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daftar tindakan yang perlu informed concentTRANSCRIPT
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 w a j ib diberikan informed
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:
NOKSM/INSTALAS
I/UNITTINDAKAN
1 KSM BedahSaraf
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
1
18 Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
NO KSM/INSTALAS I/UNIT
TINDAKAN
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
2
NOKSM/INSTALAS
I/UNIT TINDAKAN
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
3
76 VP Shunt Satu Sisi
NOKSM/INSTALAS
I/UNIT TINDAKAN
2. KSM Bedah
Kepala Leher
1 Aff Arch Barr
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 lokal
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
18 kulit
19 Eksisi tumor ganas kulit dengan flap local jauh
20 Eksisi tumor ganas kulit tanpa rekontruksi
21 Eksisi tumor jinak dengan anastesi lokal
22 Ekskokleasi epulis
23 Ekskokleasi kista folikuler
24 Ekskokleasi kista radikuler
25 Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran<2cm
26 Ekstirpasi kista dermoid
27 Endoscopic thyroidectomy
28 Fiksasi interna fraktur maksilofasial 1-2 tempat patahan
4
NoKSM/INSTALASI
/UNIT TINDAKAN
29 Fiksasi interna fraktur nasal
30 Fiksasi interna pan-facial
31 Hemiglosektomi
32 Insisi abses dengan anastesi lokal
33 Insisi flegmon dasar mulut
34 Internal Fiksasi fraktur condylus mandibula
35 Internal Fiksasi fraktur maksilofasial 3-4 tempat
36 patahan
37 Internal fiksasi fraktur maksilofasial 5 tempat patahan
38 atau lebih
39 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
5
17 Ethmoidektomi (Intranasal)
18 Ekstraksi Korpus Alienum Kavum Nasi
NOKSM/INSTALASI/
UNIT TINDAKAN
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
6
48 Laringoskopi Rigid
NOKSM/INSTALASI/
UNIT TINDAKAN
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
68 Rekontruksi Fraktur Maksila Multiple
69 Rekontruksi Fraktur Maksila Sederhana
70 Rhinoplasti
71 Rinotomi Lateral+Maksilektomi Medial
72 Rekontruksi Laring Trakea
73 Reposisi Fraktur Os Nasal
74 Reposisi & Fiksasi Fraktur Mandibula
75 Septum Koreksi+Konkotomi
76 Stapedektomi
77 Skin Pricle Test
78 Tiroidektomi Sub-Total
79 Tonsilektomi/Adenoidektomi
80 Tracheostomi
81 Turbinektomi
82 Tiroidektomi Total+ND
83 Temporal Bone Resection
84 Terapi Wicara pada Anak-Anak dan dewasa
85 Terapi Wicara Tuna Laring
7
NOKSM/INSTALAS
I/UNITTINDAKAN
4 KSM Orthopedi
Dan
Traumatologi
1 Abdominopelvic amputation
2 Achillotenotomy
3 Adductor tenotomy of hip
4 Advancement of tendon
5 Advancement of tendon of hand
6 Amputation above knee
7Amputation and disarticulation of finger- general anaesthesia
8Amputation and disarticulation of finger -local anaesthesia
9Amputation 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
19 Amputation through hand, Amputation through carpals
20 Amputation through humerus, Upper arm amputation
21 Amputation, not otherwise specified
22 Ankle fusion
23 Application of external fixator device
24 Application of external fixator device, monoplanar system
25 Application of external fixator device, ring system
8
9
26 Application of hybrid external fixator device
27 Arthrocentesis
NOKSM/INSTALAS
I/UNIT TINDAKAN
28 Arthrodesis of elbow
29 Arthrodesis of hip
30 Arthrodesis of knee
31 Arthrodesis of other specified joints
32 Arthrodesis of shoulder
33 Arthrodesis of unspecified joint
34 Arthroplasty of carpocarpal or carpometacarpal joint with implant
35 Arthroplasty of carpocarpal or carpometacarpal joint without implant
36 Arthroplasty of metacarpophalangeal and interphalangeal joint with implant
37 Arthroplasty of metacarpophalangeal and interphalangeal joint without implant
38 Arthroscopy
39 Arthrotomy for removal of prosthesis without replacement
40 Aspiration of bursa
41 Aspiration of bursa of hand
42 Aspiration of other soft tissue
43 Aspiration of other soft tissue of hand
44 Atlas-axis spinal fusion
45 Biopsy of bone
46 Biopsy of joint structure
47 Biopsy of spinal cord or spinal meninges
48 Bone graft
49 Bone marrow or hematopoietic stem cell transplant(all procedures included in this class
50 Bunionectomy with soft tissue correction and arthrodesis
51 Bunionectomy with soft tissue correction and osteotomy of the first metatarsal
52 Bursectomy
10
53 Bursectomy of hand
54 Bursotomy
NO KSM/INSTALAS I/UNIT
TINDAKAN
55 Bursotomy of hand
56 Carporadial fusion
57 Closed reduction of dislocation -General anaesthesia
58 Closed reduction of dislocation of ankle
59 Closed reduction of dislocation of elbow
60 Closed reduction of dislocation of foot and toe- general anaesthesiaClosed reduction of dislocation of foot and toe-local61 anaesthesia
62 Closed reduction of dislocation of hand and finger- general anaesthesia
63 Closed reduction of dislocation of hand and finger- local anaesthesia
64 Closed reduction of dislocation of hip
65 Closed reduction of dislocation of knee
66 Closed reduction of dislocation of other specified sites-general anaesthesia
67 Closed reduction of dislocation of other specified sites-local anaesthesia
68 Closed reduction of dislocation of other specified sites-local anaesthesia
69 Closed reduction of dislocation of shoulder
70 Closed reduction of dislocation of wrist
71 Closed reduction of dislocation-Local anaesthesia
72 Closed reduction of fracture with internal fixation - Carpal and metacarpal
11
10
1111
73 Closed reduction of fracture with internal fixation - Femur (Including : MIPO, interlocking nail, TEN)
74 Closed reduction of fracture with internal fixation - Humerus (including : Interlocking nail, TEN, MIPO)
NO KSM/INSTALAS I/UNIT
TINDAKAN
75 Closed reduction of fracture with internal fixation - Intrarticular Major Bone
76 Closed reduction of fracture with internal fixation - Phalang of foot
77 Closed reduction of fracture with internal fixation - Phalang of hand
78 Closed reduction of fracture with internal fixation - Radius and ulna (MIPO, TEN)
79 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
89 Dorsal and dorsolumbar fusion of the anterior column, anterior technique
90 Dorsal and dorsolumbar fusion of the posterior column, posterior technique
91 Excision of bone for graft
92 Excision of intervertebral disc
93 Excision of lesion of muscle
94 Excision of lesion of muscle of hand
95 Excision of lesion of other soft tissue
96 Excision of lesion of tendon sheath
Excision of lesion of tendon sheath of hand,97 Ganglionectomy of tendon sheath (wrist)-General
anaesthesiaExcision of lesion of tendon sheath of hand,
98 Ganglionectomy of tendon sheath (wrist)-LocalAnaestesi
99 Excision of muscle or fascia for graft
100 Excision of muscle or fascia of hand for graft
101 Excision of other lesion of soft tissue of hand
NO KSM/INSTALAS I/UNIT
TINDAKAN
102 Excision of semilunar cartilage of knee
103 Excision of tendon for graft
104 Excision of tendon of hand for graft
105 Excision or correction of bunionette, That with osteotomy
106 Excision or destruction of intervertebral disc, unspecified
107 Exploration of tendon sheath
108 Exploration of tendon sheath of hand
109 Exploratory thoracotomy
110 Fasciotomy
111 Fasciotomy of hand
112 Finger reattachment
113 Five-in-one repair of knee
114 Foot reattachment
115 Forearm, wrist, or hand reattachment
116 Fusion or refusion of 2-3 vertebrae
117 Fusion or refusion of 4- 8 vertebrae
118 Fusion or refusion of 9 or more vertebrae
119 Graft of muscle or fascia
120 Hip bearing surface, ceramic-on-ceramic
121 Hip bearing surface, ceramic-on-polyethylene, Hip bearing surface, oxidized zirconium-on-polyethylene
122 Hip bearing surface, metal-on-metal
123 Hip bearing surface, metal-on-polyethylene
124 Implantation of internal limb lengthening device with kinetic distraction
125 Implantation of other internal limb lengthening device
126 Implantation or replacement of peripheral neurostimulator lead (s)
12
1313
127 Implantation or replacement of spinal neurostimulator lead(s)
128 Incision and drainage of palmar or thenar space
129 Injection of anesthetic into peripheral nerve for analgesia
NO KSM/INSTALASI/UNIT
TINDAKAN
130 Injection of anesthetic into spinal canal for analgesia
131 Injection of destructive agent into spinal canal
132 Injection of locally-acting therapeutic substance into other soft tissueInjection of other agent into spinal canal, Intrathecal
133 injection of steroid, Subarachnoid perfusion of refrigerated saline
134 Injection of therapeutic substance into bursa
135 Injection of therapeutic substance into bursa of hand
136 Injection of therapeutic substance into joint or ligament
137 Injection of therapeutic substance into tendon
138 Injection of therapeutic substance into tendon of hand
139 Insertion of bone growth stimulator
140 Insertion of bone void filler
Insertion of catheter into spinal canal for infusion oftherapeutic or palliative substances, Insertion of
141 catheter into epidural, subarachnoid, or subdural space of spine with intermittent or continuous infusion of drug (with creation of any reservoir)
142 Insertion of interbody spinal fusion device
143 Insertion of other spinal devices
144 Insertion of partial spinal disc prosthesis, cervical
145 Insertion of partial spinal disc prosthesis, lumbosacral
146 Insertion of recombinant bone morphogenetic protein
147 Insertion of spinal disc prosthesis, not otherwise specified, Replacement of spinal disc, NOS
148 Insertion of spinal disc prosthesis, thoracic
149 Insertion of sternal fixation device with rigid plates
150 Insertion of total spinal disc prosthesis, cervical
1414
152 Insertion of total spinal disc prosthesis, lumbosacral
153 Insertion or replacement of (cement) spacer
154 Insertion or replacement of facet replacement device(s)
NO KSM/INSTALAS I/UNIT
TINDAKAN
155Insertion or replacement of interspinous processdevice(s)
156Insertion or replacement of pedicle-based dynamicstabilization device(s)
157 Insertion or replacement of skeletal muscle stimulator
158Internal fixation of bone without fracture reduction
159Interphalangeal fusion
160 Interthoracoscapular amputation, Forequarter amputation
161 Intra-operative neurophysiologic monitoring -Neuromonitoring
162Intervertebral chemonucleolysis
163Limb lengthening procedures
164Limb shortening procedures
165Local excision of lesion or tissue of bone
166Lower leg or ankle reattachment
167Lower limb amputation, not otherwise specified
168 Lumbar and lumbosacral fusion of the anteriorcolumn, anterior technique
169 Lumbar and lumbosacral fusion of the anteriorcolumn, posterior technique
170 Lumbar and lumbosacral fusion of the posteriorcolumn, posterior technique
171Lysis of adhesions of hand
172 Lysis of adhesions of muscle, tendon, fascia, andbursa
173Lysis of adhesions of spinal cord and nerve roots
174Metacarpocarpal fusion
175Metacarpophalangeal fusion
176Metatarsophalangeal fusion
177Midtarsal fusion
178Muscle transfer or transplantation
1515
14
1616
179 Myotomy
180 Myotomy of hand
181 Neurectasis
NO KSM/INSTALASI/ UNIT
TINDAKAN
182 Open biopsy of cranial or peripheral nerve or ganglion
183 Open biopsy of soft tissue
184 Open reduction of dislocation of ankle - Neglected dislocation
185 Open reduction of dislocation of elbow -Fresh dislocation
186 Open reduction of dislocation of hand and finger -Fresh dislocation
187 Open reduction of dislocation of hip - Fresh dislocation
188 Open reduction of dislocation of hip - Neglected dislocation
189 Open reduction of dislocation of knee - Neglected dislocation
190 Open reduction of dislocation of knee -Fresh dislocation
191 Open reduction of dislocation of other specified sites
192 Open reduction of dislocation of shoulder -Fresh dislocation
193 Open reduction of dislocation of shoulder -Neglected dislocation
194 Open reduction of dislocation of unspecified site-Fresh dislocation
195 Open reduction of dislocation of unspecified site- Neglected dislocation
196 Open reduction of dislocation of wrist -Fresh dislocation
197 Open reduction of fracture with internal fixation- radius and ulna-Simple fracture
198 Open reduction of fracture with internal fixation- unspecified site (Periarticular Major Bone )Open reduction of fracture with internal fixation-carpals
199 and metacarpals - plate & screwsHand NOS -Plate & ScrewOpen reduction of fracture with internal fixation-carpals
200 and metacarpals - plate & screwsHand NOS -Plate & ScrewOpen reduction of fracture with internal fixation-carpals
201 and metacarpals - simple implants (K-wire) Hand NOS -implant sederhana (K-wire)
202 Open reduction of fracture with internal fixation-femur- Comminutive or Segmental
203 Open reduction of fracture with internal fixation-femur- Simple fracture
1717
NOKSM/INSTALAS
I/UNITTINDAKAN
204 Open reduction of fracture with internal fixation- humerus - Simple fracture
205 Open reduction of fracture with internal fixation- humerus - Comminutive or Segmental
206 Open reduction of fracture with internal fixation-other specified bone (Intraartikular Major Bone )
207 Open reduction of fracture with internal fixation-phalanges of foot - simple implants (K-wire)
208 Open reduction of fracture with internal fixation-phalanges of foot-Plate & Screws
209 Open reduction of fracture with internal fixation-phalanges of hand- Plate & Screws
210 Open reduction of fracture with internal fixation-phalanges of hand- simple implants
211 Open reduction of fracture with internal fixation-tarsals and metatarsals- Plate & Screws
212 Open reduction of fracture with internal fixation- tarsals and metatarsals- simple implants
213 Open reduction of fracture with internal fixation-tibiaand fibula -Simple fracture
214 Open reduction of fracture with internal fixation-tibiaand fibula-Comminutive or Segmental
215 Open reduction of fracture without internal fixation
216 Open reduction of separated epiphysis
217 Osteoclasis (correction of bone deformity)
218 Other
219 Other (peripheral) vascular shunt or bypass
220 Other amputation below knee
221 Other anastomosis of cranial or peripheral nerve
222 Other and unspecified repair of the anulus fibrosus
223 Other arthrotomy
224 Other bunionectomy
225 Other bunionectomy with soft tissue correction
226 Other cervical fusion of the anterior column, anteriortechnique
227 Other cervical fusion of the posterior column,posterior technique
1818
16
1919
228 Other change in hand muscle or tendon length
229 Other change in muscle or tendon length
230 Other destruction of intervertebral disc
NOKSM/INSTALAS
I/UNITTINDAKAN
231 Other diagnostic procedures on joint structures
Other diagnostic procedures on muscle, tendon, fascia, and232
bursa, including that of hand
233 Other division of bone
234 Other excision of joint
235 Other excision of soft tissue
236 Other excision of soft tissue of hand
237 Other excision or avulsion of cranial and peripheral nerves
238 Other excision, fusion and repair of toes
Other exploration and decompression of spinal canal,239
Decompression
240 Other fasciectomy
241 Other fasciectomy of hand
242 Other fusion of foot
243 Other hand muscle transfer or transplantation
244 Other hand muscle transposition
245 Other hand tendon transfer or transplantation
246 Other hand tendon transposition
247 Other incision of bone without division
248 Other incision of soft tissue
249 Other incision of soft tissue of hand
Other injection of locally-acting therapeutic substance into250
soft tissue of hand
251 Other local excision or destruction of lesion of joint
252 Other muscle transposition
253 Other myectomy
254 Other myectomy of hand
255 Other neuroplasty
256 Other operations on muscle, tendon, fascia, and bursa
257 Other operations on muscle, tendon, fascia, and bursa,
2020
Suture of bursa
Other partial ostectomy (including : Bone curretage,258
marginal resection/excision)
NO KSM/INSTALAS I/UNIT
TINDAKAN
259 Other peripheral nerve or ganglion decompression or lysis of adhesions Peripheral nerve neurolysis NOS
260 Other plastic operations on fascia261 Other plastic operations on hand262 Other plastic operations on muscle263 Other repair of ankle264 Other repair of elbow265 Other repair of hand, fingers and wrist266 Other repair of joint267 Other repair of knee268 Other repair of shoulder269 Other repair of the collateral ligaments270 Other repair of the cruciate ligaments271 Other repair or plastic operations on bone272 Other suture of flexor tendon of hand273 Other suture of muscle or fascia274 Other suture of other tendon of hand275 Other suture of tendon276 Other tendon transposition277 Other tenodesis of hand278 Other tenonectomy279 Other tenonectomy of hand280 Other tenoplasty of hand281 Other tenotomy282 Other total shoulder replacement283 Partial hip replacement284 Partial shoulder replacement285 Patellar stabilization286 Percutaneous denervation of facet287 Percutaneous vertebral augmentation288 Percutaneous vertebroplasty289 Peripheral nerve injection, not otherwise specified290 Plastic operation on hand with graft of muscle or fascia291 Plastic operation on hand with other graft or implant292 Pollicization operation carrying over nerves and blood
supply293 Quadricepsplasty294 Reattachment of muscle295 Reattachment of muscle of hand296 Reattachment of tendon297 Reattachment of tendon of hand
2121
18
2222
298 Refusion of atlas-axis spine299 Refusion of dorsal and dorsolumbar spine, anterior
column, anterior technique
NOKSM/INSTALAS
I/UNITTINDAKAN
300 Refusion of dorsal and dorsolumbar spine, posteriorcolumn, posterior technique
301 Refusion of lumbar and lumbosacral spine, anteriorcolumn, anterior technique
302 Refusion of lumbar and lumbosacral spine, anteriorcolumn, posterior technique
303 Refusion of lumbar and lumbosacral spine, posteriorcolumn, posterior technique
304 Refusion of other cervical spine, anterior column, anterior technique
305 Refusion of other cervical spine, posterior column,posterior technique
306 Refusion of spine, not elsewhere classified307 Refusion of spine, not otherwise specified308 Release of carpal tunnel309 Release of clubfoot, not elsewhere classified310 Release of tarsal tunnel311 Removal of (cement) spacer312 Removal of bone growth stimulator (invasive)313 Removal of foreign body from spinal canal314 Removal of implanted devices from bone - carpals
and metacarpals-Plate & screw315 Removal of implanted devices from bone - carpals
and metacarpals-simple implants (K-wire)316 Removal of implanted devices from bone - External
fixator device (invasive) (317 Removal of implanted devices from bone - femur318 Removal of implanted devices from bone - humerus319 Removal of implanted devices from bone - radius and
ulna320 Removal of implanted devices from bone - scapula,
clavicle, and thorax (ribs and sternum)321 Removal of implanted devices from bone -
unspecified site (Phalanges (of foot) (of hand)) - Plate& Screw
322 Removal of implanted devices from bone -unspecified site (Phalanges (of foot) (of hand)) - simple implants (K-wire)
323 Removal of implanted devices from bone -patella324 Removal of implanted devices from bone- tarsals and
metatarsals- simple implants (K-wire)325 Removal of implanted devices from bone- tibia and
fibula
2323
326 Removal of implanted devices from bone-other(Pelvic bone and Vertebraae)
NOKSM/INSTAL
ASI/UNITTINDAKAN
327 Removal of implanted devices from bone-tarsals and metatarsals - Plate & Screw
328 Removal of internal limb lengthening device329 Removal of pedicle screw(s) used in spinal fusion330 Removal of peripheral neurostimulator lead(s)331 Removal of skeletal muscle stimulator332 Removal of spinal neurostimulator lead(s)333 Reopening of laminectomy site334 Repair of claw toe335 Repair of cleft hand336 Repair of hammer toe337 Repair of hip, not elsewhere classified338 Repair of macrodactyly339 Repair of mallet finger340 Repair of old traumatic injury of cranial and peripheral
nerves341 Repair of recurrent dislocation of shoulder342 Repair of the anulus fibrosus with graft or prosthesis343 Repair of vertebral fracture, Elevation of spinal bone
fragments, Reduction of fracture of vertebrae, Removal of bony spicules from spinal canal
344 Replacement of joint of foot and toe345 Resurfacing hip, partial, acetabulum, Hip resurfacing
arthroplasty, partial, acetabulum346 Resurfacing hip, partial, femoral head347 Revision of total knee replacement, tibial insert (liner),
Replacement of tibial insert(liner)348 Revision or replacement of artificial spinal disc
prosthesis, cervical349 Revision or replacement of artificial spinal disc
prosthesis, lumbosacral350 Revision or replacement of artificial spinal disc
prosthesis, not otherwise specified351 Revision or replacement of artificial spinal disc
prosthesis, thoracic352 Rotator cuff repair353 Separation of equal conjoined twins354 Separation of unequal conjoined twins355 Sequestrectomy356 Spinal fusion, not otherwise specified357 Subtalar fusion
358 Subtalar joint arthroereisis
2424
20
359 Suture of Artery
360 Suture of capsule or ligament of ankle and foot
NOKSM/INSTALASI
/UNITTINDAKAN
361 Suture of capsule or ligament of other lower
extremity
362 Suture of capsule or ligament of upper extremity
363 Suture of cranial and peripheral nerves
364 Suture of muscle or fascia of hand
365 Suture of tendon sheath
366 Suture of tendon sheath of hand
367 Suture of Vein
368 Synovectomy
369 Tarsometatarsal fusion
370 Tendon graft
371 Tendon pulley reconstruction
372 Tendon pulley reconstruction
373 Tendon transfer or transplantation
374 Tenotomy of hand
375 Thigh reattachment
376 Thumb reattachment
378 Toe reattachment
379 Total ankle replacement
380 Total elbow replacement
381 Total ostectomy
382 Total wrist replacement
383 Transplant from cadaver
384 Transposition of cranial and peripheral nerves -
Nerve transplantation
389 Triad knee repair
390 Triple arthrodesis
391 Unspecified operation on bone injury
392 Upper arm reattachment393 Upper limb amputation, not otherwise specified394 Wedge osteotomy
21
NOKSM/INSTALASI
/UNITTINDAKAN
5 KSM BEDAH
THORAKS
DAN
KARDIOVASKULAR
1 Biopsi Terbuka Bronkhus2 Biopsi Terbuka Diafragma3 Biopsi Terbuka Mediastinum4 Biopsi Terbuka Paru5 Biopsi Terbuka Pleura6 Biopsi Terbuka Pleura dengan VATS7 Biopsi Terbuka Tumor Dinding Thoraks8 Debridement Mediastinum (Sternotomi)9 Eksisi Pada Bronkhus
10 Eksisi Pada Paru (Lung Volume Reduction)11 Eksisi Pada Paru dengan VATS
12 Eksisi Tumor Dinding Dada dengan Rekonstruksi DindingDada
13 Eksisi Tumor Mediastinum (Thymoma, Teratoma, Neurogenic dsb)
14 Ekstraksi Corpus Alienum di Regio Toraks15 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) denganVATS
21 Lumbal Simpatektomi22 Mediastinostomy
23 Pemasangan thorak drain/water sealed drainage (WSD) (diluar alat)
24 Pleural window (Eloeser Flap)25 Pleurektomi26 Pleurodesis (Pleurosklerosis)27 Plikase Bulae / Bleb Emfisematous28 Plikasi diafragma29 Pneumonectomy30 Pneumonectomy dengan VATS31 Pulmonary Decortication32 Pulmonary Decortication dengan VATS33 Pulmonary Lobectomy/Bilobectomy34 Pulmonary Lobectomy/Bilobectomy dengan VATS35 Redo Torakotomi36 Rekonstruksi Sternum&Dinding Dada37 repair deformitas Pectus
22
38 Repair Fistula Bronkopleural39 Repair Laserasi Diafragma
NOKSM/INSTALASI
/UNIT
TINDAKAN
40 Revisi Thoraks drain/water sealed drainage (WSD) (diluar alat)
41 Thoracal Symphatectomy dengan Video AssisstedThoracoscopic Surgery (VATS)
42 Thoracocentesis43 Thymectomy44 Thymectomy dengan VATS45 Torakoplasti (Air Plumbage/Muscle Plumbage)46 Torakotomi / sternotomi Eksplorasi
47 Torakotomi Eksplorasi pada Trauma jantung/RepairLaserasi Jantung
48 Bedah Kardio (Jantung)49 Aortic Valve Repair (AVR)50 Aortic Valve Repair (AVR) dengan Bioprosthesis Valve51 Aortic Valve Repair (AVR) dengan Mechanical Valve52 Atrial septal Defect (ASD) Closure53 Bidirectional Cavo-Pulmonary Shunt (BCPS)54 Biopsi Jantung55 Biopsi Perikardium56 Blalock-Taussing Shunt (BT Shunt)57 Coronary Artery Bypass Graft (CABG)58 Eksisi Cardiac Myxoma59 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 MechanicalValve
65 Operasi Redo Open Heart (Valve Replacement)
66 Operasi Reopen oleh Karena sebab Perdarahan, Tamponade Jantung
67 Pemasangan IABP68 Pemasangan Pace Maker Permanen (diluar alat)69 Pericardiocentesis70 Perikardiektomi71 Perikardiotomi/Pericardial Window72 Pulmonal Valve Repair (PVR)
73 Pulmonal Valve Repair (PVR) dengan BioprosthesisValve
74 Pulmonal Valve Repair (PVR) dengan Mechanical Valve75 Pulmonary Artery Banding (PA)
23
NOKSM/INSTALASI/
UNIT TINDAKAN
76 Rastelli Procedure (right Ventricle-Pulonary ArteryConduit)
77 Repair (Eksisi) Aneurisma Jantung78 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)84 Septostomi Terbuka Septum Atrium (35.41)85 Total Koreksi Tetralogy of Fallot (TOF) (35.81)86 Tricuspid Valve Repair (TVR) (35.14)
87 Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve(35.27)
88 Tricuspid Valve Repair (TVR) dengan Mechanical Valve(35.28)
89 Ventricle Septal Defect (VSD) Closure (35.5)90 Amputasi Above Knee (AK) (84.17)91 Amputasi Below Knee (BK) (84.14)92 Arterial Pungsi, Kanulasi, Sectie (38.91)93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42)94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27)95 Bedah Varises Insisi Babcock (38.5)96 Biopsi Pembuluh Darah (Perifer) (38.21)97 Debriment-Nekrotomi Luka Gangren (86.22)98 Disartikulasi Sendi Ekstremitas (84.13)
6 Eksisi BiopsiTumor
Pembuluh Darah
1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)
2 Eksplorasi Vaskular (Trauma/Non trauma)
3 Embolektomi/Trombektomi Aorta4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal
5 Embolektomi/Trombektomi Pembuluh Darah ArteriEkstremitas Bawah
6 Embolektomi/Trombektomi Pembuluh Darah EkstremitasAtas (diluar alat)
7 Embolektomi/Trombektomi Pembuluh Darah EkstremitasBawah(diluar alat)
8 Embolektomi/Trombektomi Pembuluh Darah Regio servikal(Karotis, Jugular) (diluar alat)
9Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/ Traumatik)
10 Fasciotomy11 Ligasi Vaskular Ekstremitas
24
12 Mutilasi Digiti Ekstermitas
NOKSM/INSTALASI
/UNITTINDAKAN
13 Pasang Double Lumen Hemodialisis (HD) (diluar alat)
14 Pasang Implantable Central Venous Access (diluar alat: porth-a-cath, celsite)
15 Pemasangan Central Venous Catheter (CVC) (diluar alat)
16 Pemasangan Intra Aortic Baloon Pump (IABP) (diluar alat)
17 Pemasangan Peritoneal Dyalisis (PD) Catheter(diluar alat)
18 Pembedahan Teleangiectasis
19 Repair Aneurisma (True/false) Ekstremitas Superior(diluar graft)
20 Repair Aneurisma Aorta Abdominalis (DiluarProtesa)
21 Repair Pembuluh Darah Regio Servikal (Karotis, Jugular)
22 Repair Ruptur Pembuluh Arteri Abdominal23 Revisi Arteriovenous Shunt24 Skleroterapi Vena (Varises, Hemangioma)25 Stripping Varises Ekstremitas Inferior
26 Vascular Shunting (Splenorenal Shunt, De PalmaShunt)
27 Vena Punctie, Kanulasi, Sectie7 KSM BEDAH
DIGESTIVE
1 Abdominal pull through (sfingter saving procedure)
2Abdominoperineal resection (miles) dengan penyulit mayor
3Abdominoperineal resection (miles) dengan penyulit minor
4 Abdominoperineal resection (miles) tanpa penyulit5 Abdominoplasty6 Apendektomi7 Apendektomi dgn penyulit major8 Apendektomi dgn penyulit minor9 Apendektomi laparoskopik
10 Bilio-difgestif anastomosis tanpa penyulit11 Biliodigestif dengan penyulit mayor12 Biliodigestif dengan penyulit minor13 Biopsi insisional, local anastesi14 Biopsi rectum15 Eksisi hemoroid eksterna16 Eksplorasi duktus bilier & cholangiografi intra operatif17 Esofagotomi18 Fistulotomi
25
NOKSM/INSTALASI
/UNITTINDAKAN
19 Fistulotomi dgn penyulit mayor20 Fistulotomi dgn penyulit minor21 Gastrostomi22 Hemikolektomi dengan penyulit mayor23 Hemikolektomi dengan penyulit minor24 Hemikolektomi tanpa penyulit25 Hemoroid stapling (diluar alat)26 Hemoroidektomi27 Herniotomi28 Herniotomi dgn penyulit mayor29 Herniotomi dgn penyulit minor30 Herniotomi laparoskopik31 Jejunostomi / ileostomi32 Laparotomi dengan penyulit minor33 Laparotomi tanpa penyulit34 Ligasi hemoroid (diluar alat)
35 Pankreatiko-duodenektomi cephalis (Whipple)dengan penyulit mayor
36 Peritoneal dreanse (CAPD)37 Peritoneal lavase38 Polipektomi39 Potong kolostomi40 Prosedur Heller41 Rektopexy42 Repair fistel usus43 Repair fistel vesicorectal44 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 mayor49 Reseksi anterior dengan penyulit minor50 Reseksi anterior tanpa penyulit51 Reseksi esofagus-colon / ileum transposisi52 Reseksi esofagus-end to end53 Reseksi esofagus-esofago-gastrectomy54 Reseksi hati55 Second look laparoscopy56 Splenektomi / splenoraphy traumatika57 Splenektomi non trauma58 Terminal esofagus proksimal gastrektomi (TEPG)
26
59 Total gastrektomi
NOKSM/INSTALASI
/UNITTINDAKAN
60 Total pantreaktomi61 Total prokto-kolektomi62 Tutup burst abdomen (tanpa alat)63 Tutup burst abdomen dengan penyulit mayor64 Tutup burst abdomen dengan penyulit minor65 Tutup kolostomi / ileostomi66 Tutup kolostomi / ileostomi dengan penyulit mayor67 Tutup kolostomi / ileostomi dengan penyulit minor68 Repair Aorta Torakalis (38.34)69 Repair Atrioventricular Septal Defect (35.54)
8 KSM BEDAHUROLOGI
1 Adrenalektomi2 Adrenalektomi (Abdominotorakal)3 Anastomosis end to end Ureter4 Augmentasi Buli5 Biopsi Ginjal perkutan6 Biopsi Ginjal Terbuka7 Biopsi Penis8 Biopsi Prostat9 Biopsi Testis
10 Bladder Neck Rekonstruksi11 Buried Penis12 Businasi/Dilatasi Uretra13 Cabut DJ Stent14 Defooring Kista Ginjal per Laparoskopi15 Deroofing/Unroofing Kista16 Diseksi Kelenjar Getah Bening Inguinal17 Diseksi Kelenjar Getah Bening pelvis
18 Diseksi Kelenjar Getah Bening Pelvis perLaparoskopi
19 Divertikulektomi Buli20 Divertikulum Uretra21 Dorsumsisi22 Drainase Periureter23 Eksisi Chordae/Chordektomi24 Eksisi Fibroma/Rekonstruksi Penis25 Eksisi Plaque (Peyronie Disease)26 Eksisi Webbed Penis27 Eksplorasi testis (Microsurgery)28 Ekstraksi Batu29 Ekstrofi Buli Rekonstruksi30 Epispadia31 Evakuasi Bekuan Darah (Clot)32 Extended Pyelolithotomy
27
33 Fistulektomi/Repair Fistel Uretra
NOKSM/INSTALASI
/UNITTINDAKAN
34 Funikokelektomi35 Ganti Nefrostomy36 Hidrokel per Inguinal/Ligasi Tinggi37 Hidrokel per Skrotal38 Hipospadia Subkoronal39 Holmium YaG Laser (Sewa)40 Ileal Conduit (Bricker)41 Insersi DJ Stent42 Insisi Abses Perineum43 Insisi Abses Skrotum44 Insisi Posterior Urethral Valve45 Johanson46 Johanson I47 Johanson II48 Kalibrasi Uretra49 Kauterisasi50 Koreksi Horseshoe Kidney51 Koreksi Priapismus52 Laparoskopi Adrenalektomi53 Laparotomi Eksplorasi54 Ligasi V.Spermatika Interna (Microsurgery)55 Limfadenektomi Ilioinguinal56 Limfadenektomi Retroperitoneal/RPLND57 Litholapaksi58 Lithotripsi59 Masase Prostat60 Meatoplasti61 Meatotomi62 MMK/Sling Uretra63 Nefrektomi64 Nefrektomi Donor Transplant65 Nefrektomi Parsial66 Nefrektomi per Laparoskopi67 Nefrektomi Radial68 Nefropeksi/Renopeksi69 Nefrostomi Perkutan/Temporer70 Nefrostomi Terbuka/Permanen71 Nefroureterektomi72 Neobladder73 Operasi Priapismus (prosedur Winter)74 Operasi Repair Buli Trauma75 Operasi Sistokel
28
NOKSM/INSTALASI
/UNITTINDAKAN
76 Operasi Trauma Ginjal77 Operasi Urakhus/Reseksi urakhus78 Orkhidektomi79 Orkhidektomi extended80 Orkhidektomi Ligasi Tinggi81 Orkhidektomi Subkapsuler82 Orkhidopeksi (Torsio Testis)83 Orkhidopeksi (UDT)84 Orkhidopeksi per Laparoskopi85 Pasang Kateter86 Pasang Kateter dengan Mandrain87 Pasang Kateter Tenckhoff untuk CAPD88 PCNL/PNL89 Penektomi Parsial90 Penektomi Total/Amputasi Penis91 PER (Primary Endoscopic Realignment)92 Pielokalikotomi93 Pielolitotomi94 Pieloplasti95 Pieloplasti per Laparoskopi96 Prostatektomi Radikal97 Prostatektomi Retropubik98 Prostatektomi Terbuka99 Prostatektomi Terbuka dan Sectio Alta
100 Psoas Hitch/Boari Flap101 Punksi dan sklerosing Kista Ginjal102 Railroading Rupture Uretra103 Reimplantasi Ureter Bilateral
104 Reimplantasi UreterUnilateral/Ureteroneosistostomi
105 Rekontruksi Renovaskuler106 Repair Fistel Enterovesika107 Repair Fistel Vesikokutan108 Repair Fistel Vesikorektal109 Repair Fistel Vesikovagina110 Repair Fistel Vesikovagina Kompleks111 Reparasi Penis112 Reseksi-anastomosis Uretra113 RPG114 Sectio Alta/Vesikolithotomi115 Sirkumsisi115 Sistektomi Parsial/Sistoplasti Reduksi116 Sistektomi Per Laparoskopi117 Sistektomi Total/Radikal
29
4242
118 Sistoskopi119 Sistoskopi ODS
NOKSM/INSTALASI
/UNITTINDAKAN
120 Sistostomi perkutan121 Sistostomi Terbuka122 Skrotoplasti123 Spermatokelektomi124 Tailoring Ureter125 Transplan Resipien126 Transuretero-ureterostomi127 TUR Prostat/TUIP/BNI128 TUR Tumor Buli129 TVP/TMP130 Ureterokutaneostomi131 Ureterolisis132 Ureterolithotomi133 Ureterolithotomi Distal134 Ureterolithotomi Proksimal135 Ureterosigmoidostomi (Caffey)136 Ureterostomi137 Ureterouretostomi138 Uretroplasti Hipospadia139 Uretroskopi/Uretrosistoskopi140 Uretrotomi Interna (Sachse)141 URS/Lithotripsi142 Varikokelektomi (Palomo)143 Vasektomi (anestesi lokal)144 Vasektomi (narkose)145 Vasoepididimostomi146 Vasografi147 Vasovasostomi
9 KSM ILMUKESEHATAN
MATA
1 Angkat Jahitan2 Angkat Jahitan dengan GA3 Anterior Chamber Tap/Parasintesis4 Aspirasi Massa Lensa5 Blefaroplasty (2 Kelopak Mata)6 Claw Lens7 Cryopexy Kornea8 Cyclo Cryo9 Dacryocystorinostomi (Without Silicon Tube)10 Dekompresi Orbital/Lateral Orbitotomi11 Disisi Aspirasi & IOL12 ECCE13 ECCE & IOL14 Eksenterasi15 Eksisi Hordeolum / Chalazion
4343
30
4444
16 Ekstirpasi Corpus Alienum di Kornea17 Ekstirpasi Pterygium + Graft Konjungtiva
NOKSM/INSTALASI
/UNITTINDAKAN
18 Ekstripasi Corpus Alienum di Bilik Mata Depan19 Enukleasi/Eviscerasi (DFG/Bonegraft)20 Evakuasi Silikon Oil21 Fornix Repair22 ICCE23 ICCE & IOL24 Injeksi Intra Vitreal25 Injeksi Periokuler Terapetik26 IOL Explant27 Iridectomi28 Jahit Kelopak Mata Full Thickness & Lid Margin29 Jahit Kornea30 Keratoplasti (Corneal Transplantation)31 Konjungtival Flap/Amnion Graft32 Piggy Back IOL33 Pneumoretinopexy34 Repair Canalis Lacrimalis (Without Silicon Tube)35 Repair Coloboma Palpebra (Skin/Mucosal Graft)36 Reposisi IOL37 Reposisi Iris38 Resesi & Reseksi 2 Otot39 Resesi & Reseksi 3 Otot40 Resesi & Reseksi 4 Otot41 Resesi/Reseksi 1 Otot42 Sekunder Implant (Posterior Chamber)43 Sekunder Implant Claw Lens / Fiksasi Sulcus44 SICS45 SICS & IOL46 Simpel Vitrektomi47 Skleral Buckle48 Socket Repair (Contracted Socket)49 Trabekulektomi50 Trabekuletomi & Ollogen
51 Trabulektomi & Goniotomi pada PediatricGlaucoma
52 Tube Shunt (Express)53 Viscocanulostomy54 Vitrektomi +++55 Vitrektomi Lengkap & Skleral Buckle56 Wide Eksisi Tumor Kelopak Mata57 Wide Eksisi Tumor Kelopak Mata + Flap + graft
4545
NOKSM/INSTALASI
/UNITTINDAKAN
10 Divisi Onkologi 1 Aspirasi Kista Mamma Single dan Multiple2 Biopsi Core Lokal Anestesi3 Biopsi Eksisi Lokal4 Biopsi Eksisi Narkose5 Biopsi Insisi Lokal6 Biopsi Narkose7 Breast Conserving Surgery (BCS)8 Breast Conserving Surgery + LD Flap9 Debriment Mamma
10 Diseksi Axilla11 Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi12 Eksisi Fibroadenoma Multiple Narkose13 Eksisi Tumor Metastase Loco-regional14 Eksplorasi Duktus Mama15 Eksplorasi Duktus Mama+VC16 Insisi Absces Mastitis Lokal17 LD Flap + Eksisi Tumor18 Mastectomy + Tram Flap19 Modified Radical Mastectomy + Flap/Single Grafting20 Modified Radical Mastectomy Single21 Quadrantectomy / Partial Mastectomy22 Simple Mastektomy + Flap/Skin Grafting23 Simple Mastektomy Single24 Tram Flap + Eksisi Tumor25 Operasi Tumor Kulit26 Biopsi Insisi Tumor Kulit Lokal27 Biopsi Eksisi Tumor Kulit Narcose28 Eksisi Tumor Jinak ≤ 3cm29 Eksisi Tumor Jinak + Flap/Skin Graft30 Eksisi Tumor Jinak Kulit >3cm31 Wide Eksisi + Diseksi KGB32 Wide Eksisi Tumor Ganas Kulit33 Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft34 Operasi Soft Tissue Tumor35 Amputasi + Diseksi KGB36 Amputasi Jari + Flap / Skin Graft37 Amputasi Tungkai / Lengan38 Biopsi Core soft Tissue39 Biopsi Insisi Tumor Sof Tissue dengan Narcose40 Biopsi Insisi Tumor Soft Tissue Lokal Anestesi41 Eksisi Tumor Jinak > 3cm42 Eksisi Tumor Jinak Ø<3cm43 Wide Eksisi + Compartement Procedure44 Wide Eksisi + Diseksi KGB
4646
32
4747
45 Wide Eksisi Tumor Ganas46 Wide Eksisi Tumor Jinak + Flap/Skin Graft
NOKSM/INSTALASI
/UNITTINDAKAN
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
63 Modifikasi RND
64 Operasi Compartement Otot
65 Ovariectomy Bilateral
66 Reseksi Mandibula
67 Rotation Flap
68 Skin Grafting
69 Sub Total Thyroidectomy
70 Superficial Parotidectomy
71 Thoraco Abdominal Flap (TA-Flap)
72 Total Parotidectomy
73 Total Thyyroidectomy
74 Transversus-Rectus Abdominis Flap (Tram Flap)
4848
NOKSM/INSTALASI
/UNITTINDAKAN
11 DIVISI BEDAH
ANAK
1 Abdominal pull through (sfingter saving procedure)
2 Adhesiolisis
3 Appendektomi dgn penyulit
4 Appendektomi laparoskopik
5 Appendektomi tanpa penyulit
6 Biliodigesif dengan penyulit mayor
7Biliodigestif anastomosis tanpa penyulit atau penyulit minor
8 Biopsi rectum
9 By pass usus dengan penyulit mayor / minor
10 Divertikulektomy
11 Drainase abses dengan general anasthesia
12 Drainase abses local anasthesia
13 Eksisi hygroma colli
14 Eksisi kista brachialis
15 Eksisi kista duktus tiroglossus
16 Eksisi neoplasma Jinak ( lipoma, atheroma dll )
17 Eksisi sinus/granuloma umbilikalis
18 Eksisi soft tissue tumor dengan penyulit
19 Eksisi soft tissue tumor tanpa penyulit
20 Eksisi teratoma dengan penyulit dan rekonstruksi
21 Eksisi teratoma tanpa penyulit
22 Eksisi tumor jinak wajah
23 Eksisi urachus
24 Ekstirpasi fistel pre aurikulae
25 Ekstirpasiranula
26 Endoskopik diagnostik
27 Endoskopik terapeutik
28 Gastrostomi
29 Hemikolektomi
4949
34
5050
30 Herniotomi elektif tanpa penyulit
31 Herniotomi laparoskopik
NOKSM/INSTALASI
/UNITTINDAKAN
32 Hernitomi dgn penyulit / komplikasi
33 Hidrokolektomi
34 Intraoperatif kolangiografi
35 Intraoperatif kolangiografi laparoskopik
36 Jejenostomi / ileostomi dengan penyulit mayor
37 Jejenostomi / ileostomi dengan penyulit minor
38 Jejenostomi / ileostomi tanpa penyulit
39 Koledokotomi dengan penyulit mayor
40 Kolesistektomi
41 Kolesistektomi laparoskopik
42 Kolostomi / sigmoidostomi (46.11)
43 LADD Operation (54.95)
44 Laparoskopik diagnostik (61.6)
45 Ligasihemoroid (49.4)
46 Operasi kelainan umbilikal lain (54.3)
47 Orchidopexy (62.5)
48 Orchidopexy laparoskopik (62.5 + 61.6)
49 Other Repair of Abdominal Wall (Repair Omphacele) (954.72)
50 Polipektomi (48.36)
51 Posterosagital anorectoplasty (49.79)
52 Posterosagital anorectoplasty urethro vaginoplasty(70.79)
53 Potong kolostomi (46.14)
54 Potong Stump (84.3)
55 Prosedur Heller (44.6)
56 Prosedur Kasai (51.37)
57 Repair atresia esofagus (42.5)
58 Repair defek diafragma (53.8)
5151
59 Repair ekstrofia buli (57.8)
60 Repair hernia diafragma (53.7/53.8)
NOKSM/INSTALASI
/UNITTINDAKAN
61 Repair of Gastrochisis (54.71)
62 RPLND (40.59)
63 Separasi conjoined twin (84.9)
64 Sirkumsisi dengan general anesthesia (64.0)
65 Sirkumsisi dengan local anesthesia (64.0)
66 Splenektomi (41.5)
67 Splenorenal shunt (39.1)
68 Transnasal endorectal pullthrough laparascopic assisted (48.42)
69 Transplantasi organ
70 Tutup burst abdomen dengan penyulit (54.61)
71 Tutup burst abdomen tanpa penyulit (54.61)
72 Tutup ileostomi dengan penyulit (46.5)
73 Tutup kolostomi / ileostomi (46.5)
74 Tutup Stoma (46.5)
75 Urethroplasty / chordectomy (64.42)
76 Vena Sectie Aksilaris (38.94)
77 Vena sectie Femoralis / saphena magna (38.94)
78 Wound repair (86.8)
12 KSM BEDAH PLASTIK
1 Abdominoplasty2 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
5252
36
12 Blefaroptosis
NOKSM/INSTALASI
/UNITTINDAKAN
13 Bone rekonstruksi facial cleft
14 Bone rekonstruksi facial cleft
15 Cheilonasoraphy
16 Chordectomy
17 Chordectomy+urethroplasty
18 Closed Reduction Fr. Nasal
19 Comisuroplasty
20 Eks mamma aberan bilateral
21 Eksisi neoplasma jinak (lipoma, atheroma dll)
22 Eksisi luas + Deltopectoral flap
23 Eksisi luas + Fore head flap
24 Eksisi luas + Muskulocutan flap
25 Eksisi luas + rekonstruksi dengan bedah mikrovaskular
26 Eksisi malformasi lymphatik / vaskuler
27 Ekstraksi ateroma / keloid28 Ekstraksi korpus alienum29 Elevasi ear rim cartilago30 Excise hemangioma + rekonstruksi31 Excise intra keloid32 Excise polydactyly33 Excise reduksi lymedema34 Facial sling dengan allograft35 Fasciotomy burn injury36 Fasciotomy with complication37 Flap lokal sederhana38 Fr. Condylus mandibula open red39 Fr. Maksila suspensi (IOID)40 Fr. Nasal open reduction
41 Fraktur Prosesus alveolaris dengan inter dental wiring (IDW) (per rahang)
42 Fraktur Prosesus alveolaris luas dengan IDW (per rahang)
43 Fraktur rahang reduksi terbuka & inter oseus wiring(IOW)
37
5454
NOKSM/INSTALASI
/UNITTINDAKAN
44 LD flap45 Le fort I osteotomy46 Liposuction47 Lobuloplasti48 Malarplasty49 Mamma aberan unilateral50 Mandibular distraksi51 Mandibular rekonstruksi dengan costochondral graft52 Mastopexi53 Mentoplasty54 Microsurgery55 Multiple facial fraktur + implant56 Muskulokutaneus flap57 Myokutaneus flap/pectoralis mayor flap58 Nasal repair dan rekonstruksi59 Neo vagina60 Operasi bedah mikro61 Orif fraktur zygoma62 Orif fraktur hand63 Orif fraktur mandibula64 Orif fraktur maxilla65 Orif maksila plating66 Orif mandibula plating67 Orif mandibula wiring68 Orif orbital wall69 Orif orbital wall70 Orif zygoma wiring71 Osteotomy craniosynostosis reconstruction72 Osteotomy facial rekonstruksi73 Osteotomy genioplasti tanpa tarif bahan74 Osteotomy maksila Le fort I75 Osteotomy maksila Le fort II76 Palatoplasti bilateral komplit77 Palatoplasti bilateral tak komplit78 Palatoplasti unilateral komplit79 Palatoplasti unilateral tak komplit80 Palatoraphy81 Pasang archbar82 Pasang back slab/fore slab83 Pasang cast/gips tanpa reposisi84 Recheiloraphy85 Rekonstruksi dengan alloplastic material
5555
38
5656
86 Rekonstruksi facial cleft87 Rekonstruksi nasal
NOKSM/INSTALASI
/UNITTINDAKAN
88 Rekonstruksi palpebra89 Released buried penis90 Released syndactyly kompleks91 Repair canalis lacrimalis (without silicon tube)92 Repair coloboma palpebra (skin/mucosal graft)93 Repair ductus nasolacrimalis94 Repair fingertip injury95 Repair fistel urethra96 Replantation97 Reposisi fraktur nasal sederhana98 Reposisi fraktur os nasalis (complicated)99 Reseksi mandibula + bone graft
100 Rhinoplasty101 Rotation flap102 Sagital Split osteotomi mandibula103 Simple bone grafting104 Simple skin grafting105 Skin flap106 Skin graft >5 cm107 Skin graft sedang 5 cm108 Skin grafting kecil109 Skin grafting luas110 Skin grafting sedang111 Skin grafting with complication112 Tendon reconstruction113 Tendon transfer114 Tendon transfer with complication115 Tennoraphy116 Tennoraphy with complication117 TMJ arthroplasty118 TMJ arthrostomy119 Tram flap120 Wound Dressing121 Wound Repair
5757
NOKSM/INSTALASI/
UNITTINDAKAN
13 KSM OBGYN
1 Cauter serviks
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
5858
40
4141
30 Operative histeroscopy/Ablasi endometrium
31 Overectomi
NOKSM/INSTALASI
/UNITTINDAKAN
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 TamponAbdomen
51 Total abdominal hysterectomy+bilateral salfingektomi
52 Tubektomi klinik
53 Tutup burst abdomen
4242
NOKSM/INSTALASI
/UNITTINDAKAN
14 KSM
GIGI danMULUT
1 Augmentasi Tulang Per Regio (Belum TermasukBahan)
2 Debriment Mukosa dan Pengelolaan Luka Sayat3 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 GigiPenyebab
13 Extirpasi Kista Dermoid
14 Extirpasi Sialolith
15 Extraksi Corpus Alienum dengan Teknik Lindorf
16 Extraksi Gigi Anak dengan Kelainan Jantung PerRahang
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 denganIntermaksila Fiksasi
27 Frenektomi Per Rahang
28 Genioplasty
29 Gingivektomi Per Rahang
4343
42
NOKSM/INSTALASI
/UNITTINDAKAN
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)
15 DIVISI PEDIATRI GAWAT
DARURAT ILMU KESEHATAN
ANAK
1 Intubasi Endotrakea2 Krikotirotomi3 Kanulasi vena perifer4 Vena sectie5 Pungsi lumbal
6 Pungsiv Pleura
16 KSM PENYAKIT JANTUNG & PEMBULUH
DARAH
1 Diagnostik Kateterisasi Jantung
2 PTMC3 PTCA/Stenting4 Pacemaker Temporer&Permanen
5 IABP
6 Perikardiosintesis
7 Pemasangan Swan Ganz Kateter
8 Pemasangan Amplatzer/ADO/Coilling
9 CVC
10 Pelepasan Arch Bar (Intermaksila Fiksasi)
17KSM PENYAKIT
DALAMEndoscopy
43
B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang
memerlukan informed consenttersebut antara lain:
a. Semua tindakan anestesi dan sedasi di dalam kamar operasi
b. Semua tindakan anestesi dan sedasi di ICU
Tindakan Anestesi di ICU
Pemasangan intubasi ventilator
Pemasangan vena central
Pemasangan CRRTPemasangan Swan Ganz (Kateter Arteri Pulmonal)
Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)
Pemasangan Percutaneous Dilatational TracheostomyPemasangan Drain Intra Thorakal/Punksi Thorax
Pemasangan IABP
Pemasangan Drain Intra AbdominalPemasangan Gemo
Cardioversi
Bronchoskopi-FOBTEE
C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang
memerlukan informed consenttersebut antara lain:
Transfusi darah:
a. Plasma sel
b. PRC
c. Whole Blood Cell
d. Trombosite
e. Albumin
f. lain – lain
44
D. Semua Tindakan Yang Berisiko Tinggi :
NoKSM /
INSTALASINAMA TINDAKAN
1 KSM Anak
1 Chest tube2 Tindakan kemotherapi3 Pemasangan Ventilator4 Intubasi Endotrakea5 Pemasangan Laryngeal mask6 Krikotirotomi7 Infus intraosseus8 Kanulasi vena perifer9 Vena sectie10 Pengambilan darah intra vena dan intra arteri11 Pungsi lumbal12 Pungsiv Pleura13 Pemasangan kateter urine14 Pemasangan keteter rectal15 Pemasangan orogastrik tube16 Pemasangan nasogastrik tube
2 THT-KL
1 Pemeriksaan Audiometri2 Pemeriksaan Timpanometri3 Pemeriksaan Audiometri Tutur4 Pemeriksaan Sisi&Tore Decay5 Pemeriksaan Pendengaran Pada Anak6 Pemeriksaan Brainstem Evoked Response
Audiometry
3KSM Patologi
AnatomiFNAB (Fine Needle Aspiration Biopsy)
4Inst.
RadiotherapiTindakan Radiotherapi
5KSM
Neurologi
1 Cerebral Angiografi2 AVM&Embolisasi3 Aneurisma Coiling4 Embolisasi pre operasi5 Diagnosis DSA6 Lumbal Punksi7 Pain Intervention8 Injeksi Triger point9 Injeksi Triger Fringer10 Injeksi CTS11 Sub Optical Functional12 Injeksi botox13 EMG
6 KSM Patologi Phlebotomi
45
Klinik
7KSM Gigi dan
Mulut
1 Scaling2 Curettage/root planning (jika diperlukan anestesi)3 Gingivektomi4 Frenektomi5 Flap operasi (bone graft/membrance/GTR/interseptif)6 Implant7 Vital pulpektomi dan Partial Nekrose8 Cauter9 Retraksi Gingiva pada prep.crown
8Poli
Andrologi Suntik Intra Cavernosal Penis
9
KSM Kardiologi
dan Kedokteran
Vaskular
1 Dobutamin Stress Ekhokardiografi2 Transophegal Ekhokardiografi3 Treadmill Tes4 Exercise Stress Ekhokardiografi
10
KSM Pulmonologi
dan Ilmu Kedokteran Respirasi
1 Bronchoscopy/FOB2 Tindakan kemotherapi3 Thoracoscopy4 Contra Ventil/WSD5 Punctie Pleura6 FNAB7 Scalene Biopsy8 Reposisi9 Pleurodesis10 AFF WSD11 Perawatan Luka WSD12 USG Thorax Marker
11KSM
Radiologi
1 Tindakan Radiologi Injectee contrast2 Tindakan Radiologi pada pasien dengan kelainan
cardiovaskuler3 Tindakan Radiologi pada pasien dengan alergi
berat4 Tindakan Radiologi pada pasien dengan KU yang
menurun5 Tindakan Radiologi yang memerlukan FNAB
Guiding MSCT pada pasien dengan kelainan yang berdekatan dengan organ vital
6 Tindakan Radiologi pada Ibu hamil yangmemerlukan foto
12
KSM
Neurologi
1 Cerebral Angiografi2 AVM&Embolisasi3 Aneurisma Coiling4 Embolisasi pre operasi5 Diagnosis DSA
46
6 Lumbal Punksi7 Pain Intervention8 Injeksi Triger point9 Injeksi Triger Fringer10 Injeksi CTS11 Sub Optical Functional12 Injeksi botox13 EMG14 Neuro endovaskuler: Coiling,Embolisasi,DSA
13Instalasi
Hemodialisis Setiap kali melakukan tindakan Hemodialisis
14 KSM Rehabilitasi
MedikElektromiografi dan Kecepatan Hantar Saraf
16 IRNA Jiwa
1 Psycho Analisa
2 Psycho Therapy Dalam
3 Pemeriksaan Calon Pimpinan Publik
4 Aborsi Provocatus Medicinalis
5 Tindakan terapi elektroconfusi
6 Pemeriksaan kandungan zat narkotika
7 Restraint / Fiksasi : mekanik dan psikotropika
8 Pemeriksaan sengketa/ konflik dalam keluarga
15 Semua injeksi dengan obat risiko tinggi
47