CONTOH ; DAFTAR TINDAKAN – TINDAKAN YANG PERLU INFORMED CONSENT Sesuai Undang – Undang no 44 tahun 2009 tentang rumah sakit, terdapat beberapa tindakan kedokteran dan kedokteran gigi yang wajib diberikaninformed consent. Tindakan tersebut yaitu : A. Semua Tindakan Pembedahan dan Tindakan Invasive B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam ) C. Semua Tindakan Pemberian Produk Darah & Komponen Darah D. Semua Tindakan Yang Berisiko Tinggi.
A. Tindakan Pembedahan dan Tindakan Invasiveyang memerlukan informed consentantara lain:
NO 1
KSM/INSTALAS I/UNIT KSM Bedah Saraf
TINDAKAN 1 2
Amygdala Hypocampectomy (Epilepsi) 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 NO
Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan
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
28
Injeksi spinal (Pain) Insersi Elektrode Intradural (Epilepsi,movement,psikiatrik) 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
27
2
NO
KSM/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
68
Thalomotomy (Pain) Transposisi kraniostenosis,dengan orbital advancement Transposisi kraniostenosis,tanpa orbital advancement 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
66 67
3
76
NO 2.
VP Shunt Satu Sisi
KSM/INSTALAS I/UNIT KSM Bedah Kepala Leher
TINDAKAN 1 2
Aff Arch Barr 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 Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran <2cm Ekstirpasi kista dermoid Endoscopic thyroidectomy Fiksasi interna fraktur maksilofasial 1-2 tempat patahan
25 26 27 28
4
No
3.
KSM/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
KSM
1
Adenotonsilektomi
Bedah THT-KL
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
NO
17
Ethmoidektomi (Intranasal)
18
Ekstraksi Korpus Alienum Kavum Nasi
KSM/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
NO
Laringoskopi Rigid
KSM/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
NO 4
KSM/INSTALAS I/UNIT
TINDAKAN
KSM Orthopedi Dan
1
Abdominopelvic amputation
2
Achillotenotomy
Traumatologi
3
Adductor tenotomy of hip
4
Advancement of tendon
5
Advancement of tendon of hand
6
15
Amputation above knee Amputation and disarticulation of finger- general anaesthesia Amputation and disarticulation of finger -local anaesthesia Amputation and disarticulation of thumb-general anaesthesia Amputation and disarticulation of finger- general anaesthesia Amputation and disarticulation of finger -local anaesthesia Amputation and disarticulation of thumb-general anaesthesia Amputation and disarticulation of thumb-local anaesthesia Amputation of ankle through malleoli of tibia and fibula Amputation of toe-general anaesthesia
16
Amputation of toe-local anaesthesia
17
Amputation through foot
18
21
Amputation through forearm Amputation through hand, Amputation through carpals Amputation through humerus, Upper arm amputation Amputation, not otherwise specified
22
Ankle fusion
23
Application of external fixator device Application of external fixator device, monoplanar system Application of external fixator device, ring system
7 8 9 10 11 12 13 14
19 20
24 25
8
NO
26
Application of hybrid external fixator device
27
Arthrocentesis
KSM/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
40
Arthrodesis of unspecified joint Arthroplasty of carpocarpal or carpometacarpal joint with implant Arthroplasty of carpocarpal or carpometacarpal joint without implant Arthroplasty of metacarpophalangeal and interphalangeal joint with implant Arthroplasty of metacarpophalangeal and interphalangeal joint without implant Arthroscopy Arthrotomy for removal of prosthesis without replacement 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 Bone marrow or hematopoietic stem cell transplant (all procedures included in this class Bunionectomy with soft tissue correction and arthrodesis Bunionectomy with soft tissue correction and osteotomy of the first metatarsal Bursectomy
34 35 36 37 38 39
49 50 51 52
9
NO
53
Bursectomy of hand
54
Bursotomy
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 61 62 63
Closed reduction of dislocation of foot and toegeneral anaesthesia Closed reduction of dislocation of foot and toe-local anaesthesia Closed reduction of dislocation of hand and fingergeneral anaesthesia Closed reduction of dislocation of hand and fingerlocal anaesthesia
64
Closed reduction of dislocation of hip
65
Closed reduction of dislocation of knee
66 67 68
Closed reduction of dislocation of other specified sites-general anaesthesia Closed reduction of dislocation of other specified sites-local anaesthesia 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
10
73 74
NO
Closed reduction of fracture with internal fixation Femur (Including : MIPO, interlocking nail, TEN) Closed reduction of fracture with internal fixation Humerus (including : Interlocking nail, TEN, MIPO)
KSM/INSTALAS I/UNIT
TINDAKAN
84
Closed reduction of fracture with internal fixation Intrarticular Major Bone Closed reduction of fracture with internal fixation Phalang of foot Closed reduction of fracture with internal fixation Phalang of hand Closed reduction of fracture with internal fixation Radius and ulna (MIPO, TEN) Closed reduction of fracture with internal fixation Tarsal and metatarsal 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
91
Excision of lesion of other soft tissue Dorsal and dorsolumbar fusion of the anterior column, anterior technique Dorsal and dorsolumbar fusion of the posterior column, posterior technique 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
99
Excision of lesion of tendon sheath Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-General anaesthesia Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-Local Anaestesi Excision of muscle or fascia for graft
100
Excision of muscle or fascia of hand for graft
75 76 77 78 79
89 90
97
98
11
-
101
NO
Excision of other lesion of soft tissue of hand
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 Excision or correction of bunionette, That with 105 osteotomy Excision or destruction of intervertebral disc, 106 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 Hip bearing surface, ceramic-on-polyethylene, Hip 121 bearing surface, oxidized zirconium-on-polyethylene 122 Hip bearing surface, metal-on-metal 123 Hip bearing surface, metal-on-polyethylene Implantation of internal limb lengthening device with 124 kinetic distraction Implantation of other internal limb lengthening 125 device Implantation or replacement of peripheral 126 neurostimulator lead (s)
12
Implantation or replacement of spinal neurostimulator lead(s) 128 Incision and drainage of palmar or thenar space Injection of anesthetic into peripheral nerve for 129 analgesia 127
NO
TINDAKAN
KSM/INSTALASI /UNIT
130
Injection of anesthetic into spinal canal for analgesia
131
Injection of destructive agent into spinal canal Injection of locally-acting therapeutic substance into other soft tissue Injection of other agent into spinal canal, Intrathecal injection of steroid, Subarachnoid perfusion of refrigerated saline Injection of therapeutic substance into bursa
132 133 134 135 136 137 138 139 140
Injection of therapeutic substance into bursa of hand Injection of therapeutic substance into joint or ligament Injection of therapeutic substance into tendon Injection of therapeutic substance into tendon of hand Insertion of bone growth stimulator
142
Insertion of bone void filler Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances, Insertion of catheter into epidural, subarachnoid, or subdural space of spine with intermittent or continuous infusion of drug (with creation of any reservoir) Insertion of interbody spinal fusion device
143
Insertion of other spinal devices
144
148
Insertion of partial spinal disc prosthesis, cervical Insertion of partial spinal disc prosthesis, lumbosacral Insertion of recombinant bone morphogenetic protein Insertion of spinal disc prosthesis, not otherwise specified, Replacement of spinal disc, NOS Insertion of spinal disc prosthesis, thoracic
149
Insertion of sternal fixation device with rigid plates
150
Insertion of total spinal disc prosthesis, cervical
141
145 146 147
13
152
Insertion of total spinal disc prosthesis, lumbosacral
153
Insertion or replacement of (cement) spacer Insertion or replacement of facet replacement device(s)
154
NO
KSM/INSTALAS I/UNIT
TINDAKAN Insertion or replacement of interspinous process device(s) Insertion or replacement of pedicle-based dynamic 156 stabilization device(s) 157 Insertion or replacement of skeletal muscle stimulator 158 Internal fixation of bone without fracture reduction 159 Interphalangeal fusion 160 Interthoracoscapular amputation, Forequarter amputation 161 Intra-operative neurophysiologic monitoring Neuromonitoring 162 Intervertebral chemonucleolysis 163 Limb lengthening procedures 164 Limb shortening procedures 165 Local excision of lesion or tissue of bone 166 Lower leg or ankle reattachment 167 Lower limb amputation, not otherwise specified 168 Lumbar and lumbosacral fusion of the anterior column, anterior technique 169 Lumbar and lumbosacral fusion of the anterior column, posterior technique 170 Lumbar and lumbosacral fusion of the posterior column, posterior technique 171 Lysis of adhesions of hand 172 Lysis of adhesions of muscle, tendon, fascia, and bursa 173 Lysis of adhesions of spinal cord and nerve roots 174 Metacarpocarpal fusion 175 Metacarpophalangeal fusion 176 Metatarsophalangeal fusion 177 Midtarsal fusion 178 Muscle transfer or transplantation 155
14
179 180 181
NO
Myotomy Myotomy of hand Neurectasis
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
188 189
Open reduction of dislocation of hip - Neglected dislocation 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
192 193 194 195 196 197 198 199
200
201 202 203
Open reduction of dislocation of shoulder -Fresh dislocation Open reduction of dislocation of shoulder -Neglected dislocation Open reduction of dislocation of unspecified site-Fresh dislocation Open reduction of dislocation of unspecified siteNeglected dislocation Open reduction of dislocation of wrist -Fresh dislocation Open reduction of fracture with internal fixation- radius and ulna-Simple fracture Open reduction of fracture with internal fixationunspecified site (Periarticular Major Bone ) Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw Open reduction of fracture with internal fixation-carpals and metacarpals - simple implants (K-wire) Hand NOS -implant sederhana (K-wire) Open reduction of fracture with internal fixation-femurComminutive or Segmental Open reduction of fracture with internal fixation-femurSimple fracture
15
NO
KSM/INSTALAS I/UNIT
TINDAKAN 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227
Open reduction of fracture with internal fixationhumerus - Simple fracture Open reduction of fracture with internal fixationhumerus - Comminutive or Segmental Open reduction of fracture with internal fixationother specified bone (Intraartikular Major Bone ) Open reduction of fracture with internal fixationphalanges of foot - simple implants (K-wire) Open reduction of fracture with internal fixationphalanges of foot-Plate & Screws Open reduction of fracture with internal fixationphalanges of hand- Plate & Screws Open reduction of fracture with internal fixationphalanges of hand- simple implants Open reduction of fracture with internal fixationtarsals and metatarsals- Plate & Screws Open reduction of fracture with internal fixationtarsals and metatarsals- simple implants Open reduction of fracture with internal fixation-tibia and fibula -Simple fracture Open reduction of fracture with internal fixation-tibia and fibula-Comminutive or Segmental Open reduction of fracture without internal fixation Open reduction of separated epiphysis Osteoclasis (correction of bone deformity) Other Other (peripheral) vascular shunt or bypass Other amputation below knee Other anastomosis of cranial or peripheral nerve Other and unspecified repair of the anulus fibrosus Other arthrotomy Other bunionectomy Other bunionectomy with soft tissue correction Other cervical fusion of the anterior column, anterior technique Other cervical fusion of the posterior column, posterior technique
16
228 229 230
NO
Other change in hand muscle or tendon length Other change in muscle or tendon length Other destruction of intervertebral disc
KSM/INSTALAS I/UNIT
TINDAKAN 231
Other diagnostic procedures on joint structures Other diagnostic procedures on muscle, tendon, fascia, and
232
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 into
250
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,
17
Suture of bursa Other partial ostectomy (including : Bone curretage, 258
NO
marginal resection/excision)
KSM/INSTALAS I/UNIT
TINDAKAN 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297
Other peripheral nerve or ganglion decompression or lysis of adhesions Peripheral nerve neurolysis NOS Other plastic operations on fascia Other plastic operations on hand Other plastic operations on muscle Other repair of ankle Other repair of elbow Other repair of hand, fingers and wrist Other repair of joint Other repair of knee Other repair of shoulder Other repair of the collateral ligaments Other repair of the cruciate ligaments Other repair or plastic operations on bone Other suture of flexor tendon of hand Other suture of muscle or fascia Other suture of other tendon of hand Other suture of tendon Other tendon transposition Other tenodesis of hand Other tenonectomy Other tenonectomy of hand Other tenoplasty of hand Other tenotomy Other total shoulder replacement Partial hip replacement Partial shoulder replacement Patellar stabilization Percutaneous denervation of facet Percutaneous vertebral augmentation Percutaneous vertebroplasty Peripheral nerve injection, not otherwise specified Plastic operation on hand with graft of muscle or fascia Plastic operation on hand with other graft or implant Pollicization operation carrying over nerves and blood supply Quadricepsplasty Reattachment of muscle Reattachment of muscle of hand Reattachment of tendon Reattachment of tendon of hand
18
298 299
NO
Refusion of atlas-axis spine Refusion of dorsal and dorsolumbar spine, anterior column, anterior technique
KSM/INSTALAS I/UNIT
TINDAKAN 300 Refusion of dorsal and dorsolumbar spine, posterior column, posterior technique 301 Refusion of lumbar and lumbosacral spine, anterior column, anterior technique 302 Refusion of lumbar and lumbosacral spine, anterior column, posterior technique 303 Refusion of lumbar and lumbosacral spine, posterior column, 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 classified 307 Refusion of spine, not otherwise specified 308 Release of carpal tunnel 309 Release of clubfoot, not elsewhere classified 310 Release of tarsal tunnel 311 Removal of (cement) spacer 312 Removal of bone growth stimulator (invasive) 313 Removal of foreign body from spinal canal 314 Removal of implanted devices from bone - carpals and metacarpals-Plate & screw 315 Removal of implanted devices from bone - carpals and metacarpals-simple implants (K-wire) 316 Removal of implanted devices from bone - External fixator device (invasive) ( 317 Removal of implanted devices from bone - femur 318 Removal of implanted devices from bone - humerus 319 Removal of implanted devices from bone - radius and ulna 320 Removal of implanted devices from bone - scapula, clavicle, and thorax (ribs and sternum) 321 Removal of implanted devices from bone unspecified site (Phalanges (of foot) (of hand)) - Plate & Screw 322 Removal of implanted devices from bone unspecified site (Phalanges (of foot) (of hand)) simple implants (K-wire) 323 Removal of implanted devices from bone -patella 324 Removal of implanted devices from bone- tarsals and metatarsals- simple implants (K-wire) 325 Removal of implanted devices from bone- tibia and fibula
19
326 Removal of implanted devices from bone-other (Pelvic bone and Vertebraae)
NO
KSM/INSTAL ASI/UNIT
TINDAKAN 327
352 353 354 355 356 357
Removal of implanted devices from bone-tarsals and metatarsals - Plate & Screw Removal of internal limb lengthening device Removal of pedicle screw(s) used in spinal fusion Removal of peripheral neurostimulator lead(s) Removal of skeletal muscle stimulator Removal of spinal neurostimulator lead(s) Reopening of laminectomy site Repair of claw toe Repair of cleft hand Repair of hammer toe Repair of hip, not elsewhere classified Repair of macrodactyly Repair of mallet finger Repair of old traumatic injury of cranial and peripheral nerves Repair of recurrent dislocation of shoulder Repair of the anulus fibrosus with graft or prosthesis Repair of vertebral fracture, Elevation of spinal bone fragments, Reduction of fracture of vertebrae, Removal of bony spicules from spinal canal Replacement of joint of foot and toe Resurfacing hip, partial, acetabulum, Hip resurfacing arthroplasty, partial, acetabulum Resurfacing hip, partial, femoral head Revision of total knee replacement, tibial insert (liner), Replacement of tibial insert(liner) Revision or replacement of artificial spinal disc prosthesis, cervical Revision or replacement of artificial spinal disc prosthesis, lumbosacral Revision or replacement of artificial spinal disc prosthesis, not otherwise specified Revision or replacement of artificial spinal disc prosthesis, thoracic Rotator cuff repair Separation of equal conjoined twins Separation of unequal conjoined twins Sequestrectomy Spinal fusion, not otherwise specified Subtalar fusion
358
Subtalar joint arthroereisis
328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343
344 345 346 347 348 349 350 351
20
NO
359
Suture of Artery
360
Suture of capsule or ligament of ankle and foot
KSM/INSTALASI /UNIT
TINDAKAN 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
392 393 394
Upper arm reattachment Upper limb amputation, not otherwise specified Wedge osteotomy
21
NO
KSM/INSTALASI /UNIT
5
KSM BEDAH THORAKS DAN KARDIOVASKULAR
TINDAKAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
Biopsi Terbuka Bronkhus Biopsi Terbuka Diafragma Biopsi Terbuka Mediastinum Biopsi Terbuka Paru Biopsi Terbuka Pleura Biopsi Terbuka Pleura dengan VATS Biopsi Terbuka Tumor Dinding Thoraks Debridement Mediastinum (Sternotomi) Eksisi Pada Bronkhus Eksisi Pada Paru (Lung Volume Reduction) Eksisi Pada Paru dengan VATS Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding Dada Eksisi Tumor Mediastinum (Thymoma, Teratoma, Neurogenic dsb) Ekstraksi Corpus Alienum di Regio Toraks Ekstraksi Corpus Alienum di Regio Toraks dengan VATS Evakuasi Efusi Pleura/Empyema secara Torakoskopik (VATS) Fiksasi Costae (Clipp, Wire) (diluar Clipp) Fiksasi Sternum (Wire, Plate) (diluar wire/plate) Lobektomi Parsial (Reseksi Paru segmental) Lobektomi Parsial (Reseksi Paru segmental) dengan VATS Lumbal Simpatektomi Mediastinostomy Pemasangan thorak drain/water sealed drainage (WSD) (diluar alat) Pleural window (Eloeser Flap) Pleurektomi Pleurodesis (Pleurosklerosis) Plikase Bulae / Bleb Emfisematous Plikasi diafragma Pneumonectomy Pneumonectomy dengan VATS Pulmonary Decortication Pulmonary Decortication dengan VATS Pulmonary Lobectomy/Bilobectomy Pulmonary Lobectomy/Bilobectomy dengan VATS Redo Torakotomi Rekonstruksi Sternum&Dinding Dada repair deformitas Pectus
22
38 Repair Fistula Bronkopleural 39 Repair Laserasi Diafragma
NO
TINDAKAN
KSM/INSTALASI /UNIT 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Revisi Thoraks drain/water sealed drainage (WSD) (diluar alat) Thoracal Symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) Thoracocentesis Thymectomy Thymectomy dengan VATS Torakoplasti (Air Plumbage/Muscle Plumbage) Torakotomi / sternotomi Eksplorasi Torakotomi Eksplorasi pada Trauma jantung/Repair Laserasi Jantung Bedah Kardio (Jantung) Aortic Valve Repair (AVR) Aortic Valve Repair (AVR) dengan Bioprosthesis Valve Aortic Valve Repair (AVR) dengan Mechanical Valve Atrial septal Defect (ASD) Closure Bidirectional Cavo-Pulmonary Shunt (BCPS) Biopsi Jantung Biopsi Perikardium Blalock-Taussing Shunt (BT Shunt) Coronary Artery Bypass Graft (CABG) Eksisi Cardiac Myxoma Fontan Operation (Atrium-Pulmonary Artery Conduit) Internal Resusitasi/Cardiac Massage (Operasi Terbuka) Ligasi Patent Ductus Arteriosus (PDA) Mitral valve repair (MVr) Mitral Valve Repair (MVR) dengan Bioprosthesis Valve Mitral Valve Replacement (MVR) dengan Mechanical Valve Operasi Redo Open Heart (Valve Replacement) Operasi Reopen oleh Karena sebab Perdarahan, Tamponade Jantung Pemasangan IABP Pemasangan Pace Maker Permanen (diluar alat) Pericardiocentesis Perikardiektomi Perikardiotomi/Pericardial Window Pulmonal Valve Repair (PVR) Pulmonal Valve Repair (PVR) dengan Bioprosthesis Valve Pulmonal Valve Repair (PVR) dengan Mechanical Valve Pulmonary Artery Banding (PA)
23
NO
KSM/INSTALASI/ UNIT
TINDAKAN 76 Rastelli Procedure (right Ventricle-Pulonary Artery Conduit) 77 Repair (Eksisi) Aneurisma Jantung 78 Repair Aorta Torakalis (38.34) 79 Repair Atrioventricular Septal Defect (35.54) Repair Total Anomalous Pulmoanry Venous Connection 80 (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) Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve 87 (35.27) Tricuspid Valve Repair (TVR) dengan Mechanical Valve 88 (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 Biopsi Tumor Pembuluh Darah
1
Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)
2
Eksplorasi Vaskular (Trauma/Non trauma)
3 4
Embolektomi/Trombektomi Aorta Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal Embolektomi/Trombektomi Pembuluh Darah Arteri Ekstremitas Bawah Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Atas (diluar alat) Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Bawah(diluar alat) Embolektomi/Trombektomi Pembuluh Darah Regio servikal (Karotis, Jugular) (diluar alat) Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/ Traumatik) Fasciotomy Ligasi Vaskular Ekstremitas
5 6 7 8 9 10 11
24
12
NO
KSM/INSTALASI /UNIT
TINDAKAN 13 14 15 16 17 18 19 20 21 22 23 24 25 26
7
Mutilasi Digiti Ekstermitas
KSM BEDAH
27 1
DIGESTIVE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Pasang Double Lumen Hemodialisis (HD) (diluar alat) Pasang Implantable Central Venous Access (diluar alat: porth-a-cath, celsite) Pemasangan Central Venous Catheter (CVC) (diluar alat) Pemasangan Intra Aortic Baloon Pump (IABP) (diluar alat) Pemasangan Peritoneal Dyalisis (PD) Catheter (diluar alat) Pembedahan Teleangiectasis Repair Aneurisma (True/false) Ekstremitas Superior (diluar graft) Repair Aneurisma Aorta Abdominalis (Diluar Protesa) Repair Pembuluh Darah Regio Servikal (Karotis, Jugular) Repair Ruptur Pembuluh Arteri Abdominal Revisi Arteriovenous Shunt Skleroterapi Vena (Varises, Hemangioma) Stripping Varises Ekstremitas Inferior Vascular Shunting (Splenorenal Shunt, De Palma Shunt) Vena Punctie, Kanulasi, Sectie Abdominal pull through (sfingter saving procedure) Abdominoperineal resection (miles) dengan penyulit mayor Abdominoperineal resection (miles) dengan penyulit minor Abdominoperineal resection (miles) tanpa penyulit Abdominoplasty Apendektomi Apendektomi dgn penyulit major Apendektomi dgn penyulit minor Apendektomi laparoskopik Bilio-difgestif anastomosis tanpa penyulit Biliodigestif dengan penyulit mayor Biliodigestif dengan penyulit minor Biopsi insisional, local anastesi Biopsi rectum Eksisi hemoroid eksterna Eksplorasi duktus bilier & cholangiografi intra operatif Esofagotomi Fistulotomi
25
NO
KSM/INSTALASI /UNIT
TINDAKAN 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Fistulotomi dgn penyulit mayor Fistulotomi dgn penyulit minor Gastrostomi Hemikolektomi dengan penyulit mayor Hemikolektomi dengan penyulit minor Hemikolektomi tanpa penyulit Hemoroid stapling (diluar alat) Hemoroidektomi Herniotomi Herniotomi dgn penyulit mayor Herniotomi dgn penyulit minor Herniotomi laparoskopik Jejunostomi / ileostomi Laparotomi dengan penyulit minor Laparotomi tanpa penyulit Ligasi hemoroid (diluar alat) Pankreatiko-duodenektomi cephalis (Whipple) dengan penyulit mayor Peritoneal dreanse (CAPD) Peritoneal lavase Polipektomi Potong kolostomi Prosedur Heller Rektopexy Repair fistel usus Repair fistel vesicorectal Repair hernia cicatricalis Repair hernia cicatricalis dgn penyulit mayor (diluar alat) Repair hernia cicatricalis dgn penyulit minor (diluar alat) Repair Hernia Diafragmatika (diluar alat) Reseksi anterior dengan penyulit mayor Reseksi anterior dengan penyulit minor Reseksi anterior tanpa penyulit Reseksi esofagus-colon / ileum transposisi Reseksi esofagus-end to end Reseksi esofagus-esofago-gastrectomy Reseksi hati Second look laparoscopy Splenektomi / splenoraphy traumatika Splenektomi non trauma Terminal esofagus proksimal gastrektomi (TEPG)
26
59
NO
8
Total gastrektomi
KSM/INSTALASI /UNIT
KSM BEDAH UROLOGI
TINDAKAN 60 61 62 63 64 65 66 67 68 69 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Total pantreaktomi Total prokto-kolektomi Tutup burst abdomen (tanpa alat) Tutup burst abdomen dengan penyulit mayor Tutup burst abdomen dengan penyulit minor Tutup kolostomi / ileostomi Tutup kolostomi / ileostomi dengan penyulit mayor Tutup kolostomi / ileostomi dengan penyulit minor Repair Aorta Torakalis (38.34) Repair Atrioventricular Septal Defect (35.54) Adrenalektomi Adrenalektomi (Abdominotorakal) Anastomosis end to end Ureter Augmentasi Buli Biopsi Ginjal perkutan Biopsi Ginjal Terbuka Biopsi Penis Biopsi Prostat Biopsi Testis Bladder Neck Rekonstruksi Buried Penis Businasi/Dilatasi Uretra Cabut DJ Stent Defooring Kista Ginjal per Laparoskopi Deroofing/Unroofing Kista Diseksi Kelenjar Getah Bening Inguinal Diseksi Kelenjar Getah Bening pelvis Diseksi Kelenjar Getah Bening Pelvis per Laparoskopi Divertikulektomi Buli Divertikulum Uretra Dorsumsisi Drainase Periureter Eksisi Chordae/Chordektomi Eksisi Fibroma/Rekonstruksi Penis Eksisi Plaque (Peyronie Disease) Eksisi Webbed Penis Eksplorasi testis (Microsurgery) Ekstraksi Batu Ekstrofi Buli Rekonstruksi Epispadia Evakuasi Bekuan Darah (Clot) Extended Pyelolithotomy
27
33
NO
Fistulektomi/Repair Fistel Uretra
KSM/INSTALASI /UNIT
TINDAKAN 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Funikokelektomi Ganti Nefrostomy Hidrokel per Inguinal/Ligasi Tinggi Hidrokel per Skrotal Hipospadia Subkoronal Holmium YaG Laser (Sewa) Ileal Conduit (Bricker) Insersi DJ Stent Insisi Abses Perineum Insisi Abses Skrotum Insisi Posterior Urethral Valve Johanson Johanson I Johanson II Kalibrasi Uretra Kauterisasi Koreksi Horseshoe Kidney Koreksi Priapismus Laparoskopi Adrenalektomi Laparotomi Eksplorasi Ligasi V.Spermatika Interna (Microsurgery) Limfadenektomi Ilioinguinal Limfadenektomi Retroperitoneal/RPLND Litholapaksi Lithotripsi Masase Prostat Meatoplasti Meatotomi MMK/Sling Uretra Nefrektomi Nefrektomi Donor Transplant Nefrektomi Parsial Nefrektomi per Laparoskopi Nefrektomi Radial Nefropeksi/Renopeksi Nefrostomi Perkutan/Temporer Nefrostomi Terbuka/Permanen Nefroureterektomi Neobladder Operasi Priapismus (prosedur Winter) Operasi Repair Buli Trauma Operasi Sistokel
28
NO
KSM/INSTALASI /UNIT
TINDAKAN 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 115 116 117
Operasi Trauma Ginjal Operasi Urakhus/Reseksi urakhus Orkhidektomi Orkhidektomi extended Orkhidektomi Ligasi Tinggi Orkhidektomi Subkapsuler Orkhidopeksi (Torsio Testis) Orkhidopeksi (UDT) Orkhidopeksi per Laparoskopi Pasang Kateter Pasang Kateter dengan Mandrain Pasang Kateter Tenckhoff untuk CAPD PCNL/PNL Penektomi Parsial Penektomi Total/Amputasi Penis PER (Primary Endoscopic Realignment) Pielokalikotomi Pielolitotomi Pieloplasti Pieloplasti per Laparoskopi Prostatektomi Radikal Prostatektomi Retropubik Prostatektomi Terbuka Prostatektomi Terbuka dan Sectio Alta Psoas Hitch/Boari Flap Punksi dan sklerosing Kista Ginjal Railroading Rupture Uretra Reimplantasi Ureter Bilateral Reimplantasi Ureter Unilateral/Ureteroneosistostomi Rekontruksi Renovaskuler Repair Fistel Enterovesika Repair Fistel Vesikokutan Repair Fistel Vesikorektal Repair Fistel Vesikovagina Repair Fistel Vesikovagina Kompleks Reparasi Penis Reseksi-anastomosis Uretra RPG Sectio Alta/Vesikolithotomi Sirkumsisi Sistektomi Parsial/Sistoplasti Reduksi Sistektomi Per Laparoskopi Sistektomi Total/Radikal
29
118 119
NO
9
Sistoskopi Sistoskopi ODS
KSM/INSTALASI /UNIT
KSM ILMU KESEHATAN MATA
TINDAKAN 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Sistostomi perkutan Sistostomi Terbuka Skrotoplasti Spermatokelektomi Tailoring Ureter Transplan Resipien Transuretero-ureterostomi TUR Prostat/TUIP/BNI TUR Tumor Buli TVP/TMP Ureterokutaneostomi Ureterolisis Ureterolithotomi Ureterolithotomi Distal Ureterolithotomi Proksimal Ureterosigmoidostomi (Caffey) Ureterostomi Ureterouretostomi Uretroplasti Hipospadia Uretroskopi/Uretrosistoskopi Uretrotomi Interna (Sachse) URS/Lithotripsi Varikokelektomi (Palomo) Vasektomi (anestesi lokal) Vasektomi (narkose) Vasoepididimostomi Vasografi Vasovasostomi Angkat Jahitan Angkat Jahitan dengan GA Anterior Chamber Tap/Parasintesis Aspirasi Massa Lensa Blefaroplasty (2 Kelopak Mata) Claw Lens Cryopexy Kornea Cyclo Cryo Dacryocystorinostomi (Without Silicon Tube) Dekompresi Orbital/Lateral Orbitotomi Disisi Aspirasi & IOL ECCE ECCE & IOL Eksenterasi Eksisi Hordeolum / Chalazion
30
16 17
NO
Ekstirpasi Corpus Alienum di Kornea Ekstirpasi Pterygium + Graft Konjungtiva
KSM/INSTALASI /UNIT
TINDAKAN 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57
Ekstripasi Corpus Alienum di Bilik Mata Depan Enukleasi/Eviscerasi (DFG/Bonegraft) Evakuasi Silikon Oil Fornix Repair ICCE ICCE & IOL Injeksi Intra Vitreal Injeksi Periokuler Terapetik IOL Explant Iridectomi Jahit Kelopak Mata Full Thickness & Lid Margin Jahit Kornea Keratoplasti (Corneal Transplantation) Konjungtival Flap/Amnion Graft Piggy Back IOL Pneumoretinopexy Repair Canalis Lacrimalis (Without Silicon Tube) Repair Coloboma Palpebra (Skin/Mucosal Graft) Reposisi IOL Reposisi Iris Resesi & Reseksi 2 Otot Resesi & Reseksi 3 Otot Resesi & Reseksi 4 Otot Resesi/Reseksi 1 Otot Sekunder Implant (Posterior Chamber) Sekunder Implant Claw Lens / Fiksasi Sulcus SICS SICS & IOL Simpel Vitrektomi Skleral Buckle Socket Repair (Contracted Socket) Trabekulektomi Trabekuletomi & Ollogen Trabulektomi & Goniotomi pada Pediatric Glaucoma Tube Shunt (Express) Viscocanulostomy Vitrektomi +++ Vitrektomi Lengkap & Skleral Buckle Wide Eksisi Tumor Kelopak Mata Wide Eksisi Tumor Kelopak Mata + Flap + graft
31
NO 10
KSM/INSTALASI /UNIT Divisi Onkologi
TINDAKAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Aspirasi Kista Mamma Single dan Multiple Biopsi Core Lokal Anestesi Biopsi Eksisi Lokal Biopsi Eksisi Narkose Biopsi Insisi Lokal Biopsi Narkose Breast Conserving Surgery (BCS) Breast Conserving Surgery + LD Flap Debriment Mamma Diseksi Axilla Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi Eksisi Fibroadenoma Multiple Narkose Eksisi Tumor Metastase Loco-regional Eksplorasi Duktus Mama Eksplorasi Duktus Mama+VC Insisi Absces Mastitis Lokal LD Flap + Eksisi Tumor Mastectomy + Tram Flap Modified Radical Mastectomy + Flap/Single Grafting Modified Radical Mastectomy Single Quadrantectomy / Partial Mastectomy Simple Mastektomy + Flap/Skin Grafting Simple Mastektomy Single Tram Flap + Eksisi Tumor Operasi Tumor Kulit Biopsi Insisi Tumor Kulit Lokal Biopsi Eksisi Tumor Kulit Narcose Eksisi Tumor Jinak ≤ 3cm Eksisi Tumor Jinak + Flap/Skin Graft Eksisi Tumor Jinak Kulit >3cm Wide Eksisi + Diseksi KGB Wide Eksisi Tumor Ganas Kulit Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft Operasi Soft Tissue Tumor Amputasi + Diseksi KGB Amputasi Jari + Flap / Skin Graft Amputasi Tungkai / Lengan Biopsi Core soft Tissue Biopsi Insisi Tumor Sof Tissue dengan Narcose Biopsi Insisi Tumor Soft Tissue Lokal Anestesi Eksisi Tumor Jinak > 3cm Eksisi Tumor Jinak Ø<3cm Wide Eksisi + Compartement Procedure Wide Eksisi + Diseksi KGB
32
45 46
NO
Wide Eksisi Tumor Ganas Wide Eksisi Tumor Jinak + Flap/Skin Graft
KSM/INSTALASI /UNIT
TINDAKAN 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)
33
NO 11
KSM/INSTALASI /UNIT DIVISI BEDAH ANAK
TINDAKAN 1 2
Abdominal pull through (sfingter saving procedure) Adhesiolisis
3
Appendektomi dgn penyulit
4
Appendektomi laparoskopik
5
Appendektomi tanpa penyulit
6
8
Biliodigesif dengan penyulit mayor Biliodigestif anastomosis tanpa penyulit atau penyulit minor 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 28
Endoskopik terapeutik
29
Hemikolektomi
7
Gastrostomi
34
NO
30
Herniotomi elektif tanpa penyulit
31
Herniotomi laparoskopik
KSM/INSTALASI /UNIT
TINDAKAN 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) Other Repair of Abdominal Wall (Repair Omphacele) (954.72) Polipektomi (48.36)
49 50 51
53
Posterosagital anorectoplasty (49.79) Posterosagital anorectoplasty urethro vaginoplasty (70.79) 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)
52
35
NO
59
Repair ekstrofia buli (57.8)
60
Repair hernia diafragma (53.7/53.8)
KSM/INSTALASI /UNIT
TINDAKAN 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
69
Splenorenal shunt (39.1) Transnasal endorectal pullthrough laparascopic assisted (48.42) 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)
68
75 Urethroplasty / chordectomy (64.42) 76 Vena Sectie Aksilaris (38.94) 77 Vena sectie Femoralis / saphena magna (38.94) 12
KSM BEDAH PLASTIK
78
Wound repair (86.8)
1 2 3
Abdominoplasty Aff archbar, Lokal Anastesi 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
36
12
NO
Blefaroptosis
KSM/INSTALASI /UNIT
TINDAKAN 13 14
Bone rekonstruksi facial cleft 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 Eksisi luas + rekonstruksi dengan bedah mikrovaskular Eksisi malformasi lymphatik / vaskuler Ekstraksi ateroma / keloid Ekstraksi korpus alienum Elevasi ear rim cartilago Excise hemangioma + rekonstruksi Excise intra keloid Excise polydactyly Excise reduksi lymedema Facial sling dengan allograft Fasciotomy burn injury Fasciotomy with complication Flap lokal sederhana Fr. Condylus mandibula open red Fr. Maksila suspensi (IOID) Fr. Nasal open reduction Fraktur Prosesus alveolaris dengan inter dental wiring (IDW) (per rahang) Fraktur Prosesus alveolaris luas dengan IDW (per rahang) Fraktur rahang reduksi terbuka & inter oseus wiring (IOW)
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
37
NO
KSM/INSTALASI /UNIT
TINDAKAN 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
LD flap Le fort I osteotomy Liposuction Lobuloplasti Malarplasty Mamma aberan unilateral Mandibular distraksi Mandibular rekonstruksi dengan costochondral graft Mastopexi Mentoplasty Microsurgery Multiple facial fraktur + implant Muskulokutaneus flap Myokutaneus flap/pectoralis mayor flap Nasal repair dan rekonstruksi Neo vagina Operasi bedah mikro Orif fraktur zygoma Orif fraktur hand Orif fraktur mandibula Orif fraktur maxilla Orif maksila plating Orif mandibula plating Orif mandibula wiring Orif orbital wall Orif orbital wall Orif zygoma wiring Osteotomy craniosynostosis reconstruction Osteotomy facial rekonstruksi Osteotomy genioplasti tanpa tarif bahan Osteotomy maksila Le fort I Osteotomy maksila Le fort II Palatoplasti bilateral komplit Palatoplasti bilateral tak komplit Palatoplasti unilateral komplit Palatoplasti unilateral tak komplit Palatoraphy Pasang archbar Pasang back slab/fore slab Pasang cast/gips tanpa reposisi Recheiloraphy Rekonstruksi dengan alloplastic material
38
86 87
NO
Rekonstruksi facial cleft Rekonstruksi nasal
KSM/INSTALASI /UNIT
TINDAKAN 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121
Rekonstruksi palpebra Released buried penis Released syndactyly kompleks Repair canalis lacrimalis (without silicon tube) Repair coloboma palpebra (skin/mucosal graft) Repair ductus nasolacrimalis Repair fingertip injury Repair fistel urethra Replantation Reposisi fraktur nasal sederhana Reposisi fraktur os nasalis (complicated) Reseksi mandibula + bone graft Rhinoplasty Rotation flap Sagital Split osteotomi mandibula Simple bone grafting Simple skin grafting Skin flap Skin graft >5 cm Skin graft sedang 5 cm Skin grafting kecil Skin grafting luas Skin grafting sedang Skin grafting with complication Tendon reconstruction Tendon transfer Tendon transfer with complication Tennoraphy Tennoraphy with complication TMJ arthroplasty TMJ arthrostomy Tram flap Wound Dressing Wound Repair
39
NO 13
KSM/INSTALASI/ UNIT KSM OBGYN
TINDAKAN 1 2 3
Cauter serviks Cordosentesis 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
16
Lap op: myomektomi Laparoskopi (Kistektomi Ovarium, Salphingektomi, Adhesiolisis) 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
15
40
NO
30
Operative histeroscopy/Ablasi endometrium
31
Overectomi
KSM/INSTALASI /UNIT
TINDAKAN 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
51
TAH+BSO dengan Penyulit TAH+BSO dengan Penyulit Pemasangan Tampon Abdomen Total abdominal hysterectomy+bilateral salfingektomi
52
Tubektomi klinik
53
Tutup burst abdomen
50
41
NO
KSM/INSTALASI /UNIT
TINDAKAN
14
KSM
1
GIGI dan MULUT
2 3 4
Augmentasi Tulang Per Regio (Belum Termasuk Bahan) Debriment Mukosa dan Pengelolaan Luka Sayat Dislokasi Sendi Mandibula 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
13
Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi Enukleasi Kista radikuler Per Rahang + Extraksi Gigi Penyebab Extirpasi Kista Dermoid
14
Extirpasi Sialolith
15
17
Extraksi Corpus Alienum dengan Teknik Lindorf Extraksi Gigi Anak dengan Kelainan Jantung Per Rahang Extraksi Gigi Anak Per Rahang
18
Extraksi Gigi Dewasa Per Rahang
19
Fissure Sealant pada Autis
20
22
Fraktur Dento alveolar Dengan arch Bar Fraktur Dento alveolar Dengan Bracket (belum termasuk bahan) fraktur Dento Alveolar dengan Eyelet
23
Fraktur Maksila dengan Suspensi Wiring
24
Fraktur Nasal close Reduksi
25
27
Fraktur Nasal Open Reduksi Fraktur Rahang Reduksi Tertutup dengan Intermaksila Fiksasi Frenektomi Per Rahang
28
Genioplasty
29
Gingivektomi Per Rahang
12
16
21
26
42
NO
KSM/INSTALASI /UNIT
TINDAKAN 30
Hemi Maksilektomi Tanpa Rekonstruksi
31
Insisi Abses / Phlegmon
32
Insisional Biopsi Neoplasma Jinak
33
Mandibular Distraksi
34
36
Odontektomi Per Gigi ORIF Maksila + Zygoma + Mandibula (belum termasuk implant) 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)
DIVISI PEDIATRI GAWAT DARURAT ILMU KESEHATAN ANAK
1
6
Intubasi Endotrakea Krikotirotomi Kanulasi vena perifer Vena sectie Pungsi lumbal Pungsiv Pleura
KSM PENYAKIT JANTUNG & PEMBULUH DARAH
1 2 3 4 5
Diagnostik Kateterisasi Jantung PTMC PTCA/Stenting Pacemaker Temporer&Permanen IABP
6
Perikardiosintesis
7
Pemasangan Swan Ganz Kateter
8
Pemasangan Amplatzer/ADO/Coilling
9
CVC
10
Pelepasan Arch Bar (Intermaksila Fiksasi)
35
15
16
17
KSM PENYAKIT DALAM
2 3 4 5
Endoscopy
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 CRRT Pemasangan Swan Ganz (Kateter Arteri Pulmonal) Pemasangan Intra Arterial Catheher (Kateter Intra Arterial) Pemasangan Percutaneous Dilatational Tracheostomy Pemasangan Drain Intra Thorakal/Punksi Thorax Pemasangan IABP Pemasangan Drain Intra Abdominal Pemasangan Gemo Cardioversi Bronchoskopi-FOB TEE
C. Tindakan Pemberian Produk Darah dan Komponen Darah,tindakan yang memerlukan informed consenttersebut antara lain: Transfusi darah: a. Plasma sel b. PRC c. Whole Blood Cell d. Trombosite e. Albumin f.
lain – lain
44
D. Semua Tindakan Yang Berisiko Tinggi : No
KSM / INSTALASI
KSM Anak
1
2
THT-KL
NAMA TINDAKAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6
Chest tube Tindakan kemotherapi Pemasangan Ventilator Intubasi Endotrakea Pemasangan Laryngeal mask Krikotirotomi Infus intraosseus Kanulasi vena perifer Vena sectie Pengambilan darah intra vena dan intra arteri Pungsi lumbal Pungsiv Pleura Pemasangan kateter urine Pemasangan keteter rectal Pemasangan orogastrik tube Pemasangan nasogastrik tube Pemeriksaan Audiometri Pemeriksaan Timpanometri Pemeriksaan Audiometri Tutur Pemeriksaan Sisi&Tore Decay Pemeriksaan Pendengaran Pada Anak Pemeriksaan Brainstem Evoked Response Audiometry
KSM Patologi 3
Anatomi
FNAB (Fine Needle Aspiration Biopsy)
Inst. 4
Radiotherapi
KSM 5
6
Neurologi
Tindakan Radiotherapi 1 2 3 4 5 6 7 8 9 10 11 12 13
Cerebral Angiografi AVM&Embolisasi Aneurisma Coiling Embolisasi pre operasi Diagnosis DSA Lumbal Punksi Pain Intervention Injeksi Triger point Injeksi Triger Fringer Injeksi CTS Sub Optical Functional Injeksi botox EMG
KSM Patologi Phlebotomi
45
Klinik
7
8
9
10
1 2 3 KSM Gigi dan 4 5 Mulut 6 7 8 9 Poli Andrologi KSM Kardiologi dan Kedokteran Vaskular
KSM Pulmonologi dan Ilmu Kedokteran Respirasi
Suntik Intra Cavernosal Penis 1 2 3 4
Dobutamin Stress Ekhokardiografi Transophegal Ekhokardiografi Treadmill Tes Exercise Stress Ekhokardiografi
1 2 3 4 5 6 7 8 9 10 11 12 1 2
Bronchoscopy/FOB Tindakan kemotherapi Thoracoscopy Contra Ventil/WSD Punctie Pleura FNAB Scalene Biopsy Reposisi Pleurodesis AFF WSD Perawatan Luka WSD USG Thorax Marker Tindakan Radiologi Injectee contrast Tindakan Radiologi pada pasien dengan kelainan cardiovaskuler Tindakan Radiologi pada pasien dengan alergi berat Tindakan Radiologi pada pasien dengan KU yang menurun Tindakan Radiologi yang memerlukan FNAB Guiding MSCT pada pasien dengan kelainan yang berdekatan dengan organ vital Tindakan Radiologi pada Ibu hamil yang memerlukan foto Cerebral Angiografi AVM&Embolisasi Aneurisma Coiling Embolisasi pre operasi Diagnosis DSA
3
11
KSM Radiologi
4 5
6
KSM 12
Neurologi
Scaling Curettage/root planning (jika diperlukan anestesi) Gingivektomi Frenektomi Flap operasi (bone graft/membrance/GTR/interseptif) Implant Vital pulpektomi dan Partial Nekrose Cauter Retraksi Gingiva pada prep.crown
1 2 3 4 5
46
6 7 8 9 10 11 12 13 14 13 14
16
15
Lumbal Punksi Pain Intervention Injeksi Triger point Injeksi Triger Fringer Injeksi CTS Sub Optical Functional Injeksi botox EMG Neuro endovaskuler: Coiling,Embolisasi,DSA
Instalasi Hemodialisis
Setiap kali melakukan tindakan Hemodialisis
KSM Rehabilitasi Medik
Elektromiografi dan Kecepatan Hantar Saraf
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 Semua injeksi dengan obat risiko tinggi
47
