contoh tindakan yg memerlukan informed consent

57
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 diberikan informed consent. Tindakan tersebut yaitu : A. Semua Tindakan Pembedahan dan Tindakan Invasive B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam ) C. Semua Tindakan Pemberian Produk Darah & Komponen Darah D. Semua Tindakan Yang Berisiko Tinggi. A. Tindakan Pembedahan dan Tindakan Invasive yang memerlukan informed consent antara lain: NO KSM/ INSTALASI/ UNIT TINDAKAN 1 KSM Bedah Saraf 1 Amygdala Hypocampectomy (Epilepsi) 2 Anterior Temporomesial Lobectomi (Epilepsi) 3 Biopsi Saraf Tepi/Otot 4 Blok Saraf Perifer I 5 Cingulotomy (Psichiatric) 6 Corpus Callosotomi (Epilepsi) 7 Debrimen Rekonstruksi Vulnus Kulit Kepala 8 Dekompresi Saraf Tepi 9 Dekompresi Tulang Durameter 10 Dekortikasi Sinus Frontalis 11 Denervasi Facet 12 DREZ Lession (Pain) 13 Eksisi Ensefalokel/Mielokel 14 Eksisi Kista Jinak Kulit Kepala 15 Eksisi Osteoma/Osteositosis 1

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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 diberikan informed consent.

Tindakan tersebut yaitu :

A. Semua Tindakan Pembedahan dan Tindakan Invasive

B. Semua Tindakan Anestesi & Sedasi ( Sedasi Sedang dan Sedasi Dalam )

C. Semua Tindakan Pemberian Produk Darah & Komponen Darah

D. Semua Tindakan Yang Berisiko Tinggi.

A. Tindakan Pembedahan dan Tindakan Invasive yang memerlukan informed consent antara lain:

NOKSM/

INSTALASI/UNIT

TINDAKAN

1 KSM BedahSaraf

1 Amygdala Hypocampectomy (Epilepsi)

2 Anterior Temporomesial Lobectomi (Epilepsi)

3 Biopsi Saraf Tepi/Otot

4 Blok Saraf Perifer I

5 Cingulotomy (Psichiatric)

6 Corpus Callosotomi (Epilepsi)

7 Debrimen Rekonstruksi Vulnus Kulit Kepala

8 Dekompresi Saraf Tepi

9 Dekompresi Tulang Durameter

10 Dekortikasi Sinus Frontalis

11 Denervasi Facet

12 DREZ Lession (Pain)

13 Eksisi Ensefalokel/Mielokel

14 Eksisi Kista Jinak Kulit Kepala

15 Eksisi Osteoma/Osteositosis

16 Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan

17 Dura

1

18 Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan

NOKSM/

INSTALASI/UNIT

TINDAKAN

19 Dura

20 Extirpasi Tumor Jinak Saraf Kulit Kepala

21 Fusi Stabilisasi Corpus Vertebra

22 Graft/Transposisi Saraf Tepi

23 Hemisferektomi (Epilepsi)

24 Hemisferoktomi (Epilepsi)

25 Injeksi saraf perifer (dengan radiofrekuensi)

26 Injeksi spinal (Pain)

27Insersi Elektrode Intradural (Epilepsi,movement,psikiatrik)

28 Kordotomi Perkutan

29 Kordotomi Servikal Open (Pain)

30 Kordotomi Servikal Perkutan (Pain)

31 Kranioplasti dua sisi

32 Kranioplasti satu sisi

33 Kraniotomi Biopsi otak

34 Laminektomi Eksisi Tumor Spinal

35 Laminoplasti

36 Laminotomi Biopsi Mielum

37 Laminotomi Diskektomi HNP/Stenosis>1 level

38 Laminotomi Diskektomi HNP/Stenosis 1 level

39 Lesionectomy (Epilepsi)

40 Lobektomi (Epilepsi)

41 Mesencephalectomy (Pain)

42 Mikrodisekktomi HNP

43 MVD (Microvascular Decompression)

44 Neurektomi/Neurolise

45 Neuroendoskopi (Otak,Spinal)

46 Neuroplasti

47 Omaya drain

2

NOKSM/

INSTALASI/UNIT

TINDAKAN

48 Pallidotomi (movement Disorder)

49 Paravertebral Blok Perkutan

50 Pemasangan Traksi Servikal

51 Penjahitan Saraf Tepi

52 Punksi Cairan Otak

53 Reseksi Extra-Temporal (Epilepsi)

54 Revisi VP Shunt

55 Rhizotomi Selektif (Spastisitas)

56 Rhizotomy (Pain)

57 Selective Nerve Root Block

58 Selective Thalamotomi (Movement Disorder)

59 Simpatektomi Open (Pain)

60 Simpatektomi Perkutan

61 SLTH

62 Stereotactic Ablative Procedure (Psichiatric)

63 Subthalamotomy (Movement Disorder)

64 Suturektomi Kraniostenosis

65 Thalomotomy (Pain)

66Transposisi kraniostenosis,dengan orbital advancement

67Transposisi kraniostenosis,tanpa orbital advancement

68 Trepanasi Cedera Kepala (<4jam)

69 Trepanasi Cedera Kepala (>4jam)

70 Trepanasi CVA Bleeding

71 Trepanasi kelainan Saraf Kranial

72 Trepanasi Kelainan Vascular Otak

73 Trepanasi Tumor Otak

74 VA Shunt

75 VP Shunt Multiple

3

76 VP Shunt Satu Sisi

NOKSM/

INSTALASI/UNIT

TINDAKAN

2. KSM Bedah 1 Aff Arch Barr

Kepala Leher 2 Aff Arch Barr dan suspensi maksila

3 Biopsy Insisional dengan anastesi lokal

4 Deseksi submandibula

5 Diseksi leher radikal/radikal neck dissection

6 Eksisi gld submandibula

7 Eksisi higroma leher

8 Eksisi kista tiroglosus

9 Eksisi luas tumor ganas bibir dengan rekontruksi

10 flap lokal

11 Eksisi luas tumor ganas dengan rekontruksi flap jauh

12 Eksisi luas tumor ganas kulit dengan rekontruksi

13 flap 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

25Ekstirpasi/eksisi tumor jinak jaringan lunak ukuran <2cm

26 Ekstirpasi kista dermoid

27 Endoscopic thyroidectomy

28Fiksasi interna fraktur maksilofasial 1-2 tempat patahan

4

NoKSM/

INSTALASI/UNITTINDAKAN

29 Fiksasi interna fraktur nasal

30 Fiksasi interna pan-facial

31 Hemiglosektomi

32 Insisi abses dengan anastesi lokal

33 Insisi flegmon dasar mulut

34 Internal Fiksasi fraktur condylus mandibula

35 Internal Fiksasi fraktur maksilofasial 3-4 tempat

36 patahan

37 Internal fiksasi fraktur maksilofasial 5 tempat patahan

38 atau lebih

39 Laringectomi

3. KSM

Bedah THT-KL

1 Adenotonsilektomi

2 Anthrostomi+Sinuskopi

3 BLM Simple (Kista,Polip,Nodul,Granulasi)

4 Biopsi Tumor

5 Bronkoskopi Rigid

6 BLM Advance (Stenosis, Subjektif/Trakea, Papiloma

Laring/Trakea)

7 Cald Well Luc

8 Cochlear Implant/Implan Baha

9 Dekompresi Nervus Fasialis

10 DCR

11 Eksisi Ekstostosis

12 Ekstirpasi Kista Branchial

13 Ekstirpasi Kista Ductus Tiroglosus

14 Ekstraksi granulasi MAE/Kolesteatosis

15 Ekstraksi Polip

16 Esofagoskopi Rigid & Fleksibel

17 Ethmoidektomi (Intranasal)

18 Ekstraksi Korpus Alienum Kavum Nasi

5

NOKSM/

INSTALASI/UNITTINDAKAN

19 Ekstraksi Korpus Alienum Kavum Nasi Endoskopi

20 Ekstirpasi Fistel Pre Aurikuler

21 Ekstraksi Korpus Alienum MAE

22 Ekstirpasi Kelenjar Sub Mandibula

23 Ekstirpasi Angiofibroma Nasofaring

24 Eksplorasi Abses Parafaringeal

25 Ekstirpasi Tumor Jinak Kepala & Leher (Aterom Lipoma)

26 Faringotomi

27 FESS

28 FESS Advance

29 Frontal Sinusotomi

30 Fore Head Flap

31 Fronto Etmoidektomi (Ekstranasal)

32 FOL

33 Glosektomi Total/Parsial

34 Glosektomi Total/Hemiglosektomi+RND

35 Hemiglosektomi+SOHND

36 Insisi Abses Leher Dalam

37 Inversi Grommet

38 Insisi Perikondritis

39 Irigasi Sinus Maksila

40 Insisi Abses Peritonsil

41 Imunoterapi

42 Konka Reduksi

43 Kaustik Konka Inferior

44 Laringektomi

45 Laringektomi+ND

46 Laringo Fisur/Eksplorasi Laring

47 Ligasi A. Karotis Eksternal

48 Laringoskopi Rigid

6

NOKSM/

INSTALASI/UNITTINDAKAN

49 Laringoskopi Fleksible

50 Laringoskopi Direkta

51 Maksilektomi Total+Rekontruksi

52 Mastoidektomi Radikal

53 Mini FESS

54 Myocutaneus Flap (Pectoral Mayor)

55 Myringoplasty/Timpaniplasti

56 Mandibulekromi

57 Neurektomi Saraf Vidian

58 Osteotomi+Septum koreksi

68 Rekontruksi Fraktur Maksila Multiple

69 Rekontruksi Fraktur Maksila Sederhana

70 Rhinoplasti

71 Rinotomi Lateral+Maksilektomi Medial

72 Rekontruksi Laring Trakea

73 Reposisi Fraktur Os Nasal

74 Reposisi & Fiksasi Fraktur Mandibula

75 Septum Koreksi+Konkotomi

76 Stapedektomi

77 Skin Pricle Test

78 Tiroidektomi Sub-Total

79 Tonsilektomi/Adenoidektomi

80 Tracheostomi

81 Turbinektomi

82 Tiroidektomi Total+ND

83 Temporal Bone Resection

84 Terapi Wicara pada Anak-Anak dan dewasa

85 Terapi Wicara Tuna Laring

7

NOKSM/

INSTALASI/UNIT

TINDAKAN

4 KSM Orthopedi 1 Abdominopelvic amputation

Dan 2 Achillotenotomy

Traumatologi 3 Adductor tenotomy of hip

4 Advancement of tendon

5 Advancement of tendon of hand

6 Amputation above knee

7Amputation and disarticulation of finger- general anaesthesia

8Amputation and disarticulation of finger -local anaesthesia

9Amputation and disarticulation of thumb-general anaesthesia

10Amputation and disarticulation of finger- general anaesthesia

11Amputation and disarticulation of finger -local anaesthesia

12Amputation and disarticulation of thumb-general anaesthesia

13Amputation and disarticulation of thumb-local anaesthesia

14Amputation of ankle through malleoli of tibia and fibula

15 Amputation of toe-general anaesthesia

16 Amputation of toe-local anaesthesia

17 Amputation through foot

18 Amputation through forearm

19Amputation through hand, Amputation through carpals

20Amputation through humerus, Upper arm amputation

21 Amputation, not otherwise specified

22 Ankle fusion

23 Application of external fixator device

24Application of external fixator device, monoplanar system

25 Application of external fixator device, ring system

26 Application of hybrid external fixator device

8

27 Arthrocentesis

NOKSM/

INSTALASI/UNIT

TINDAKAN

28 Arthrodesis of elbow

29 Arthrodesis of hip

30 Arthrodesis of knee

31 Arthrodesis of other specified joints

32 Arthrodesis of shoulder

33 Arthrodesis of unspecified joint

34Arthroplasty of carpocarpal or carpometacarpal joint with implant

35Arthroplasty of carpocarpal or carpometacarpal joint without implant

36Arthroplasty of metacarpophalangeal and interphalangeal joint with implant

37Arthroplasty of metacarpophalangeal and interphalangeal joint without implant

38 Arthroscopy

39Arthrotomy for removal of prosthesis without replacement

40 Aspiration of bursa

41 Aspiration of bursa of hand

42 Aspiration of other soft tissue

43 Aspiration of other soft tissue of hand

44 Atlas-axis spinal fusion

45 Biopsy of bone

46 Biopsy of joint structure

47 Biopsy of spinal cord or spinal meninges

48 Bone graft

49Bone marrow or hematopoietic stem cell transplant (all procedures included in this class

50Bunionectomy with soft tissue correction and arthrodesis

51Bunionectomy with soft tissue correction and osteotomy of the first metatarsal

52 Bursectomy

9

53 Bursectomy of hand

54 Bursotomy

NOKSM/

INSTALASI/UNIT

TINDAKAN

55 Bursotomy of hand

56 Carporadial fusion

57Closed reduction of dislocation -General anaesthesia

58 Closed reduction of dislocation of ankle

59 Closed reduction of dislocation of elbow

60Closed reduction of dislocation of foot and toe-general anaesthesia

61Closed reduction of dislocation of foot and toe-local anaesthesia

62Closed reduction of dislocation of hand and finger-general anaesthesia

63Closed reduction of dislocation of hand and finger-local anaesthesia

64 Closed reduction of dislocation of hip

65 Closed reduction of dislocation of knee

66Closed reduction of dislocation of other specified sites-general anaesthesia

67Closed reduction of dislocation of other specified sites-local anaesthesia

68Closed 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

72Closed reduction of fracture with internal fixation - Carpal and metacarpal

10

73Closed reduction of fracture with internal fixation - Femur (Including : MIPO, interlocking nail, TEN)

74Closed reduction of fracture with internal fixation - Humerus (including : Interlocking nail, TEN, MIPO)

NOKSM/

INSTALASI/UNIT

TINDAKAN

75Closed reduction of fracture with internal fixation - Intrarticular Major Bone

76Closed reduction of fracture with internal fixation - Phalang of foot

77Closed reduction of fracture with internal fixation - Phalang of hand

78Closed reduction of fracture with internal fixation - Radius and ulna (MIPO, TEN)

79Closed reduction of fracture with internal fixation - Tarsal and metatarsal

84 Excision of bone for graft

85 Excision of intervertebral disc

86 Excision of lesion of muscle

87 Excision of lesion of muscle of hand

88 Excision of lesion of other soft tissue

89Dorsal and dorsolumbar fusion of the anterior column, anterior technique

90Dorsal and dorsolumbar fusion of the posterior column, posterior technique

91 Excision of bone for graft

92 Excision of intervertebral disc

93 Excision of lesion of muscle

94 Excision of lesion of muscle of hand

95 Excision of lesion of other soft tissue

96 Excision of lesion of tendon sheath

97Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-General anaesthesia

98Excision of lesion of tendon sheath of hand, Ganglionectomy of tendon sheath (wrist)-Local Anaestesi

99 Excision of muscle or fascia for graft

100 Excision of muscle or fascia of hand for graft

11

101 Excision of other lesion of soft tissue of hand

NOKSM/

INSTALASI/UNIT

TINDAKAN

102 Excision of semilunar cartilage of knee

103 Excision of tendon for graft

104 Excision of tendon of hand for graft

105Excision or correction of bunionette, That with osteotomy

106Excision or destruction of intervertebral disc, unspecified

107 Exploration of tendon sheath

108 Exploration of tendon sheath of hand

109 Exploratory thoracotomy

110 Fasciotomy

111 Fasciotomy of hand

112 Finger reattachment

113 Five-in-one repair of knee

114 Foot reattachment

115 Forearm, wrist, or hand reattachment

116 Fusion or refusion of 2-3 vertebrae

117 Fusion or refusion of 4- 8 vertebrae

118 Fusion or refusion of 9 or more vertebrae

119 Graft of muscle or fascia

120 Hip bearing surface, ceramic-on-ceramic

121Hip bearing surface, ceramic-on-polyethylene, Hip bearing surface, oxidized zirconium-on-polyethylene

122 Hip bearing surface, metal-on-metal

123 Hip bearing surface, metal-on-polyethylene

124Implantation of internal limb lengthening device with kinetic distraction

125Implantation of other internal limb lengthening device

126Implantation or replacement of peripheral neurostimulator lead (s)

12

127Implantation or replacement of spinal neurostimulator lead(s)

128 Incision and drainage of palmar or thenar space

129Injection of anesthetic into peripheral nerve for analgesia

NOKSM/

INSTALASI/UNITTINDAKAN

130 Injection of anesthetic into spinal canal for analgesia

131 Injection of destructive agent into spinal canal

132Injection of locally-acting therapeutic substance into other soft tissue

133Injection of other agent into spinal canal, Intrathecal injection of steroid, Subarachnoid perfusion of refrigerated saline

134 Injection of therapeutic substance into bursa

135 Injection of therapeutic substance into bursa of hand

136Injection of therapeutic substance into joint or ligament

137 Injection of therapeutic substance into tendon

138Injection of therapeutic substance into tendon of hand

139 Insertion of bone growth stimulator

140 Insertion of bone void filler

141

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)

142 Insertion of interbody spinal fusion device

143 Insertion of other spinal devices

144 Insertion of partial spinal disc prosthesis, cervical

145Insertion of partial spinal disc prosthesis, lumbosacral

146Insertion of recombinant bone morphogenetic protein

147Insertion of spinal disc prosthesis, not otherwise specified, Replacement of spinal disc, NOS

148 Insertion of spinal disc prosthesis, thoracic

149 Insertion of sternal fixation device with rigid plates

150 Insertion of total spinal disc prosthesis, cervical

13

152 Insertion of total spinal disc prosthesis, lumbosacral

153 Insertion or replacement of (cement) spacer

154Insertion or replacement of facet replacement device(s)

NOKSM/

INSTALASI/UNIT

TINDAKAN

155Insertion or replacement of interspinous process device(s)

156Insertion or replacement of pedicle-based dynamic stabilization device(s)

157 Insertion or replacement of skeletal muscle stimulator

158Internal fixation of bone without fracture reduction

159Interphalangeal fusion

160 Interthoracoscapular amputation, Forequarter amputation

161 Intra-operative neurophysiologic monitoring - Neuromonitoring

162Intervertebral chemonucleolysis

163Limb lengthening procedures

164Limb shortening procedures

165Local excision of lesion or tissue of bone

166Lower leg or ankle reattachment

167Lower limb amputation, not otherwise specified

168 Lumbar and lumbosacral fusion of the 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

171Lysis of adhesions of hand

172 Lysis of adhesions of muscle, tendon, fascia, and bursa

173Lysis of adhesions of spinal cord and nerve roots

174Metacarpocarpal fusion

175Metacarpophalangeal fusion

176Metatarsophalangeal fusion

177Midtarsal fusion

14

178Muscle transfer or transplantation

179Myotomy

180Myotomy of hand

181Neurectasis

NO KSM/INSTALASI/UNIT

TINDAKAN

182 Open biopsy of cranial or peripheral nerve or ganglion

183 Open biopsy of soft tissue

184Open reduction of dislocation of ankle - Neglected dislocation

185 Open reduction of dislocation of elbow -Fresh dislocation

186Open reduction of dislocation of hand and finger -Fresh dislocation

187 Open reduction of dislocation of hip - Fresh dislocation

188Open reduction of dislocation of hip - Neglected dislocation

189Open 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

192Open reduction of dislocation of shoulder -Fresh dislocation

193Open reduction of dislocation of shoulder -Neglected dislocation

194Open reduction of dislocation of unspecified site-Fresh dislocation

195Open reduction of dislocation of unspecified site-Neglected dislocation

196 Open reduction of dislocation of wrist -Fresh dislocation

197Open reduction of fracture with internal fixation- radius and ulna-Simple fracture

198Open reduction of fracture with internal fixation- unspecified site (Periarticular Major Bone )

199Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw

200Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws Hand NOS -Plate & Screw

201Open reduction of fracture with internal fixation-carpals and metacarpals - simple implants (K-wire) Hand NOS -implant sederhana (K-wire)

202Open reduction of fracture with internal fixation-femur-Comminutive or Segmental

203 Open reduction of fracture with internal fixation-femur-

15

Simple fracture

NOKSM/

INSTALASI/UNIT

TINDAKAN

204Open reduction of fracture with internal fixation-humerus - Simple fracture

205 Open reduction of fracture with internal fixation-humerus - Comminutive or Segmental

206 Open reduction of fracture with internal fixation-other specified bone (Intraartikular Major Bone )

207 Open reduction of fracture with internal fixation-phalanges of foot - simple implants (K-wire)

208 Open reduction of fracture with internal fixation-phalanges of foot-Plate & Screws

209 Open reduction of fracture with internal fixation-phalanges of hand- Plate & Screws

210 Open reduction of fracture with internal fixation-phalanges of hand- simple implants

211 Open reduction of fracture with internal fixation-tarsals and metatarsals- Plate & Screws

212 Open reduction of fracture with internal fixation-tarsals and metatarsals- simple implants

213 Open reduction of fracture with internal fixation-tibia and fibula -Simple fracture

214 Open reduction of fracture with internal fixation-tibia and fibula-Comminutive or Segmental

215Open reduction of fracture without internal fixation

216Open reduction of separated epiphysis

217Osteoclasis (correction of bone deformity)

218Other

219Other (peripheral) vascular shunt or bypass

220Other amputation below knee

221Other anastomosis of cranial or peripheral nerve

222Other and unspecified repair of the anulus fibrosus

223Other arthrotomy

224Other bunionectomy

225Other bunionectomy with soft tissue correction

226 Other cervical fusion of the anterior column, anterior technique

16

227 Other cervical fusion of the posterior column, posterior technique

228Other change in hand muscle or tendon length

229Other change in muscle or tendon length

230Other destruction of intervertebral disc

NOKSM/

INSTALASI/UNIT

TINDAKAN

231 Other diagnostic procedures on joint structures

232Other diagnostic procedures on muscle, tendon, fascia, and

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

239Other exploration and decompression of spinal canal,

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

250Other injection of locally-acting therapeutic substance into

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

17

256 Other operations on muscle, tendon, fascia, and bursa

257Other operations on muscle, tendon, fascia, and bursa,

Suture of bursa

258Other partial ostectomy (including : Bone curretage,

marginal resection/excision)

NOKSM/

INSTALASI/UNIT

TINDAKAN

259Other peripheral nerve or ganglion decompression or lysis of adhesions Peripheral nerve neurolysis NOS

260 Other plastic operations on fascia261 Other plastic operations on hand262 Other plastic operations on muscle263 Other repair of ankle264 Other repair of elbow265 Other repair of hand, fingers and wrist266 Other repair of joint267 Other repair of knee268 Other repair of shoulder269 Other repair of the collateral ligaments270 Other repair of the cruciate ligaments271 Other repair or plastic operations on bone272 Other suture of flexor tendon of hand273 Other suture of muscle or fascia274 Other suture of other tendon of hand275 Other suture of tendon276 Other tendon transposition277 Other tenodesis of hand278 Other tenonectomy279 Other tenonectomy of hand280 Other tenoplasty of hand281 Other tenotomy282 Other total shoulder replacement283 Partial hip replacement284 Partial shoulder replacement285 Patellar stabilization286 Percutaneous denervation of facet287 Percutaneous vertebral augmentation288 Percutaneous vertebroplasty289 Peripheral nerve injection, not otherwise specified290 Plastic operation on hand with graft of muscle or fascia291 Plastic operation on hand with other graft or implant292 Pollicization operation carrying over nerves and blood

supply293 Quadricepsplasty294 Reattachment of muscle

18

295 Reattachment of muscle of hand296 Reattachment of tendon297 Reattachment of tendon of hand298 Refusion of atlas-axis spine299 Refusion of dorsal and dorsolumbar spine, anterior

column, anterior technique

NOKSM/

INSTALASI/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 classified307 Refusion of spine, not otherwise specified308 Release of carpal tunnel309 Release of clubfoot, not elsewhere classified310 Release of tarsal tunnel311 Removal of (cement) spacer312 Removal of bone growth stimulator (invasive)313 Removal of foreign body from spinal canal314 Removal of implanted devices from bone - carpals

and metacarpals-Plate & screw315 Removal of implanted devices from bone - carpals

and metacarpals-simple implants (K-wire)316 Removal of implanted devices from bone - External

fixator device (invasive) (317 Removal of implanted devices from bone - femur318 Removal of implanted devices from bone - humerus319 Removal of implanted devices from bone - radius and

ulna320 Removal of implanted devices from bone - scapula,

clavicle, and thorax (ribs and sternum)321 Removal of implanted devices from bone -

unspecified site (Phalanges (of foot) (of hand)) - Plate & Screw

322 Removal of implanted devices from bone - unspecified site (Phalanges (of foot) (of hand)) - simple implants (K-wire)

323 Removal of implanted devices from bone -patella

19

324 Removal of implanted devices from bone- tarsals and metatarsals- simple implants (K-wire)

325 Removal of implanted devices from bone- tibia and fibula

326 Removal of implanted devices from bone-other (Pelvic bone and Vertebraae)

NOKSM/

INSTALASI/UNIT

TINDAKAN

327 Removal of implanted devices from bone-tarsals and metatarsals - Plate & Screw

328 Removal of internal limb lengthening device329 Removal of pedicle screw(s) used in spinal fusion330 Removal of peripheral neurostimulator lead(s)331 Removal of skeletal muscle stimulator332 Removal of spinal neurostimulator lead(s)333 Reopening of laminectomy site334 Repair of claw toe335 Repair of cleft hand336 Repair of hammer toe337 Repair of hip, not elsewhere classified338 Repair of macrodactyly339 Repair of mallet finger340 Repair of old traumatic injury of cranial and peripheral

nerves341 Repair of recurrent dislocation of shoulder342 Repair of the anulus fibrosus with graft or prosthesis343 Repair of vertebral fracture, Elevation of spinal bone

fragments, Reduction of fracture of vertebrae, Removal of bony spicules from spinal canal

344 Replacement of joint of foot and toe345 Resurfacing hip, partial, acetabulum, Hip resurfacing

arthroplasty, partial, acetabulum346 Resurfacing hip, partial, femoral head347 Revision of total knee replacement, tibial insert (liner),

Replacement of tibial insert(liner)348 Revision or replacement of artificial spinal disc

prosthesis, cervical349 Revision or replacement of artificial spinal disc

prosthesis, lumbosacral350 Revision or replacement of artificial spinal disc

prosthesis, not otherwise specified351 Revision or replacement of artificial spinal disc

prosthesis, thoracic352 Rotator cuff repair353 Separation of equal conjoined twins354 Separation of unequal conjoined twins

20

355 Sequestrectomy356 Spinal fusion, not otherwise specified357 Subtalar fusion

358 Subtalar joint arthroereisis

359 Suture of Artery

360 Suture of capsule or ligament of ankle and foot

NOKSM/

INSTALASI/UNITTINDAKAN

361 Suture of capsule or ligament of other lower

extremity

362 Suture of capsule or ligament of upper extremity

363 Suture of cranial and peripheral nerves

364 Suture of muscle or fascia of hand

365 Suture of tendon sheath

366 Suture of tendon sheath of hand

367 Suture of Vein

368 Synovectomy

369 Tarsometatarsal fusion

370 Tendon graft

371 Tendon pulley reconstruction

372 Tendon pulley reconstruction

373 Tendon transfer or transplantation

374 Tenotomy of hand

375 Thigh reattachment

376 Thumb reattachment

378 Toe reattachment

379 Total ankle replacement

380 Total elbow replacement

381 Total ostectomy

382 Total wrist replacement

383 Transplant from cadaver

384 Transposition of cranial and peripheral nerves -

Nerve transplantation

389 Triad knee repair

390 Triple arthrodesis

391 Unspecified operation on bone injury

392 Upper arm reattachment393 Upper limb amputation, not otherwise specified394 Wedge osteotomy

21

NOKSM/

INSTALASI/UNIT

TINDAKAN

5 KSM BEDAH 1 Biopsi Terbuka BronkhusTHORAKS 2 Biopsi Terbuka Diafragma

DAN 3 Biopsi Terbuka MediastinumKARDIOVASKULAR 4 Biopsi Terbuka Paru

5 Biopsi Terbuka Pleura6 Biopsi Terbuka Pleura dengan VATS7 Biopsi Terbuka Tumor Dinding Thoraks8 Debridement Mediastinum (Sternotomi)9 Eksisi Pada Bronkhus10 Eksisi Pada Paru (Lung Volume Reduction)11 Eksisi Pada Paru dengan VATS

12Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding Dada

13Eksisi Tumor Mediastinum (Thymoma, Teratoma, Neurogenic dsb)

14 Ekstraksi Corpus Alienum di Regio Toraks15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS

16Evakuasi Efusi Pleura/Empyema secara Torakoskopik (VATS)

17 Fiksasi Costae (Clipp, Wire) (diluar Clipp)18 Fiksasi Sternum (Wire, Plate) (diluar wire/plate)19 Lobektomi Parsial (Reseksi Paru segmental)

20Lobektomi Parsial (Reseksi Paru segmental) dengan VATS

21 Lumbal Simpatektomi22 Mediastinostomy

23Pemasangan thorak drain/water sealed drainage (WSD) (diluar alat)

24 Pleural window (Eloeser Flap)25 Pleurektomi26 Pleurodesis (Pleurosklerosis)27 Plikase Bulae / Bleb Emfisematous28 Plikasi diafragma29 Pneumonectomy30 Pneumonectomy dengan VATS31 Pulmonary Decortication32 Pulmonary Decortication dengan VATS33 Pulmonary Lobectomy/Bilobectomy34 Pulmonary Lobectomy/Bilobectomy dengan VATS

22

35 Redo Torakotomi36 Rekonstruksi Sternum&Dinding Dada37 repair deformitas Pectus38 Repair Fistula Bronkopleural39 Repair Laserasi Diafragma

NOKSM/

INSTALASI/UNIT

TINDAKAN

40Revisi Thoraks drain/water sealed drainage (WSD) (diluar alat)

41Thoracal Symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS)

42 Thoracocentesis43 Thymectomy44 Thymectomy dengan VATS45 Torakoplasti (Air Plumbage/Muscle Plumbage)46 Torakotomi / sternotomi Eksplorasi

47Torakotomi Eksplorasi pada Trauma jantung/Repair Laserasi Jantung

48 Bedah Kardio (Jantung)49 Aortic Valve Repair (AVR)50 Aortic Valve Repair (AVR) dengan Bioprosthesis Valve51 Aortic Valve Repair (AVR) dengan Mechanical Valve52 Atrial septal Defect (ASD) Closure53 Bidirectional Cavo-Pulmonary Shunt (BCPS)54 Biopsi Jantung55 Biopsi Perikardium56 Blalock-Taussing Shunt (BT Shunt)57 Coronary Artery Bypass Graft (CABG)58 Eksisi Cardiac Myxoma59 Fontan Operation (Atrium-Pulmonary Artery Conduit)60 Internal Resusitasi/Cardiac Massage (Operasi Terbuka)61 Ligasi Patent Ductus Arteriosus (PDA)62 Mitral valve repair (MVr)63 Mitral Valve Repair (MVR) dengan Bioprosthesis Valve

64 Mitral Valve Replacement (MVR) dengan Mechanical Valve

65 Operasi Redo Open Heart (Valve Replacement)

66 Operasi Reopen oleh Karena sebab Perdarahan, Tamponade Jantung

67 Pemasangan IABP68 Pemasangan Pace Maker Permanen (diluar alat)69 Pericardiocentesis70 Perikardiektomi71 Perikardiotomi/Pericardial Window72 Pulmonal Valve Repair (PVR)73 Pulmonal Valve Repair (PVR) dengan Bioprosthesis

23

Valve74 Pulmonal Valve Repair (PVR) dengan Mechanical Valve75 Pulmonary Artery Banding (PA)

NOKSM/

INSTALASI/UNITTINDAKAN

76 Rastelli Procedure (right Ventricle-Pulonary Artery Conduit)

77 Repair (Eksisi) Aneurisma Jantung78 Repair Aorta Torakalis (38.34)79 Repair Atrioventricular Septal Defect (35.54)

80Repair Total Anomalous Pulmoanry Venous Connection (TAPVC) (35.82)

81 Repair Transposition of Great Arteries (TGA) (35.84)82 Repair Trunkus Arteriosus (35.83)83 Revisi/Aff Pace Maker Permanen (diluar alat) (37.89)84 Septostomi Terbuka Septum Atrium (35.41)85 Total Koreksi Tetralogy of Fallot (TOF) (35.81)86 Tricuspid Valve Repair (TVR) (35.14)

87Tricuspid Valve Repair (TVR) dengan Bioprosthesis Valve (35.27)

88Tricuspid Valve Repair (TVR) dengan Mechanical Valve (35.28)

89 Ventricle Septal Defect (VSD) Closure (35.5)90 Amputasi Above Knee (AK) (84.17)91 Amputasi Below Knee (BK) (84.14)92 Arterial Pungsi, Kanulasi, Sectie (38.91)93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42)94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27)95 Bedah Varises Insisi Babcock (38.5)96 Biopsi Pembuluh Darah (Perifer) (38.21)97 Debriment-Nekrotomi Luka Gangren (86.22)

98 Disartikulasi Sendi Ekstremitas (84.13)6 Eksisi Biopsi 1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma)

Tumor Pembuluh 2 Eksplorasi Vaskular (Trauma/Non trauma)

Darah 3 Embolektomi/Trombektomi Aorta4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal

5Embolektomi/Trombektomi Pembuluh Darah Arteri Ekstremitas Bawah

6Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Atas (diluar alat)

7Embolektomi/Trombektomi Pembuluh Darah Ekstremitas Bawah(diluar alat)

8Embolektomi/Trombektomi Pembuluh Darah Regio servikal (Karotis, Jugular) (diluar alat)

9Evakuasi Hematom di Ekstremitas (Pasca Pungsi HD/ Traumatik)

24

10 Fasciotomy11 Ligasi Vaskular Ekstremitas12 Mutilasi Digiti Ekstermitas

NOKSM/

INSTALASI/UNITTINDAKAN

13Pasang Double Lumen Hemodialisis (HD) (diluar alat)

14Pasang Implantable Central Venous Access (diluar alat: porth-a-cath, celsite)

15Pemasangan Central Venous Catheter (CVC) (diluar alat)

16Pemasangan Intra Aortic Baloon Pump (IABP) (diluar alat)

17Pemasangan Peritoneal Dyalisis (PD) Catheter (diluar alat)

18 Pembedahan Teleangiectasis

19Repair Aneurisma (True/false) Ekstremitas Superior (diluar graft)

20Repair Aneurisma Aorta Abdominalis (Diluar Protesa)

21Repair Pembuluh Darah Regio Servikal (Karotis, Jugular)

22 Repair Ruptur Pembuluh Arteri Abdominal23 Revisi Arteriovenous Shunt24 Skleroterapi Vena (Varises, Hemangioma)25 Stripping Varises Ekstremitas Inferior

26Vascular Shunting (Splenorenal Shunt, De Palma Shunt)

27 Vena Punctie, Kanulasi, Sectie7 KSM BEDAH 1 Abdominal pull through (sfingter saving procedure)

DIGESTIVE 2Abdominoperineal resection (miles) dengan penyulit mayor

3Abdominoperineal resection (miles) dengan penyulit minor

4 Abdominoperineal resection (miles) tanpa penyulit5 Abdominoplasty6 Apendektomi7 Apendektomi dgn penyulit major8 Apendektomi dgn penyulit minor9 Apendektomi laparoskopik10 Bilio-difgestif anastomosis tanpa penyulit11 Biliodigestif dengan penyulit mayor12 Biliodigestif dengan penyulit minor13 Biopsi insisional, local anastesi14 Biopsi rectum15 Eksisi hemoroid eksterna16 Eksplorasi duktus bilier & cholangiografi intra operatif17 Esofagotomi

25

18 Fistulotomi

NOKSM/

INSTALASI/UNITTINDAKAN

19 Fistulotomi dgn penyulit mayor20 Fistulotomi dgn penyulit minor21 Gastrostomi22 Hemikolektomi dengan penyulit mayor23 Hemikolektomi dengan penyulit minor24 Hemikolektomi tanpa penyulit25 Hemoroid stapling (diluar alat)26 Hemoroidektomi27 Herniotomi28 Herniotomi dgn penyulit mayor29 Herniotomi dgn penyulit minor30 Herniotomi laparoskopik31 Jejunostomi / ileostomi32 Laparotomi dengan penyulit minor33 Laparotomi tanpa penyulit34 Ligasi hemoroid (diluar alat)

35Pankreatiko-duodenektomi cephalis (Whipple) dengan penyulit mayor

36 Peritoneal dreanse (CAPD)37 Peritoneal lavase38 Polipektomi39 Potong kolostomi40 Prosedur Heller41 Rektopexy42 Repair fistel usus43 Repair fistel vesicorectal44 Repair hernia cicatricalis

45Repair hernia cicatricalis dgn penyulit mayor (diluar alat)

46Repair hernia cicatricalis dgn penyulit minor (diluar alat)

47 Repair Hernia Diafragmatika (diluar alat)48 Reseksi anterior dengan penyulit mayor49 Reseksi anterior dengan penyulit minor50 Reseksi anterior tanpa penyulit51 Reseksi esofagus-colon / ileum transposisi52 Reseksi esofagus-end to end53 Reseksi esofagus-esofago-gastrectomy54 Reseksi hati55 Second look laparoscopy56 Splenektomi / splenoraphy traumatika57 Splenektomi non trauma58 Terminal esofagus proksimal gastrektomi (TEPG)

26

59 Total gastrektomi

NOKSM/

INSTALASI/UNITTINDAKAN

60 Total pantreaktomi61 Total prokto-kolektomi62 Tutup burst abdomen (tanpa alat)63 Tutup burst abdomen dengan penyulit mayor64 Tutup burst abdomen dengan penyulit minor65 Tutup kolostomi / ileostomi66 Tutup kolostomi / ileostomi dengan penyulit mayor67 Tutup kolostomi / ileostomi dengan penyulit minor68 Repair Aorta Torakalis (38.34)69 Repair Atrioventricular Septal Defect (35.54)

8 KSM BEDAH 1 AdrenalektomiUROLOGI 2 Adrenalektomi (Abdominotorakal)

3 Anastomosis end to end Ureter4 Augmentasi Buli5 Biopsi Ginjal perkutan6 Biopsi Ginjal Terbuka7 Biopsi Penis8 Biopsi Prostat9 Biopsi Testis10 Bladder Neck Rekonstruksi11 Buried Penis12 Businasi/Dilatasi Uretra13 Cabut DJ Stent14 Defooring Kista Ginjal per Laparoskopi15 Deroofing/Unroofing Kista16 Diseksi Kelenjar Getah Bening Inguinal17 Diseksi Kelenjar Getah Bening pelvis

18Diseksi Kelenjar Getah Bening Pelvis per Laparoskopi

19 Divertikulektomi Buli20 Divertikulum Uretra21 Dorsumsisi22 Drainase Periureter23 Eksisi Chordae/Chordektomi24 Eksisi Fibroma/Rekonstruksi Penis25 Eksisi Plaque (Peyronie Disease)26 Eksisi Webbed Penis27 Eksplorasi testis (Microsurgery)28 Ekstraksi Batu29 Ekstrofi Buli Rekonstruksi30 Epispadia31 Evakuasi Bekuan Darah (Clot)32 Extended Pyelolithotomy

27

33 Fistulektomi/Repair Fistel Uretra

NOKSM/

INSTALASI/UNITTINDAKAN

34 Funikokelektomi35 Ganti Nefrostomy36 Hidrokel per Inguinal/Ligasi Tinggi37 Hidrokel per Skrotal38 Hipospadia Subkoronal39 Holmium YaG Laser (Sewa)40 Ileal Conduit (Bricker)41 Insersi DJ Stent42 Insisi Abses Perineum43 Insisi Abses Skrotum44 Insisi Posterior Urethral Valve45 Johanson46 Johanson I47 Johanson II48 Kalibrasi Uretra49 Kauterisasi50 Koreksi Horseshoe Kidney51 Koreksi Priapismus52 Laparoskopi Adrenalektomi53 Laparotomi Eksplorasi54 Ligasi V.Spermatika Interna (Microsurgery)55 Limfadenektomi Ilioinguinal56 Limfadenektomi Retroperitoneal/RPLND57 Litholapaksi58 Lithotripsi59 Masase Prostat60 Meatoplasti61 Meatotomi62 MMK/Sling Uretra63 Nefrektomi64 Nefrektomi Donor Transplant65 Nefrektomi Parsial66 Nefrektomi per Laparoskopi67 Nefrektomi Radial68 Nefropeksi/Renopeksi69 Nefrostomi Perkutan/Temporer70 Nefrostomi Terbuka/Permanen71 Nefroureterektomi72 Neobladder73 Operasi Priapismus (prosedur Winter)74 Operasi Repair Buli Trauma75 Operasi Sistokel

28

NOKSM/

INSTALASI/UNITTINDAKAN

76 Operasi Trauma Ginjal77 Operasi Urakhus/Reseksi urakhus78 Orkhidektomi79 Orkhidektomi extended80 Orkhidektomi Ligasi Tinggi81 Orkhidektomi Subkapsuler82 Orkhidopeksi (Torsio Testis)83 Orkhidopeksi (UDT)84 Orkhidopeksi per Laparoskopi85 Pasang Kateter86 Pasang Kateter dengan Mandrain87 Pasang Kateter Tenckhoff untuk CAPD88 PCNL/PNL89 Penektomi Parsial90 Penektomi Total/Amputasi Penis91 PER (Primary Endoscopic Realignment)92 Pielokalikotomi93 Pielolitotomi94 Pieloplasti95 Pieloplasti per Laparoskopi96 Prostatektomi Radikal97 Prostatektomi Retropubik98 Prostatektomi Terbuka99 Prostatektomi Terbuka dan Sectio Alta

100 Psoas Hitch/Boari Flap101 Punksi dan sklerosing Kista Ginjal

102 Railroading Rupture Uretra103 Reimplantasi Ureter Bilateral

104Reimplantasi Ureter Unilateral/Ureteroneosistostomi

105 Rekontruksi Renovaskuler106 Repair Fistel Enterovesika107 Repair Fistel Vesikokutan108 Repair Fistel Vesikorektal109 Repair Fistel Vesikovagina110 Repair Fistel Vesikovagina Kompleks111 Reparasi Penis112 Reseksi-anastomosis Uretra113 RPG114 Sectio Alta/Vesikolithotomi115 Sirkumsisi115 Sistektomi Parsial/Sistoplasti Reduksi116 Sistektomi Per Laparoskopi117 Sistektomi Total/Radikal118 Sistoskopi

29

119 Sistoskopi ODS

NOKSM/

INSTALASI/UNITTINDAKAN

120 Sistostomi perkutan121 Sistostomi Terbuka122 Skrotoplasti123 Spermatokelektomi124 Tailoring Ureter125 Transplan Resipien126 Transuretero-ureterostomi127 TUR Prostat/TUIP/BNI128 TUR Tumor Buli129 TVP/TMP130 Ureterokutaneostomi131 Ureterolisis132 Ureterolithotomi133 Ureterolithotomi Distal134 Ureterolithotomi Proksimal135 Ureterosigmoidostomi (Caffey)136 Ureterostomi137 Ureterouretostomi138 Uretroplasti Hipospadia139 Uretroskopi/Uretrosistoskopi140 Uretrotomi Interna (Sachse)141 URS/Lithotripsi142 Varikokelektomi (Palomo)143 Vasektomi (anestesi lokal)144 Vasektomi (narkose)145 Vasoepididimostomi146 Vasografi147 Vasovasostomi

9 KSM ILMU 1 Angkat JahitanKESEHATAN 2 Angkat Jahitan dengan GA

MATA 3 Anterior Chamber Tap/Parasintesis4 Aspirasi Massa Lensa5 Blefaroplasty (2 Kelopak Mata)6 Claw Lens7 Cryopexy Kornea8 Cyclo Cryo9 Dacryocystorinostomi (Without Silicon Tube)10 Dekompresi Orbital/Lateral Orbitotomi11 Disisi Aspirasi & IOL12 ECCE13 ECCE & IOL14 Eksenterasi15 Eksisi Hordeolum / Chalazion16 Ekstirpasi Corpus Alienum di Kornea

30

17 Ekstirpasi Pterygium + Graft Konjungtiva

NOKSM/

INSTALASI/UNITTINDAKAN

18 Ekstripasi Corpus Alienum di Bilik Mata Depan19 Enukleasi/Eviscerasi (DFG/Bonegraft)20 Evakuasi Silikon Oil21 Fornix Repair22 ICCE23 ICCE & IOL24 Injeksi Intra Vitreal25 Injeksi Periokuler Terapetik26 IOL Explant27 Iridectomi28 Jahit Kelopak Mata Full Thickness & Lid Margin29 Jahit Kornea30 Keratoplasti (Corneal Transplantation)31 Konjungtival Flap/Amnion Graft32 Piggy Back IOL33 Pneumoretinopexy34 Repair Canalis Lacrimalis (Without Silicon Tube)35 Repair Coloboma Palpebra (Skin/Mucosal Graft)36 Reposisi IOL37 Reposisi Iris38 Resesi & Reseksi 2 Otot39 Resesi & Reseksi 3 Otot40 Resesi & Reseksi 4 Otot41 Resesi/Reseksi 1 Otot42 Sekunder Implant (Posterior Chamber)43 Sekunder Implant Claw Lens / Fiksasi Sulcus44 SICS45 SICS & IOL46 Simpel Vitrektomi47 Skleral Buckle48 Socket Repair (Contracted Socket)49 Trabekulektomi50 Trabekuletomi & Ollogen

51Trabulektomi & Goniotomi pada Pediatric Glaucoma

52 Tube Shunt (Express)53 Viscocanulostomy54 Vitrektomi +++55 Vitrektomi Lengkap & Skleral Buckle56 Wide Eksisi Tumor Kelopak Mata57 Wide Eksisi Tumor Kelopak Mata + Flap + graft

31

NOKSM/

INSTALASI/UNITTINDAKAN

10 Divisi Onkologi 1 Aspirasi Kista Mamma Single dan Multiple2 Biopsi Core Lokal Anestesi3 Biopsi Eksisi Lokal4 Biopsi Eksisi Narkose5 Biopsi Insisi Lokal6 Biopsi Narkose7 Breast Conserving Surgery (BCS)8 Breast Conserving Surgery + LD Flap9 Debriment Mamma10 Diseksi Axilla11 Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi12 Eksisi Fibroadenoma Multiple Narkose13 Eksisi Tumor Metastase Loco-regional14 Eksplorasi Duktus Mama15 Eksplorasi Duktus Mama+VC16 Insisi Absces Mastitis Lokal17 LD Flap + Eksisi Tumor18 Mastectomy + Tram Flap19 Modified Radical Mastectomy + Flap/Single Grafting20 Modified Radical Mastectomy Single21 Quadrantectomy / Partial Mastectomy22 Simple Mastektomy + Flap/Skin Grafting23 Simple Mastektomy Single24 Tram Flap + Eksisi Tumor25 Operasi Tumor Kulit26 Biopsi Insisi Tumor Kulit Lokal27 Biopsi Eksisi Tumor Kulit Narcose28 Eksisi Tumor Jinak ≤ 3cm29 Eksisi Tumor Jinak + Flap/Skin Graft30 Eksisi Tumor Jinak Kulit >3cm31 Wide Eksisi + Diseksi KGB32 Wide Eksisi Tumor Ganas Kulit33 Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft34 Operasi Soft Tissue Tumor35 Amputasi + Diseksi KGB36 Amputasi Jari + Flap / Skin Graft37 Amputasi Tungkai / Lengan38 Biopsi Core soft Tissue39 Biopsi Insisi Tumor Sof Tissue dengan Narcose40 Biopsi Insisi Tumor Soft Tissue Lokal Anestesi41 Eksisi Tumor Jinak > 3cm42 Eksisi Tumor Jinak Ø<3cm43 Wide Eksisi + Compartement Procedure44 Wide Eksisi + Diseksi KGB45 Wide Eksisi Tumor Ganas46 Wide Eksisi Tumor Jinak + Flap/Skin Graft

32

NOKSM/

INSTALASI/UNITTINDAKAN

47 Operasi Tindakan Tertentu

48 Advancement Flap

49 Aspirasi Effusi Pleura

50 Aspirasi Paru + Pleurodhesis

51 Delto Pectoral Flap (DP Flap)

52 Diseksi Axilla

53 Diseksi Inguinal

54 Diseksi Para Aorta

55 Eksisi Tumor Lidah

56 Eksisi Tumor Sub Mandibula/Sub Mental

57 Insersi Chest Tube

58 Ismulobectomy

59 Kemoterapi Perinfus

60 Latissimus Dorsi Flap (LD Flap)

61 Maksilektomi Total

62 Mastopexy

63 Modifikasi RND

64 Operasi Compartement Otot

65 Ovariectomy Bilateral

66 Reseksi Mandibula

67 Rotation Flap

68 Skin Grafting

69 Sub Total Thyroidectomy

70 Superficial Parotidectomy

71 Thoraco Abdominal Flap (TA-Flap)

72 Total Parotidectomy

73 Total Thyyroidectomy

74 Transversus-Rectus Abdominis Flap (Tram Flap)

33

NOKSM/

INSTALASI/UNITTINDAKAN

11 DIVISI BEDAH 1 Abdominal pull through (sfingter saving procedure)

ANAK 2 Adhesiolisis

3 Appendektomi dgn penyulit

4 Appendektomi laparoskopik

5 Appendektomi tanpa penyulit

6 Biliodigesif dengan penyulit mayor

7Biliodigestif anastomosis tanpa penyulit atau penyulit minor

8 Biopsi rectum

9 By pass usus dengan penyulit mayor / minor

10 Divertikulektomy

11 Drainase abses dengan general anasthesia

12 Drainase abses local anasthesia

13 Eksisi hygroma colli

14 Eksisi kista brachialis

15 Eksisi kista duktus tiroglossus

16 Eksisi neoplasma Jinak ( lipoma, atheroma dll )

17 Eksisi sinus/granuloma umbilikalis

18 Eksisi soft tissue tumor dengan penyulit

19 Eksisi soft tissue tumor tanpa penyulit

20 Eksisi teratoma dengan penyulit dan rekonstruksi

21 Eksisi teratoma tanpa penyulit

22 Eksisi tumor jinak wajah

23 Eksisi urachus

24 Ekstirpasi fistel pre aurikulae

25 Ekstirpasiranula

26 Endoskopik diagnostik

27 Endoskopik terapeutik

28 Gastrostomi

29 Hemikolektomi

30 Herniotomi elektif tanpa penyulit

31 Herniotomi laparoskopik

34

NOKSM/

INSTALASI/UNITTINDAKAN

32 Hernitomi dgn penyulit / komplikasi

33 Hidrokolektomi

34 Intraoperatif kolangiografi

35 Intraoperatif kolangiografi laparoskopik

36 Jejenostomi / ileostomi dengan penyulit mayor

37 Jejenostomi / ileostomi dengan penyulit minor

38 Jejenostomi / ileostomi tanpa penyulit

39 Koledokotomi dengan penyulit mayor

40 Kolesistektomi

41 Kolesistektomi laparoskopik

42 Kolostomi / sigmoidostomi (46.11)

43 LADD Operation (54.95)

44 Laparoskopik diagnostik (61.6)

45 Ligasihemoroid (49.4)

46 Operasi kelainan umbilikal lain (54.3)

47 Orchidopexy (62.5)

48 Orchidopexy laparoskopik (62.5 + 61.6)

49Other Repair of Abdominal Wall (Repair Omphacele) (954.72)

50 Polipektomi (48.36)

51 Posterosagital anorectoplasty (49.79)

52Posterosagital anorectoplasty urethro vaginoplasty (70.79)

53 Potong kolostomi (46.14)

54 Potong Stump (84.3)

55 Prosedur Heller (44.6)

56 Prosedur Kasai (51.37)

57 Repair atresia esofagus (42.5)

58 Repair defek diafragma (53.8)

59 Repair ekstrofia buli (57.8)

60 Repair hernia diafragma (53.7/53.8)

35

NOKSM/

INSTALASI/UNITTINDAKAN

61 Repair of Gastrochisis (54.71)

62 RPLND (40.59)

63 Separasi conjoined twin (84.9)

64 Sirkumsisi dengan general anesthesia (64.0)

65 Sirkumsisi dengan local anesthesia (64.0)

66 Splenektomi (41.5)

67 Splenorenal shunt (39.1)

68Transnasal endorectal pullthrough laparascopic assisted (48.42)

69 Transplantasi organ

70 Tutup burst abdomen dengan penyulit (54.61)

71 Tutup burst abdomen tanpa penyulit (54.61)

72 Tutup ileostomi dengan penyulit (46.5)

73 Tutup kolostomi / ileostomi (46.5)

74 Tutup Stoma (46.5)

75 Urethroplasty / chordectomy (64.42)

76 Vena Sectie Aksilaris (38.94)

77 Vena sectie Femoralis / saphena magna (38.94)

78 Wound repair (86.8)

12 KSM BEDAH 1 AbdominoplastyPLASTIK 2 Aff archbar, Lokal Anastesi

3 Aff Suspensi, Lokal Anastesi

4 Amputasi above elbow

5 Amputasi bellow elbow

6 Amputasi digital

7 Amputasi jari >1

8 Amputasi jari single

9 Augmentasi mamae

10 Blefaroplasty (2 kelopak mata)

11 Blefaroplasty pada kasus sulit

12 Blefaroptosis

36

NOKSM/

INSTALASI/UNITTINDAKAN

37

13 Bone rekonstruksi facial cleft

14 Bone rekonstruksi facial cleft

15 Cheilonasoraphy

16 Chordectomy

17 Chordectomy+urethroplasty

18 Closed Reduction Fr. Nasal

19 Comisuroplasty

20 Eks mamma aberan bilateral

21 Eksisi neoplasma jinak (lipoma, atheroma dll)

22 Eksisi luas + Deltopectoral flap

23 Eksisi luas + Fore head flap

24 Eksisi luas + Muskulocutan flap

25Eksisi luas + rekonstruksi dengan bedah mikrovaskular

26 Eksisi malformasi lymphatik / vaskuler

27 Ekstraksi ateroma / keloid28 Ekstraksi korpus alienum29 Elevasi ear rim cartilago30 Excise hemangioma + rekonstruksi31 Excise intra keloid32 Excise polydactyly33 Excise reduksi lymedema34 Facial sling dengan allograft35 Fasciotomy burn injury36 Fasciotomy with complication37 Flap lokal sederhana38 Fr. Condylus mandibula open red39 Fr. Maksila suspensi (IOID)40 Fr. Nasal open reduction

41Fraktur Prosesus alveolaris dengan inter dental wiring (IDW) (per rahang)

42Fraktur Prosesus alveolaris luas dengan IDW (per rahang)

43Fraktur rahang reduksi terbuka & inter oseus wiring (IOW)

NOKSM/

INSTALASI/UNITTINDAKAN

44 LD flap

38

45 Le fort I osteotomy46 Liposuction47 Lobuloplasti48 Malarplasty49 Mamma aberan unilateral50 Mandibular distraksi51 Mandibular rekonstruksi dengan costochondral graft52 Mastopexi53 Mentoplasty54 Microsurgery55 Multiple facial fraktur + implant56 Muskulokutaneus flap57 Myokutaneus flap/pectoralis mayor flap58 Nasal repair dan rekonstruksi59 Neo vagina60 Operasi bedah mikro61 Orif fraktur zygoma62 Orif fraktur hand63 Orif fraktur mandibula64 Orif fraktur maxilla65 Orif maksila plating66 Orif mandibula plating67 Orif mandibula wiring68 Orif orbital wall69 Orif orbital wall70 Orif zygoma wiring71 Osteotomy craniosynostosis reconstruction72 Osteotomy facial rekonstruksi73 Osteotomy genioplasti tanpa tarif bahan74 Osteotomy maksila Le fort I75 Osteotomy maksila Le fort II76 Palatoplasti bilateral komplit77 Palatoplasti bilateral tak komplit78 Palatoplasti unilateral komplit79 Palatoplasti unilateral tak komplit80 Palatoraphy81 Pasang archbar82 Pasang back slab/fore slab83 Pasang cast/gips tanpa reposisi84 Recheiloraphy85 Rekonstruksi dengan alloplastic material86 Rekonstruksi facial cleft87 Rekonstruksi nasal

NOKSM/

INSTALASI/UNITTINDAKAN

88 Rekonstruksi palpebra

39

89 Released buried penis90 Released syndactyly kompleks91 Repair canalis lacrimalis (without silicon tube)92 Repair coloboma palpebra (skin/mucosal graft)93 Repair ductus nasolacrimalis94 Repair fingertip injury95 Repair fistel urethra96 Replantation97 Reposisi fraktur nasal sederhana98 Reposisi fraktur os nasalis (complicated)99 Reseksi mandibula + bone graft

100 Rhinoplasty101 Rotation flap102 Sagital Split osteotomi mandibula103 Simple bone grafting104 Simple skin grafting105 Skin flap106 Skin graft >5 cm107 Skin graft sedang 5 cm108 Skin grafting kecil109 Skin grafting luas110 Skin grafting sedang111 Skin grafting with complication112 Tendon reconstruction113 Tendon transfer114 Tendon transfer with complication115 Tennoraphy116 Tennoraphy with complication117 TMJ arthroplasty118 TMJ arthrostomy119 Tram flap120 Wound Dressing121 Wound Repair

NOKSM/

INSTALASI/UNITTINDAKAN

13 KSM 1 Cauter serviks

OBGYN 2 Cordosentesis

40

3 Debulking tumor ovarium

4 Eksplorasi vagina

5 Embryotomi

6 Extirpasi + kuret polip endoserviks

7 Extirpasi geboren mioma

8 Extirpasi geboren mioma+kuiretasi

9 Histeroctomy pada mola / chorio Ca

10 Histeroctomy radikal

11 Kistektomi

12 Konisasi serviks

13 Kuret abortus incompletes

14 Lap op: myomektomi

15Laparoskopi (Kistektomi Ovarium, Salphingektomi, Adhesiolisis)

16 Laparoskopi Histerektomi

17 Laparoskopi steril

18 Laparoskopik Diagnostik

19 Laparotomi dengan penyulit mayor

20 Laparotomi dengan penyulit minor

21 Laparotomi tanpa penyulit

22 LEEP

23 Micro kuretase DUB

24 Mikrokuret

25 Miomectomy

26 Neovagina

27 Operasi Ca vagina

28 Operasi kanker corpus uteri

29 Operasi tumor ganas ovarium

30 Operative histeroscopy/Ablasi endometrium

31 Overectomi

NOKSM/

INSTALASI/UNITTINDAKAN

32 Painless labor

41

33 Persalinan normal

34 Persalinan normal dengan penyulit

35 Persalinan pervaginam tindakan operatif

36 Persalinan sungsang

37 Rekanalisasi

38 Rekanalisasi tuba

39 Salfingektomi unilateral

40 Salvingoovarectomi unilateral

41 Secound look surgery Ca ovarium

42 Seksio sesaria

43 Seksio sesaria dengan penyulit penyulit

44 Sirklase serviks

45 Seksio sesaria dengan penyulit penyulit

46 Sirklase serviks

47 Supra vaginal hyterectomy

48 Surgical staging

49 TAH+BSO dengan Penyulit

50TAH+BSO dengan Penyulit Pemasangan Tampon Abdomen

51 Total abdominal hysterectomy+bilateral salfingektomi

52 Tubektomi klinik

53 Tutup burst abdomen

NOKSM/

INSTALASI/UNITTINDAKAN

14 KSM 1Augmentasi Tulang Per Regio (Belum Termasuk Bahan)

GIGI dan 2 Debriment Mukosa dan Pengelolaan Luka SayatMULUT 3 Dislokasi Sendi Mandibula

42

4 Eksisi Epulis Per Rahang

5 Eksisi Kelenjar Ludah Submandibula

6 Eksisi Kista Odontogenik Keratosis + Ostektomi

7 Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil

8 Eksisi Parsial + Marsupialisasi Ranula

9 Eksisi Plunging Ranula

10 Eksisional Biopsi Neoplasma Jinak

11 Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi

12Enukleasi Kista radikuler Per Rahang + Extraksi Gigi Penyebab

13 Extirpasi Kista Dermoid

14 Extirpasi Sialolith

15 Extraksi Corpus Alienum dengan Teknik Lindorf

16Extraksi Gigi Anak dengan Kelainan Jantung Per Rahang

17 Extraksi Gigi Anak Per Rahang

18 Extraksi Gigi Dewasa Per Rahang

19 Fissure Sealant pada Autis

20 Fraktur Dento alveolar Dengan arch Bar

21Fraktur Dento alveolar Dengan Bracket (belum termasuk bahan)

22 fraktur Dento Alveolar dengan Eyelet

23 Fraktur Maksila dengan Suspensi Wiring

24 Fraktur Nasal close Reduksi

25 Fraktur Nasal Open Reduksi

26Fraktur Rahang Reduksi Tertutup dengan Intermaksila Fiksasi

27 Frenektomi Per Rahang

28 Genioplasty

29 Gingivektomi Per Rahang

NOKSM/

INSTALASI/UNITTINDAKAN

30 Hemi Maksilektomi Tanpa Rekonstruksi

31 Insisi Abses / Phlegmon

32 Insisional Biopsi Neoplasma Jinak

43

33 Mandibular Distraksi

34 Odontektomi Per Gigi

35ORIF Maksila + Zygoma + Mandibula (belum termasuk implant)

36 ORIF Maksila Plating (belum termasuk implant)

37 ORIF Mandibula Plating (belum termasuk implant)

38 ORIF Zygoma Plating (belum termasuk implant)

39 Osteotomi Maksila le Fort I

40 Osteotomi Maksila le Fort II

41 Pelepasan Arch Bar (Intermaksila Fiksasi)

15 DIVISI PEDIATRI 1 Intubasi Endotrakea

GAWAT 2 KrikotirotomiDARURAT 3 Kanulasi vena perifer

ILMU 4 Vena sectieKESEHATAN 5 Pungsi lumbal

ANAK 6 Pungsiv Pleura

16 KSM PENYAKIT 1 Diagnostik Kateterisasi Jantung

JANTUNG & 2 PTMCPEMBULUH 3 PTCA/Stenting

DARAH 4 Pacemaker Temporer&Permanen

5 IABP

6 Perikardiosintesis

7 Pemasangan Swan Ganz Kateter

8 Pemasangan Amplatzer/ADO/Coilling

9 CVC

10 Pelepasan Arch Bar (Intermaksila Fiksasi)

17KSM PENYAKIT

DALAMEndoscopy

B. Tindakan Anestesi &Sedasi ( Sedang dan Dalam), tindakan yang

memerlukan informed consent tersebut antara lain:

a. Semua tindakan anestesi dan sedasi di dalam kamar operasi

b. Semua tindakan anestesi dan sedasi di ICU

44

Tindakan Anestesi di ICU

Pemasangan intubasi ventilatorPemasangan vena centralPemasangan CRRTPemasangan Swan Ganz (Kateter Arteri Pulmonal)Pemasangan Intra Arterial Catheher (Kateter Intra Arterial)Pemasangan Percutaneous Dilatational TracheostomyPemasangan Drain Intra Thorakal/Punksi ThoraxPemasangan IABPPemasangan Drain Intra AbdominalPemasangan GemoCardioversiBronchoskopi-FOBTEE

C. Tindakan Pemberian Produk Darah dan Komponen Darah, tindakan yang

memerlukan informed consent tersebut antara lain:

Transfusi darah:

a. Plasma sel

b. PRC

c. Whole Blood Cell

d. Trombosite

e. Albumin

f. lain – lain

D. Semua Tindakan Yang Berisiko Tinggi :

NoKSM /

INSTALASINAMA TINDAKAN

1 KSM Anak 1 Chest tube2 Tindakan kemotherapi3 Pemasangan Ventilator

45

4 Intubasi Endotrakea5 Pemasangan Laryngeal mask6 Krikotirotomi7 Infus intraosseus8 Kanulasi vena perifer9 Vena sectie10 Pengambilan darah intra vena dan intra arteri11 Pungsi lumbal12 Pungsiv Pleura13 Pemasangan kateter urine14 Pemasangan keteter rectal15 Pemasangan orogastrik tube16 Pemasangan nasogastrik tube

2 THT-KL

1 Pemeriksaan Audiometri2 Pemeriksaan Timpanometri3 Pemeriksaan Audiometri Tutur4 Pemeriksaan Sisi&Tore Decay5 Pemeriksaan Pendengaran Pada Anak6 Pemeriksaan Brainstem Evoked Response

Audiometry

3KSM Patologi

AnatomiFNAB (Fine Needle Aspiration Biopsy)

4Inst.

RadiotherapiTindakan Radiotherapi

5 KSM

Neurologi

1 Cerebral Angiografi2 AVM&Embolisasi3 Aneurisma Coiling4 Embolisasi pre operasi5 Diagnosis DSA6 Lumbal Punksi7 Pain Intervention8 Injeksi Triger point9 Injeksi Triger Fringer10 Injeksi CTS11 Sub Optical Functional12

Injeksi botox

1 EMG

46

3

6KSM Patologi

KlinikPhlebotomi

7KSM Gigi dan

Mulut

1 Scaling2 Curettage/root planning (jika diperlukan anestesi)3 Gingivektomi4 Frenektomi5 Flap operasi (bone graft/membrance/GTR/interseptif)6 Implant7 Vital pulpektomi dan Partial Nekrose8 Cauter9 Retraksi Gingiva pada prep.crown

8Poli

AndrologiSuntik Intra Cavernosal Penis

9

KSM Kardiologi

dan Kedokteran

Vaskular

1 Dobutamin Stress Ekhokardiografi2 Transophegal Ekhokardiografi3 Treadmill Tes4 Exercise Stress Ekhokardiografi

10

KSM Pulmonologi

dan Ilmu Kedokteran Respirasi

1 Bronchoscopy/FOB2 Tindakan kemotherapi3 Thoracoscopy4 Contra Ventil/WSD5 Punctie Pleura6 FNAB7 Scalene Biopsy8 Reposisi9 Pleurodesis10 AFF WSD11 Perawatan Luka WSD12 USG Thorax Marker

11KSM

Radiologi

1 Tindakan Radiologi Injectee contrast2 Tindakan Radiologi pada pasien dengan kelainan

cardiovaskuler3 Tindakan Radiologi pada pasien dengan alergi

berat4 Tindakan Radiologi pada pasien dengan KU yang

menurun5 Tindakan Radiologi yang memerlukan FNAB

Guiding MSCT pada pasien dengan kelainan yang berdekatan dengan organ vital

6 Tindakan Radiologi pada Ibu hamil yang memerlukan foto

47

12

KSM

Neurologi

1 Cerebral Angiografi2 AVM&Embolisasi3 Aneurisma Coiling4 Embolisasi pre operasi5 Diagnosis DSA6 Lumbal Punksi7 Pain Intervention8 Injeksi Triger point9 Injeksi Triger Fringer10 Injeksi CTS11 Sub Optical Functional12 Injeksi botox13 EMG14 Neuro endovaskuler: Coiling,Embolisasi,DSA

13Instalasi

HemodialisisSetiap kali melakukan tindakan Hemodialisis

14 KSM Rehabilitasi

MedikElektromiografi dan Kecepatan Hantar Saraf

16 IRNA Jiwa

1 Psycho Analisa

2 Psycho Therapy Dalam

3 Pemeriksaan Calon Pimpinan Publik

4 Aborsi Provocatus Medicinalis

5 Tindakan terapi elektroconfusi

6 Pemeriksaan kandungan zat narkotika

7 Restraint / Fiksasi : mekanik dan psikotropika

8 Pemeriksaan sengketa/ konflik dalam keluarga

15 Semua injeksi dengan obat risiko tinggi

48