Daftar. Tindakan Yg Perlu Informed Consent 1r3b4m

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 ts

32

Arthrodesis of shoulder

33

40

Arthrodesis of unspecified t Arthroplasty of carpocarpal or carpometacarpal t with implant Arthroplasty of carpocarpal or carpometacarpal t without implant Arthroplasty of metacarpophalangeal and interphalangeal t with implant Arthroplasty of metacarpophalangeal and interphalangeal t 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 t 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 t 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 by 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 t structures Other diagnostic procedures on muscle, tendon, fascia, and

232

bursa, including that of hand

233

Other division of bone

234

Other excision of t

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 t

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 t 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 t 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 coned twins Separation of unequal coned twins Sequestrectomy Spinal fusion, not otherwise specified Subtalar fusion

358

Subtalar t 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 (BS) Biopsi Jantung Biopsi Perikardium Blalock-Taussing Shunt (BT Shunt) Coronary Artery By 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 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 coned 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 Treill 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