lavaae of nasal sinus throuah natural ostium
158 atrium (heart)
159 auditory canal or meatus, external
160 Augmentation rhinoplastv
161 auricle
162 Autotransplantation of adrenal tissue
163 Autotransplantation of cells of Islets of Langerhans
164 Autotransplantation of parathyroid tissue
165 Autotransplantation of thyroid tissue
166 Auxiliarv liver transplant
167 auxiliary ventricle
168 axilla
169 baffle. atrial or interatrial
170 Bartholin's gland or cyst
171 Bilateral adrenalectomy
172 Bilateral exploration of adrenal field
173 Bilateral inauinal hernia repair with araft or prosthesis
174 Bilateral nephrectomv
175 Bilateral orchiectomy
176 Bilateral repair of direct inauinal hernia
177 Bilateral repair of direct inguinal hernia with graft or prosthesis
178 Bilateral repair of femoral hernia with araft or prosthesis
179 Bilateral repair of indirect inguinal hernia
180 Bilateral repair of indirect inguinal hernia with graft or prosthesis
181 Bilateral rer:,alr of inaulnal hernia. not otherwise soecified
182 Bilateral repair of inaulnal hernia. one direct and one indirect
183 Bilateral repair of inauinal hernia. one direct and one indirect
184 Bilateral salolnao-ooohorectomy
186 Biiaterai vulvectomv
186 bile duct
187 biliary fistulous tract into stomach or intestine
188 Biopsy of abdominal wall or umbilicus
189 Biopsy of alveolus
190 Biopsy of blood vessel
191 Biopsy of bony oalate
192 Biopsy of chest wall
193 Biopsy of coniunctiva
194 Biopsy of cul-de-sac
195 Biopsy of eyelid
196 Biopsy of aum
197 BIODSY of heart
198 Biopsy of lacrimal aland
199 Biopsy of lacrimal sac
200 Biopsy of Up
201 Biocsy of lymphatic structure
202 Biopsy of mouth
203 Biopsy of. penis
204 Biopsy of pericardium
206 Blocsv of cericrostatic tissue
206 Bloosv of oerirectal tissue
207 Biopsy of perirenal or periveslcal tissue
208 Biopsy of oeritoneum
209 Biopsy of periurethral tissue
210 Biopsy of pineal aland
211 Biopsy of pituitary aland. transfrontal aocroach
212 Biopsy of pituitary aland. transsphenoidal aocroach
213 Biopsy of pituitary aland. unspecified aooroach
214 Biopsy of skull
215 Biopsy of spermatic cord, epididymis, or vas deferens
216 Biopsy of thymus
217 Biopsy of urethra
218 Biopsy of uvula and soft palate
219 Biopsy of vulva
220 bipolar endoprosthesis (femoral head)
221 bladder sphincter.artificialCinflatable)
222 Blepharorrhaohy
223 Blood Transfusion
224 blood vessels to· myocardium
225 breast (for augmentation) (bilateral)
226 Breech extraction
227 Bronchial dilation
228 Buryina of fimbriae in uterine wall
229 Cannulation of pancreatic duct
230 Cannulation of thoracic duct
231 Canthorrhaphy
232 Canthotomy
233 cardiac suooort device (CSD)
234 cardiac support device (CSD)
235 cardiomyostimulation system
236 Cardiopleaia
237 Cardiotomy
238 cardioverter/defibrillator (automatic)
239 carpocerpal, carpometacarpal
240 Catheter based invasive electrophysiologic testing
241 Cauterization of hemorrhoids
242 Caval-pulmonary artery anastomosis
243 Cecectomy
244 Cervical esophagostomy
245 Cesarean section and removal of fetus
246 chemoterapi
247 chemothalamectomy
248 Cholecvstectomv
249 Choledochoenterostomy
250 Choledochoplasty
251 Circumcision
252 cistemal pucture
253 Cliooing of aneurysm
254 Closed [aspiration] [needle] (percutaneous] biopsy of pancreas
255 Closed [endoscopic biopsy of bronchus
256 Closed [endoscopicl biopsy of esoohacus-
257 Closed endoscopic biopsy of larynx
258 Closed endoscopic biopsy of small intes
259 Closed endoscopic biopsy of trachea
260 Closed [needle] biopsy of salivary aland or duct
261 Closed [needle] biopsy of tongue
262 Closed [percutaneous] [needle] biopsy of adrenal gland
263 Closed [percutaneousl [needle] biopsy of lung
264 Closed [percutaneous] [needle] biopsy of luna
265 Closed [percutaneous] (needle] blopsvof mediastinum
266 Closed [percutaneous] [needle] biopsy of prostate
267 Closed [percutaneous] [needle] biopsy of testis
268 Closed [percutaneous] biopsy of seminal vesicles
269 Closed transurethrall biopsy of bladder
270 Closed biopsy of uterine ligaments
271 Closed biopsy of uterus
272 Closed endoscopic biopsy of lung
273 Closed endoscopic biopsy of lung
274 Closed endoscopic biopsy of ureter
275 Closed heart valvotomy, aortic valve
276 Closed heart valvotorny, mitral valve
277 closed heart valvotornv, pulmonary valve
278 Closed heart valvotomy, tricusoid valve
279 Closed heart valvotomv, unspecified valve
280 closed percutaneous biopsy of brain
281 Closed percutaneous biopsy of ureter
282 closed precutneus biopsy of cerebral mennges
283 Closed reduction of nasal fracture
284 Closure of anal fistula
285 Closure of aooendiceal fistula
286 Closure of branchial cleft fistula
287 Closure of bronchial fistula
288 Closure of cholecvstostomv
289 Closure of cvstostomy
290 Closure of esophagostomv
291 Closure ·of external fistula of trachea
292 Closure of fistula of diaphragm
293 Closure of fistula of duodenum
294 Closure of fistula of larae intestine
295 Closure of fistula of larynx
296 Closure of fistula of mouth
297 Closure of fistula of small intestine
298 Closure of fistula of thoracic duct
299 Closure of fistula of uterus
300 Closure of aastrostomy
301 Closure of laceration of liver
302 Closure of laceration of lung
303 Closure of nasal fistula
304 Closure of nasal sinus fistula
305 Closure of neohrostomv and pyelostomv
306 Closure of other fistula of kidney
307 Closure of other fistula of pharynx
308 Closure of other fistula of thorax
309 Closure of other fistula of ureter
310 Closure of other fistula of urethra
311 Closure of other gastric fistula
312 Closure of other rectal fistula
313 Closure of eroctcstomv
314 Closure of stoma of large intestine
315 Closure of stoma of small intestine
316 Closure of thoracostomv
317 Closure of ureterostomv
318 Closure of urethrostomy
319 Colostomv
320 Combined right and left heart cardiac catheterization
321 Common duct exoloratlon for relief of other obstruction
322 Common duct exploration for removal of calculus
323 Complete alossectomy
324 Complete larvnaectomv
325 Complete oarathvroldectomy
326 Complete pneumonectomy
327 Complete removal of one lobe of thvroid (with removal of isthmus or
328 Complete substemal thyroidectomv
329 Complete thyroldectomy
330 Conization of cervix
331 Coniunctivocvstorhinostomy
332 Coniunctivorhlnostomv with insertion of tube or stent
333 Construction of penis
334 Continent ileostomy
335 control of (,ostoperative~ hemorrhage
336 Control of oostooeratlve , hemorrhaae of an
337 Control of oostooeratlve , hemorrhaae of bladder
338 Control of postoperative , hemorrhaae of prostate
339 Control of hemorrhaae after tonslllectomv and adenoidectomv
340 Control of hemorrhaae following vascular surgery
341 come a
342 Correction of cleft palate
343 Correction of everted punctum
344 Correction of eyelid ptosis NOS
345 Correction of lid retraction
346 Correction of ureterooelvlc Junction
347 Creation of conduit between atrium and oulmonarv arterv
348 Creation of conduit between left ventricle and aorta
349 Creation of conduit between riaht ventricle and pulmonarv arterv
350 Creation of oleuroperitoneal shunt
351 Creation of septal defect in heart
352 Cricopharvnaeal mvotomv
353 Crvosuralcal eollation of evelid
354 Culdocentesis
355 Culdotomv
356 custodis eve
357 Cystourethroolastv and Plastic rer:,alr of bladder neck
358 Dacrvocvstorhinostomy [OCR]
359 Decapsulation of kidney
360 Decortication of luna
361 Delayed openina of colostomv
362 Delayed opening of ileostomy
363 dental (endosseous) (prosthetic)
364 Destruction of hemorrhoids ev cryotherapy
365 Destruction of hemorrhoids bv cryotherapy
366 Destruction of lesion of cervix bv cauterization
367 Destruction of lesion of cervix by crvosuraerv
368 Destruction of lesion of conlunctiva
369 Destruction of lesion of eyelid
370 Destruction of ohrenic nerve for collapse of lung
371 Destruction of rectal lesion or tissue by crvosuraerv
372 Destruction of rectal lesion or tissue by laser
373 diaphragmatic pacemaker
374 Dilation and curettaae followina deliverv or abortion
375 Diiation and curettage for termination of preanancv
376 Dilation and curettaae of uterus
377 Dilation of bladder neck
378 Dilation of cervical canal
379 Diiation of esophagus
380 Dilation of fallopian tube
381 Dilation of pharynx
382 Dilation of pylorus by incision
383 Dilation of sphincter of Oddi
384 Dilation of ureteral meatus
385 Dilation of urethra
386 Distal pancreatectomy
387 Division of endometrial synechiae
388 Division of laryngeal nerve
389 Division of nerves to adrenal glands
390 Division of thyroid isthmus
391 Dorsal or lateral slit of prepuce
392 Double internal mammary-coronary artery bvoass
393 drainage by Incision (06.09)
394 Oralnaae of hematoma bv Incision
395 Dralnaae of pancreatJc cyst by catheter
396 Drainaae of thvroalossal tract bv incision
397 Duhamel resection of rectum
398 elbow (total)
399 Electrosuralcal eollatlon of evelld
400 Endarterectomy
401 Endocervical biopsy
402 Endometrlal ablation
403 endor:,rosthesls
404 Endoscopic control of gastric or duodenal bleedino
405 Endoscopic dilation of pylorus
408 endoscoDlc excision or destruction of lesion or tissue of
407 Endoscoolc excision or destruction of lesion or tissue of luna
408 Endoscopic excision or destruction of lesion or tissue of stomach
409 Endoscopic excision or destruction of lesion or tissue of urethra
410 Endoscopic Insertion of other bronchial device or substancesu
411 Endoscopic Insertion of stent (tube) Into eanereatlc duct
412 Endoscopic Insertion or reolacement of bronchial valve(s
413 Endoscopic insertion, reolacement and removal of therapeutic device or
414 Endoscopic removal of bronchial device(s) or substances
415 Endoscopic removal of stone(s) from pancreatic duct
416 Endoscopic retrograde pancreatography [ERP]
417 Endoscopic transmyocardlal revascularizatlon
418 EndoscoDY (avstosconvl llooooscoov)of ileal conduit
419 Endoscopy of small Intestine throuah artlflclal stoma
420 endosseous (dental)
421 Endovascular implantation of araft In abdominal aorta
422 Endovascular implantation of araft In thoracic aorta
423 Endovascular removal of obstruction from head and neck
424 Endovascular repair of vessel
425 Endovascular repair or occlusion of head and neck vessels
426 Enlaraement of existina atrial seotal defect
427 eploardlal SUDDOrt device
428 Eoididvmectomv
429 EPididvmotomv
430 Epidldymovasostomy
431 epidural pegs
432 Eoialottidectomv
433 epikeratoprosthesis
434 Episiotomy
435 ercutaneous insertion of other precerebral (extracranial) artery stent
436 Esoohaaectomv. not otherwise soecified
437 Esophagogastroplasty
438 Esophagoscopy through artificial stoma
439 Esoohaaostomv, not otherwise specified
440 estradiol (pellet)
441 Ethmoidotomy
442 Evacuation of thrombosed hemorrhoids
443 Excision Involving one-fourth or more of lid margin, full-thickness
444 Excision involvina one-fourth or more of lid marain, partial-thickness
445 Excision of ampulla of Vater (with reimplantation of common duct)
446 Excision of aneurvsm of heart
447 Excision of anus
448 Excision of axillary lymph node
449 Excision of branchlal cleft cvst or vestlae
450 Excision of chalazion
451 Excision of cyst of epidldvmls
452 Excision of cystic duct remnant
453 Excision of deep cervical lymph node
454 Excision of dental lesion of law
455 Excision of hemorrhoids
456 Excision of hvdrocele (of tunica vaginalls)
457 Excision of Inguinal lymph node
458 Excision of internal mammary lymph node
459 Excision of lacrimal gland. not otherwise specified
460 Excision of lacrimal sac and passage
461 Excision of lesion of adrenal gland
462 Excision of lesion of lacrimal aland
463 Excision of lesion of maxillary sinus with Caldwell-Luc approach
464 Excision of lesion of thyroid
465 Excision of lesion of tonsil and adenoid
466 Excision of lesion of tunlca vaainalis other than bvdrocele
467 Excision of lesion or tissue of conjunctiva
468 Excision of lesion or tissue of diaohraam
469 Excision of llngual thyroid
470 Excision of lingual tonsil
471 Excision of malor lesion of eyelid, full-thickness
472 Excision of other lesion or tissue of soermatic cord and epididvmis
473 Excision of other minor lesion of eyelid
474 Excision of perianal skin taas
475 Excision of neriorostetlc tissue
476 Excision of cerirectal tissue
477 Excision of perlurethral tissue
478 Excision of seminal vesicle
479 Excision of thvroalossal duct or tract
480 Excision of urachus
481 Excision of uvula
482 Excision of varicocele and hvdrocele of spermatlc cord
483 Excision of: verucca
484 Excision of:wart
485 Excision or destruction of leslon of chest wall
486 Excision or destruction of lesion of cul-de- sac
487 Excision or destruction of lesion of nose, not otherwise specified
488 Excision or destruction of lesion of vaalna
489 Excision or destruction of leslon or tissue of larynx
490 Excision or destruction of lesion or tissue of medlastinum
491 Excision or destruction of lesion or tissue of scrotum
492 Excision or destruction of lesion or tissue of uterus and supporting
493 Excision or destruction of other lesion or tissue of heart,
494 Excision or destruction of testicular lesion
495 Excision or other destruction of Bartholin's gland (cyst)
496 Excludes: aspiration biopsy of thyroid (06. 11}
497 Excludes: division of Isthmus (08.91)
498 Excludes: postoperative exploration
499 Exploration of adrenal field, not otherwise specified
500 Exploration of common duct
501 Exploration of pineal field
502 Exploratory laoarotcmv
503 Exploratory thoracotom
504 Exposure of tooth
505 Exteriorization of esophageal pouch
506 Exteriorization of larae intestine
507 Exteriorization of small intestine
508 Extracorooreal circulation auxiliary to open heart surgery
509 Extracorporeal hepatic assistance
510 Extracorporeal membrane oxygenation [ECMOl
511 Extracranial-intracranial (EC-IC) vascular bvoass
512 Extraction of deciduous tooth
513 extra peritoneal
514 extremity (bioelectric) (cineplastic) (kineolastic)
515 eye (Iowa type)
516 facial bone, synthetic (alloplastic)
517 fallopian tube (Mulligan hood) (silastic tube) (stent)
518 fascial sling
519 femoral (bli:,olar endoprosthesls)
522 femoral component only
525 femoral head (bipolar)
526 femoral head only and/or
527 femoral head only and/or acetabular liner
529 Fiber-optic bronchoscopy
530 finaer;
531 fistula
532 Fistulization of thoracic duct
533 Fitting of external prosthesis of penis
534 Fixation of large intestine to abdominal wall
535 Fixation of small intestine to abdominal w
536 for hallux valgus repair
537 Forceps aoolication to aftercoming head
538 Forceps rotation of fetal he
539 Formation of cutaneous uretero-ileostomy
540 Formation of other cutaneous ureterostomy
541 Freeing of vessel
542 Frontal sinusectomv
543 Frontal sinusotomv
544 Full-thickness skin araft to lio and mouth
545 I aastroeDioolic artery to coronary artery
546 Gastropexv
547 Ginaivoplasty
548 Gracilis muecle transolant for anal Incontinence
549 half-heart
550 hand (metacarpophalangeal) (interphalangeal)
661 hearina device. electromaanetic
552 heart
553 Heart revascularization by arterial implant
554 Heart transplantation
555 Hemilarvnaectomv
666 Hemithyroldectomy
657 Hemodialvsis
558 Hepatotomy
559 Heterotransolant of oancreas
560 Hlah forceos ooeratlon
561 Hiah aastric byp
562 Hiahlv selective vaaotomv
563 hie loartial) 81.52
564 Homotransplant of pancreas
565 Hymenectomy
566 Hymenorrhaphy
568 Hypothermia (systemic) incidental to open heart surgery
569 Hvsterotomv
570 ICCE (intracapsular cataract extraction)
571 lleocecostomy
572 lleocolectomv
573 lleocolostomv
574 lleocolotomv
575 lleocvstoolastv
576 lleoduodenotomv
577 lleoectomy (partial)
578 lleoesophaaostomv
579 lleoileostomv
580 lleopancreatostomy
581 lleopexy
582 lleoproctostomy
583 lleorectostomv
584 lleorrhaphy
585 lleoscopy
586 lleosigmoldostomy
587 lleostomv
588 lleostomy, not otherwise specified
589 lleotomy
590 I leotransversostomy
591 lleoureterostomy (Bricker's) (ileal bladder)
592 impantation or replacement of cardiac resynchronization defibriltion pulse generator device
only (CRT-0)
593 imoantation or replacement of cardiac resynchronization pacemaker pulse generator only (CRT-P)
594 Implant of external heart assist system
595 Implant of pulsation balloon
596 Implant, implantation
597 implantation cardiac resvnchronization pacemacker without mention of defibrilatlon. total
system (CRT-P)
598 Implantation of artificial urinary sphincter [AUS]
599 Implantation of automatic cardioverter/defibrlllator lead(s)
600 Implantation of automatic cardioverter/defibrillator pulse
601 implantation of cardiac resynchronization defibrilation, total system (CRT-D)
602 Implantation of cardiomyostimulation system
603 Implantation of diaphragmatic pacemaker
604 Implantation of electromagnetic hearina device
605 Implantation of electronic bladder stimulator
606 Implantation of electronic ureteral stimulator
607 Implantation of prosthetic cardiac suooort device around the heart
608 implantation of replacement of trans venous lead (electrode) Into left ventricular coronarv venous
system
609 Implantation of total replacement heart system
610 Implantation or replacement of cochlear prosthetic device.
611 Implantation or replacement of mechanical kidney
612 Implantation or replacement of prosthesis of fallopian tube
613 Implantation or revision of artificial anal sphincter
614 implntation or replacement of subcutaneous device for intracardiac hemodinamic monitoring
615 Incision (and dralnaae)
616 incision and drainage of cranial sinus
617 Incision and drainaoe of tonsil and peritonsillar structures
618 Incision of adrenal gland
619 Incision of anal seotum
620 Incision of Bartholin's aland (cvst)
621 Incision of bronchus
622 incision of cerebral meninaes
623 Incision of cervix to assist delivery
624 Incision of chest wall
625 Incision of cornea
626 Incision of duo
627 Incision of esophaaeal web
628 Incision of external ear
629 Incision of gum or alveolar bone
630 Incision of intestine
631 Incision of lacrlmal canallculi
632 Incision of lacrimal aland
633 Incision of lacrimal punctum
634 Incision of lacrimal sac
635 Incision of larae Intestine
636 Incision of lid margin
637 Incision of medlastinum
638 Incision of middle ear
639 Incision of other bile ducts for relief of obstruction
640 Incision of palate
641 Incision of perianal abscess
642 Incision of periprostatic tissue
643 Incision of Derlrectal tissue
644 Incision of perlurethral tissue
645 Incision of petrous pyramid air cells
646 Incision of pineal gland
647 Incision of prostate
648 Incision of seminal vesicle
649 Incision of spermatic cord
650 Incision of testis
651 Incision of thyroid field
652 Incision of uvula
653 Incision of vessel
654 Incision or excision of congenital septum of uterus
655 lncisional hernia repair
656 lncisional hernia repair with prosthesis
657 inert material
658 lnfundibulectomv
659 lnauinal hernlorrhaphy NOS
660 Injection into inner ear
661 Injection into prostate test link
662 Injection Into thoracic cavity
663 Injection of hemorrhoids
664 Injection of imolant into urethra and/or bladder neck
665 lnJectlon of locallv-actlna theraDeutlc substance Into trachea
666 tnlecnon of sclerosina aaent into vein
667 lniection of therapeutic substance into testis
668 Injection of tvmpanum
669 Insertion of catheter into canlal cavity or tissue
670 Insertion of choledochohepatlc tube for decompression
671 Insertion of drua-elutina coronary artery stent(s)
672 insertion of drua-elutina peripheral vessel stent
673 Insertion of fixed bridae
674 Insertion of gastric bubble (balloon}
675 Insertion of imolantable heart assist system
676 Insertion of indwelling urinary catheter
677 Insertion of lntercostal catheter for drainag
678 Insertion of intrauterine contraceotlve device
679 Insertion of non-drua-elutina coronary artery stent(s)
680 Insertion of non-implantable heart assist system
681 Insertion of percutaneous external heart assist device
682 Insertion of permanent tube into esoohaaus
683 Insertion of subcutaneous electrical anal stimulator
684 Insertion of temoorarv transvenous pacemaker system
685 Insertion of valve in vas deferens
686 Insertion of vessel-to-vessel cannula
687 insertion or replacement of Implantable pressure sensor (lead) for intracardiac hemodvnamic
monitorina
688 Insertion or replacement of inflatable oenile prosthesis
689 Insertion or reelaeement of non-Inflatable r:,enlle orosthesis
690 Insertion. replacement, removal. and revision of pacemaker device
691 Insertion, revision, replacement, and removal of leads: insertion of
692 lnsufflatlon of fallopian tube
693 lnsufflatlon of theraDeutlc agent Into fallopian tubes
694 interbodv spinal fusion device
695 Internal and combined version and extraction
696 Internal dralnaae of pancreatic cyst
697 lnterohalanaeal
698 Interposition operation
699 Interruption of the vena cava
700 Intestinal anastomosis,
701 into uterus
702 Intra-abdominal venous shunt
703 Intra-amniotic injection for abortion
704 intracardlac hemodvnamlc monitor. subcutaneous
705 lntracoronarv artery thrombolvtlc Infusion
706 lntraoperative cardiac pacemaker
707 lntraooerative manipulation of stomach
708 lntrathoracic esophageal anastomosis with interposition of colon
709 lntrathoraclc esoohaaeal anastomosis with lnteroositlon of small bowel
710 lntrathoracic esophagoesophagostomv
711 lntrathoracic esophagogastrostomv
712 Intrauterine transfusion
713 lntravascular lmaalna of blood vessel
714 Intubation of nasolacrimal duct
715 ischiorectal
716 lsthmectomv
717 joint (prosthesis) (silastic} (Swanson tvpe)
718 kidney, mechanical
719 knee (partial) (total)
720 Labial frenotomy
721 laparoscoplc
722 Laearosccctc ablation of liver lesion or tissue
723 Laoaroscooic ablation of renal lesion or tissu
724 Laparoscopic appendectomy
725 Laoaroscooic bioosv of ovarv
726 Laparoscopic cholecystectomy
727 Laoaroscopic aastric restrictive procedure
728 Laparoscopic gastroenter
729 Laparoscooic aastroplastv
730 Laearoscoolc incidental aooendectomy
731 Laparoscopic lysis of adhesions of ovary and fallopian tube
732 Laparoscopic lysis of perirenal or periureteral adhesions
733 Laparoscopic lysis of perivesical adhesions
734 Lacaroscopic marsupializatlon of ovarian cyst
735 Laoaroscoplc oophorotomy
736 taparoscoplc partial cholecystectomv
737 Laparoscopic procedures for creation of esochacccastric sphlncteric competence
738 Laparoscopic radical abdominal hysterectomy
739 Laparoscopic radical vaginal hysterectomy
740 Laparoscopic relmplantation of ovary
741 Laoaroscoplc removal of both ovaries at same operative episod
742 Laoaroscoolc removal of aastric restrictive device(s)
743 Laparoscopic removal of remaining ovary
744 Laparoscopic revision of gastric restrictive procedure
745 Laparoscopic salpingo-oophoroplasty
746 Laoaroscoplc simple suture of ovarv
741 Laoaroscoolc sur:,racervlcal hvsterectomv
748 Laparoscopic total abdominal hysterectomy
749 Laoaroscoelc unilateral oophorectomy
750 Laparoscopic unilateral salpinao-oophorectomv
751 Laparoscopic wedae resection of ovarv
752 Laparoscopically assisted vaginal hysterectomv
753 Lao-Band
754 Large-to-larae intestinal anastomosis
755 larynx
756 larynx
757 Left heart cardiac catheterization
758 Left hemicolectomy
759 Left lateral anal sphlncterotomv
760 leoentectropy
761 Levator muscle operation for urethrovesical suspension
762 Llaation and striooina of varicose veins
763 Llaatlon of bronchus
764 Ligation of esophageal varices
765 Liaation of aastric varices
766 Llaation of soermatlc cord
767 Ligation of thoracic duct
768 Ligation of thyroid vessels
769 Ligation of ureter
770 Ligation of vas deferens
771 Limited rhlnor:,lastv
772 Linear repair of laceration of eyelid or evebrow
773 Lingual frenectomv
774 Llnaual frenotomv
775 llp
776 Lobectomy of liver
777 Lobectomy of lung
778 lobotomy and tractotomy
779 Local excision of esoohaaeal dlverticulum
780 Local excision of lesion of prostate .
781 Local excision of other lesion or tissue of esoehaaus
782 Local excision of other lesion or tissue of stomach
783 Local excision or destruction of Intranasal lesion
784 Local excision or destruction of lesion of oenls
785 Local excision or destruction of lesion or tissue of bony palate
786 Local excision or destruction of lesion or tissue of bronchus
787 Local excision or destruction of lesion or tissue of trachea
788 Local perfusion of kidney
789 Local oerfusion of large intestine
790 Local perfusion of small intestine
791 Localized perfusion of liver
792 Low forceps operation
793 Low forceps operation with eolsiotomy
794 lower
795 Lower eyelid rhvtldectomv
796 Lung transplantation, not otherwise specified
797 Luna volume reduction suraerv
798 Lvsis of adhesions of conjunctiva and eyelid
799 Lysis of adhesions of nose
800 Lvsis of adhesions of soermatic cord
801 Lysis of adhesions of tongue
802 tvsts of adhesions of trachea or larvnx
803 Lysis of intraluminal adhesions of ureter
804 Lysls of lntraluminal adhesions of vaaina
805 Lysls of intraluminal adhesions with incision into bladder
806 Lvsis of pharvnaeal adhesions
807 Lvsis of vulvar adhesions
808 Magnetic removal of embedded foreign body from cornea
809 Male sterilization procedure.
810 mammarv to ventricular wall (Vineberg}
811 Manipulation of lacrimal passage
812 Manual rupture of ovarian cyst
813 Marsuplallzation of Bartholln's gland {cyst)
814 Marsupiallzation of cervical cvst
815 Marsupiallzation of kidney lesion
816 Marsuoialization of larvnaeal cvst
817 Marsuplallzatlon of lesion of liver
818 Marsuoialization of ovarian cyst
819 Marsupialization of pancreatic cyst
820 Marsuoiallzation of salivarv aland cyst
821 Mediastlnal tracheostomy
822 Mediastinoscopy
823 Medical induction of labor
824 metacarooohalanaeal
825 Mid forceos operation
826 mitral
827 mitral
828 multiele channel
829 Multiple segmental resection of large intestine
830 Multiple seamental resection of small intestine
831 muscle or aponeurosis
832 Myotomv of other carts of colon
833 Myotomy of sigmoid colon
834 Myrinaotomy with insertion of tube
835 neck by Incision
836 Nephrectomy of remaining kidney
837 Nephrocystanastomosls
838 Neohronexv
839 Neohrooexv
840 Neohrostomy
841 Nephrotomv
842 Nephroureterectomy
843 nose
844 Obliteration and total excision of vagina
845 Obliteration of lacrlmal cunctum
846 Obliteration of vaainal vault
847 omental
848 Open ablation of liver lesion or tissue
849 Open ablation of lung lesion or tissue I ·i
850 Open ablation of renal lesion or tissue
851 Open biopsy of adrenal gland
852 Open biopsy of bladder
853 open biopsy of brain
854 Open bloosy of bronchus
855 open biopsy of cerebral meninaes
866 Open biopsy of esophaa
857 Open biopsy of kldnev
858 Open biopsy of larynx or trachea
859 Open biopsy of lunQ
860 Open biopsy of luna
861 Open biopsy of pancreas
862 Open biopsy of prostate
863 Open biopsy of salivary gland or duct
864 Open biopsy of seminal vesicles
865 Open biopsy of small intestine
866 Open biopsy of testis
867 Open biopsy of teneue
868 Open biopsy of ureter
869 Ooen bioosv of uterine liaaments
870 Ooen biopsv of uterus
871 Ooen chest coronarv arterv anaioplasty
872 Open chest transmvocardial revascularization
873 Open excision or destruction of other lesion or tissue of bladder
874 Ooen heart valvuloolasty of aortic valve without replacement
875 Ooen heart valvuloplastv of mltral valve without replacement
876 Open heart valvuloplastv of pulmonary valve without replacement
877 Open heart valvuloolastv of tricusoid valve without replacement
878 Ooen heart valvuloolas~ without reelacement, uns12ecified valve
879 Open mediastinal biopsy
880 Ooen reduction of nasal fracture
881 Ooerations for sex transformation.
882 Ooeratlons on carotid bodv and other vascular bodies
883 Ooerations on chordae tendineae
884 Operations on clitoris
885 Operations on Eustachian tube
886 Operations on external ear
887 Ooeratlons on oaolllarv muscle
888 Ooerations on thvroid and parathvroid alands
889 Operations on trabeculae cameae cordis
890 Ooerations on valves and septa of heart
891 Ooeratlons on vessels of heart
892 Ooerative esoohaaoscopy by incision
893 opratlon of the endokrin svstem
894 ooration of the nervous system
895 Orbicularis ocull muscle slina for correction of blepharoptosis
896 orbit {eve socket)
897 Orchiopexv
898 other cardiovascular procedure
899 Other destructive procedures on coniunctiva
900 Other diaanostic orocedures on adrenal alands, pituitary gland,
901 Other diaanostic procedures on evelid
902 Other diaanostic procedures on lacrimal svstem
903 Other eoilatlon of evelld
904 Other eyelid repair
905 Other incision of evelid
906 Other incision of lacrimal eassaces
907 Other Incision of thvrold field
908 Other operations on parathyroid glands
909 Other operations on pineal gland
910 Other operations on thyroid glands
911 Other oarathvroldectomv
912 Other partial adrenalectomv
913 Other partial dacrvoadenectomv
914 Other oartial dacrvoadenectomv
915 Other reconstruction of evelld. full-thickness
916 Other reconstruction of eyelid, partial-thickness
917 Other repair of entroelon or ectroplon
918 Other reoair of laceration of eyelid, full-thickness
919 Other reoalr of laceration of evelld. partial-thickness
920 Other reoalr of ounctum
921 Other transmyocardial revascularization ®
922 Ovarian denervation
923 lcalidotomv
924 oallidoansectomv
925 oancreatlc duct
926 Pancreatic sohlncteroplastv
927 Pancreatic sohlncterotomv
928 Pancreatic transplant, not otherwise soecified
929 Paracervical uterine denervation
930 Parathvrold tissue reimolantation
931 Paraurethral susoension
932 oartial
933 oartial
934 Partial cvstectomv
935 Partial esochaaectomv
936 Partial excision of pineal Qland
937 Partial excision of Pituitarv aland. transfrontal aooroach
938 Partial excision of thvmus
939 Partial aastrectomv with anastomosis to duodenum
940 Partial gastrectomy with anastomosis to esophagus
941 Partial aastrectomv with anastomosis to ieiunum
942 Partial hepatectomv
943 Partial nephrectomv
944 Partial substemal thvroidectomv
945 Partial thvroidectomv NOS
946 Partial ureterectomv
947 Partial ventriculectomv
948 patellar component
950 ioelvic (female}
951 Pelvic evisceration
952 oercutaneous transluminal coronary angioplasti (PTCA} or coronary atherectomv
953 Percutaneous (endoscopic) lelunostomv
954 Percutaneous lendcsconlcl aastroieiunostomv
955 Percutaneous rendoscopicl aastrostomv
956 Percutaneous ablation of liver lesion or tissue
957 Percutaneous ablation of luna lesion or tlssue.:
958 Percutaneous ablation of renal leslon or tissue
959 Percutaneous anaioscopy
960 Percutaneous aspiration of Bartholin's oland (cvst)
961 Percutaneous aspiration of bladder
962 Percutaneous aspiration of aallbladder
963 Percutaneous aspiration of kidney (pelvis)
964 Percutaneous asoiration of liver
965 Percutaneous aspiration of prostate
966 Percutaneous aspiration of seminal vesicle
967 Percutaneous aspiration of tunica vaainalis
968 Percutaneous cardiooulmonarv bypass
969 Percutaneous cvstostomy
970 Percutaneous extraction of common duct stones
971 oercutaneous insertion of carotid artery stent
972 percutaneous insertion of intracranial vascular stent
973 Percutaneous nephrostomy with fragmentation
974 Percutaneous neohrostomv without fraamentation
975 Percutaneous or needle drainage of thyroid field
976 I oercutaneous transmvocardial revascularization
977 Percutaneous valvuloolastv
978 I oercutaneus analoolastv or atheerctom of lntracranlal vesel
979 I oercutaneus analoolastv or atherectomv of oaracerebral (extracranan vesel
980 oerianal
981 Pericardiectomv
982 Perlcardlotomv
983 I oeriaastric
984 Perinea! orostatectomv
986 Perinea! urethroscoov
986 I perlsplenlc
987 I peritoneal NEC
988 Permanent colostomy
989 Pharvnoeal diverticulectomy
990 Pharvnaectomv
991 Pharvnaotomv
992 I oineal aland, and thymus
993 I olacement of intracerebral catheter via burr holes
994 Pleural blODSV
995 Plication of emohvsematous bleb
996 Plication of the dlaohraam
997 Plication of urethroveslcal Junction
998 Pneumooerltoneum for collaose of luna
999 portion of other lobe)
1000 Posterior anal sohincterotomv
1001 Posterior resection of rectum
1002 costooeratlve asolratlon of field (06.02)
1003 Probina of lacrimal canalicull
1004 Problna of lacrlmal ounctum
1005 Probina of nasolacrimal duct
1006 Problna of salivarv duct
1007 Proctotomv
1008 Production of subcutaneous tunnel without esophageal anastomosis
1009 orosthetic cardiac sueoort device
1010 Proximal pancreatectomv
1011 Pubiotomy to assist delivery
1012 pulmonary
1014 Puncture of lung
1015 Puncture of nasal sinus for aspiration or lavage
1016 Pyelostomy
1017 Pvelotomy
1018 Pyloromyotomy
1019 Radical cystectomy
1020 Radical electrocoagulation of rectal lesion or tissue
1021 Radical excision of axillary lymph nodes
1022 Radical excision of iliac lymph nodes
1023 Radical excision of lvmph nodes
1024 Radical excision of other lymph nodes
1025 Radical alossectomy
1026 Radical aroin dissection
1027 Radical laryngectomy
1028 Radical mastoidectomy
1029 Radical maxlllarv antrotomy
1030 Radical neck dissection, bilateral
1031 Radical neck dissection. not otherwise specified
1032 Radical neck dissection, unilateral
1033 Radical prostatectomv
1034 Radical subtotal pancreatectomv
1035 Radical vulvectomy
1036 Reanastomosis of urethra
1037 Reattachment of amputated ear
1038 Reconstruction of conjunctiva! cul-de-sac with free araft
1039 Reconstruction of external auditory canal
1040 Reconstruction of eyelid involvina lid margin, full-thickness
1041 Reconstruction of evelld lnvolvlna lid maraln. oartlal·thickneas
1042 Reconstruction of eyelid with hair follicle graft
1043 Reconstruction of eyelid with mucous membrane flap or graft
1044 Reconstruction of evelid with skin flap or graft
1045 Reconstruction of eyelid with tarsoconjunctival flap
1046 Reconstruction of eyelid, not otherwise specified
1047 Reconstruction of penis
1048 Reconstruction of suraically divided vas deferens
1049 Reconstruction of trachea and construction of artificial larynx
1050 Reconstruction of urinarv bladder
1051 Rectorectostomy
1052 Reduction of anal
1053 Reduction of hemorrhoids
1054 Reduction of overcorrection of ntosls
1055 Reduction of torsion of renal oedlcle
1066 Re-entrv ooeratlon (aorta)
1067 Realonal lvmoh node excision
1058 Relmplantatlon of aberrant renal vessel
1059 Reimplantation of adrenal tissue
1060 Reimolantation of oancreatic tissue
1061 reinsertion
1062 Release of chordee
1063 Release of torsion of ovary
1064 Release of urethral stricture
1065 Removal of arteriovenous shunt for renal dialysis
1066 Removal of artificial anal sphincter
1067 removal of catheter from cranial cavitl or tissue
1068 Removal of electronic bladder stimulator
1089 Removal of electronic ureteral atlmulator
1070 Removal of embedded forelan bodv.from conjunctiva by incision
1071 Removal of foreign body by Incision
1072 Removal of foreian body from tonsil and adenoid by incision
1073 Removal of gastric bubble (balloon)
1074 Removal of heart assist system
1075 removal of hematoma
1076 removal of hematoma by aspiration
1077 Removal of Internal prosthesis of penis
1078 removal of lntrcranial neurostlmulatr lead
1079 Removal of lead(s) relectrode] without replacement
1080 Removal of lesion of evelld, not otherwise specified
1081 Removal of ligature from ureter
1082 Removal of liaature from vas deferens
1083 Removal of mechanical kidney
1084 Removal .of meibomian gland NOS
1085 Removal of prosthetic device from bile duct
1086 Removal of residual root
1087 Removal of transplanted or rejected kidney
1088 Removal of valve from vas deferens
1089 Renal autotransplantation
1090 Reopenina of recent laparotomy site
1091 Reopenina of recent thoracotomy site
1092 reooenina of wound of the thvroid field
1093 Reopening of wound of thyroid field for:
1094 Repair of aneurysm of coronarv vessel
1095 Repair of arteriovenous fistula
1096 Repair of atrial seDtal defect with prosthesis. closed techniaue
1097 Repair of atrial seotal defect with prosthesis, open techniQue
1098 Reoair of atrial seotal defect with tissue graft
1099 Repair of bladder exstroohv
1100 Repair of blepharoptosis by frontalis muscle techniQue with
1101 Repair of blepharoptosis by frontalis muscle techniaue with suture
1102 Repair of bfepharoptosis bv other revator muscle technfaues
1103 Repair of blepharoptosis by other techniaues
1104 Repair of bleoharootosis bv resection or advancement of levator
1105 Repair of bleoharoptosis bv tarsal techniaue
1106 Repair of blood vessel with synthetic patch araft
1107 Repair of blood vessel with tissue patch araft
1108 Repair of canaliculus
1109 Reeair of colovaginal fistula
1110 Reoair of current obstetric laceration of uterus
1111 Repair of cystocele
1112 Repair of cvstocele and rectocele
1113 Repair of diaphragmatic hernia with thoracic aooroach
1114 Repair of diaphragmatic hernia. abdominal aooroach
1115 Repair of direct inguinal hernia
1116 Repair of direct inauinal hernia with araft or prosthesis
1117 Repair of endocardial cushion defect with tissue araft
1118 Repair of entropion or ectropion by suture techniQue
1119 Repair of entroplon or ectrooion bv thermocauterization
1120 Repair of entroplon or ectrooion with lid reconstruction
1121 Repair of entrooion or ectropion with wedge resection
1122 ReDair of esoohaaeal fistula
1123 Repair of esophageal stricture
1124 Repair of fistula lnvolvina bladder and intestine
1125 Repair of fistula of cervix
1126 ReDalr of fistula of vulva or narfneum
1127 Repair of heart assist svstem
1128 Repair of hypospadfas or eoisoadias
1129 Repair of indirect Inguinal hernia
1130 Repair of indirect inguinal hernia with graft or prosthesis
1131 Repair of Inguinal hernia with graft or prosthesis
1132 Repair of laceration involvina lid margin, full-thickness
1133 Repair of laceration involving lid maraln. partial-thickness
1134 Reoair of laceration of coniunctiva
1135 Repair of laceration of aallbladder
1136 Reoair of larvnaeal fracture
1137 Repair of other fistula of bladder
1138 ReDafr of other hernia of anterior abdominal wall
1139 Repair of other hernia of anterior abdominal wall with Drostheals
1140 Repair of other vaainoenteric fistula
1141 Repair of parastemal hemfa
1142 Reoair of cactus deformltv
1143 Repair of oerlcolostomv hernia
1144 Repair of pleura
1145 Repair of prostate
1146 Reoair of rectocele
1147 Repair of rectovaalnal fistula
1148 Reoair of scrotal fistula
1149 Repair of spermatic cord and epldldymls
1150 Repair of symbleDharon with free araft
1151 Repair of tonaue and alossoolastv
1152 Repair of umbilical hernia with prosthesis
1153 Repair of unspecified septal defect of heart with prosthesis
1154 Repair of unsnecified seotal defect of heart with tissue graft
1155 Repair of ventricular seDtal defect with prosthesis, ooen
1156 Repair of ventricular seotal defect with tissue graft
1157 repenina of cranlotomv site
1158 Replacement of aortic valve with tissue graft
1159 Replacement of automatic cardioverter/defibrillator lead(s) onlv
1160 Replacement of automatic cardioverter/defibrillator pulse
1161 Replacement of electronic bladder stimulator
1162 Replacement of electronic ureteral stimulator
1163 Replacement of indwelling urinary catheter
1164 Replacement of mitral valve with tissue araft
1165 Replacement of nephrostomy tube
1166 Replacement of pulmonary valve with tissue graft
1167 RepJacement of ovelostomvtube
1168 Reclacement of transvenous atrial and/or ventricular lead(s)
1169 Replacement of tricuspid valve with tissue araft
1170 Replacement of unspecified heart valve
1171 Replacement of vessel-to-vessel cannula
1172 Replacement or reoair of other imolantable comoonent of total
1173 Replacement or repair of thoracic unit of totar replacement heart
1174 Repfantatfon of oenrs
1175 Resection of exteriorized seament of larae intestine
1176 Resection of exteriorized segment of small intestine
1177 Resection of nose
1178 Resection of transverse colon
1179 Resection of vessel with anastomosis
1180 Resection of vessel with reolacement
1181 Restoration of tooth by filllna
1182 Restoration of tooth by inlay
1183 retroperitoneal
1184 Retroperitoneal dissection
1185 Retropubic prostatectomy
1186 Retropubic urethral suspension
1194 revision (acetabufar and femoral components}
1195 revision NOS
1196 revision NOS
1197 revision NOS
1198 Revision of anastomosis of biliarv tract
1199 Revision of anastomosis of larae intestine
1200 Revision of anastomosis of small Intestine
1201 Revision of arteriovenous shunt for renal dialvsis
1202 Revision of cleft palate repair
1203 Revision of corrective Drocedure on heart
1204 Revision of cutaneous uretero-lleostomv
1205 Revision of fenestration of Inner ear
1206 Revision of aastric anastomosis
1207 revision of hiD reDfacement. acetabufar comoonent
1208 revision of hip replacement. acetabular llnler and /or femoral head only
1209 revision of hip replacement. both acetabular and femoral comonents
1210 revision of hip reclacement. femoral comoonent
1211 Revision of larvnaostomv
1212 Revision of mastoldectomv
1213 Revision of other cutaneous ureterostomv
1214 Revision of stacedectomv with lncus reolacement
1215 Revision of stoma of small Intestine
1216 Revision of tracheostomy
1217 Revision of tympanoplasty
1218 Revision of ureterointestinal anastomosis
1219 Revision or closure of veslcostomv
1220 Revision or relocation of oacemaker oocket
1221 Revision rhinoclasty
1222 Rlaht heart cardiac catheterization
1223 Right hemicolectomv
1224 Root canal therapy with lrrlaatlon
1225 Salpingo-oophorostomv
1226 Salpingo-salplngostomv
1227 Salcinaostomv
1228 Salpinaotomy
1229 Salpingo-uterostomv
1230 sciera
1231 scleral shell (cup) (with evisceration of eyeball)
1232 Segmental resection of lung
1233 seotum
1234 Severing of blepharorrhaphy
1235 shoulder (partial)
1236 Slaloadenectom
1237 Siamoidectomv
NO JENIS TINDAKAN
1238 Simple excision of other lvmphatic structure
1239 Simole mastoidectomv
1240 Simple suture of common bile duct
1241 Simole suture of falloolan tube
1242 sim:lle channel
1243 Sinale intemal mammarv-coronarv arterv bvoass
1244 Sinusectomv
1245 skin
1246 Small-to-small intestinal anastomosis
1247 Soave submucosal resection of rectum
1248 Sohenoidotomv
1249 Sohincterotomv of bladder
1250 splenotomv
1251 Staoedectomv with incus replacement
1252 Staoes mobilization
1253 subcutaneous tissue
1254 subdiaohraamatic
1255 subheoatic
1256 Submucous resection of nasal septum
1267 aubDhrenlc
1258 substances in bronchus or luna
1259 Substemal thvroidectomy
1260 Substemal thvroidectomv. not otherwise soecified
1261 Sucracublc crostatectomv
1262 Suoraoublc slina operation
1263 Suraical correction of prominent ear
1264 Suture of arterv
1265 Suture of duodenal ulcer site
1266 Suture of aastric ulcer site
1267 Suture of laceration of anus
1268 Suture of laceration of bladder
1269 Suture of laceration of bronchus
1270 Suture of laceration of cervix
1271 Suture of laceration of diaohragm
1272 Suture of laceration of duodenum
1273 Suture of laceration of esonhaaus
1274 Suture of laceration of kidney
1275 Suture of laceration of large intestine
1276 Suture of laceration of larvnx
1277 Suture of laceration of lie
1278 Suture of laceration of other part of mouth
1279 Suture of laceration of oalate
1280 Suture of laceration of cenis
1281 Suture of laceration of charvnx
1282 Suture of laceration of rectum
1283 Suture of laceration of sallvarv aland
1284 Suture of laceration of scrotum and tunica vaainalis
1285 Suture of laceration of small Intestine
1288 Suture of laceration of testis
1287 Suture of laceration of tonaue
1288 Suture of laceration of trachea
1289 Suture of laceration of ureter
1290 Suture of laceration of urethra
1291 Suture of laceration of uterus
1292 Suture of laceration of vaaina
1293 Suture of laceration of vas deferens and ecididvmis
1294 Suture of laceration of vulva or perineum
1295 Suture of Dentlc ulcer
1296 Suture of thvroid aland
1297 SuttJre of unaceclfied blood vessel
1298 Suture of vein
1299 Svmohvsiotomv for horseshoe kidnev
1300 Svstemic to oulmonary artery shunt
1301 TarsorrhaDhv
1302 Temoorarv colostomv
1303 Temoorarv Heostomv
1304 temoorarv cacemaker system: or revision of cardiac device DO
1305 Temaorarv tracheostomv
1306 Tenon's caosule lwlth enucleatlon of evebalO
1307 thalamotomv .
1308 Thoracentesis
1309 Thoracoolastv
1310 Thoracoscooic ablation of luna lesion or tissue1'
1311 Thvmectomv. not otherwise specified
1312 thvroid (field) bv incision
1313 Thvroidotomy NOS by incision
1314 tibial component
1316 tibial insert
1317 tibial insert
1318 tissue graft
1319 toe
1320 Tonsillectomy with adenoidectomv
1321 Tonsillectomy without adenoidectomy
1322 total
1323 total (acetabular and femoral comoonents)
1324 total Cacetabular and femoral components)
1325 total (all comoonents)
1326 Total bilateral salpfnaectomv
1327 Total body perfusion
1328 Total correction of transcosition of areat vessels
1329 Total dacrvoadenectomv
1330 Total esoohaaectomv
1331 Total excision of pineal aland
1332 Total excision of thvmus
1333 Total gastrectomy with intestinal interoosition
1334 Total hepatectomy
1335 Total nasal reconstruction
1336 Total pancreatectomv
1337 Total Dancreatectomy
1338 Total repair of tetralogy of Fallot
1339 Total reoafr of total anomalous oulmonarv venous connection
1340 Total reoair of truncus arteriosus
1341 total replacement system
1342 total replacement system
1343 Total splenectomy
1344 Total unilateral saloinaectomv
1345 Total ureterectomy
1346 Tracheoesoohaaeal fistullzation
1347 Transabdominal cerclaae of cervix
1348 Transabdominal endoscopy of small inte
1349 Transcatheter embollzation for gastric or duodenal bleeding
1350 Transection of thyroid isthmus
1351 Transfer of tarsoconJunctival flap from oooosina lid
1352 Transolant of intestine
1353 Transplantation of cells of Islets of Lanaerhans.
1354 Transplantation of ovarv
1355 Transpleural thoracoscopy
1356 Transsacral rectoslamoldectomv
1357 Transureteroureterostomv
1358 Transurethral (ultrasound) aulded laser Induced urostatectomv
1359 Transurethral balloon dilation of the prostatic urethra
1360 Transurethral clearance of bladder
1361 Transurethral destruction of prostate tissue bv microwave
1362 Transurethral lvsls of lntralumlnal adhesions
1363 Transurethral removal of obstruction from ureter and renal oelvls
1364 tricusoid
1366 Trocar cholecvstostomv
1367 Truncal vagotomv
1368 Turbinectomv by diathermy or crvosuraerv
1389 Tympanosvmoathectomv
1370 Tvoe II tympanoplastv
1371 Type IV tvmoanoplastv
1372 Tvoe V tvmoanoolastv
1373 unilateral
1375 Unilateral destruction or occlusion of faltoolan tube
1376 Unilateral exploration of adrenal field
1377 Unilateral orchiectomv
1378 Unilateral reoair of femoral hemia with graft or prosthesis
1379 Unilateral repair of inguinal hemla, not otherwise soeclfled
1380 Unilateral thyroid lobectomv
1381 Unilateral vulvectomy
1382 uooer
1383 Uooer evelld rhvtldectomv
1384 Ureteral meatotomv
1385 Ureterectomy
1386 Ureteroneocvstostomv
1387 Ureteropexy
1388 Ureterotomv
1389 urethra
1390 Urethral meatoolastv
1391 Urethral meatotomv
1392 Urethrotomv
1393 Urinary diversion to intestine
1394 uture of laceration of chest wall
1395 Vacuum extraction
1396 Vaqinal biopsy
1397 Vaqinal construction
1398 Vaqinal reconstruction
1399 Vaginal repair of chronic inversion of uterus
1400 Vaginal suspension and fixation
1401 valve(s) prosthesis or synthetic device loartial) lsvnthetic) (total)
1402 vas deferens
1403 Vasectomv
1404 Vasotomy
1405 Venous catheterization
1406 Venous catheterization for renal dialysis
1407 Venous cutdown
1408 ventricular support device 37.41
1409 ventriculopreitoneal trouqh previously implanted chateter
1410 Vesicostomy
1411 vocal cord(s)
1412 Vocal cordectomv
1413 WedQe resection of eyelid
1414 Wedoe resection of ovarv
1415 Wide excision of lesion of lip
1416 Wide excision or destruction of lesion or tissue of bonv palate
1417 with appendectomv

DIREKTUR UTAMA

Dr. Syamsul Bahri MS. Hi. Idris, Sp.OG.SH.M.M.Kes.

NIP : 19650210 199603 1 003