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DAFTAR TINDAKAN INFORMED CONSENT
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Open reduction offracturewithoutinternalfixation
Open reduction ofseparatedepiphysis
Osteoclasis(correction ofbonedeformity)
Other
Other (peripheral) vascular shunt orbypass
Other amputationbelowknee
Other anastomosisofcranial or peripheralnerve
Other andunspecified repair oftheanulusfibrosus
Other arthrotomy
Other bunionectomy
Other bunionectomywithsofttissuecorrection
Other cervicalfusion oftheanterior column, anteriortechnique
Other cervicalfusion oftheposterior column,posterior technique
16
11Other changeinhandmuscleor tendonlengthOther changein muscleor tendonlengthOther destructionofintervertebral disc
NOKSM/INSTALASI/UNITTINDAKAN
231 Otherdiagnosticproceduresonjointstructures
Otherdiagnosticproceduresonmuscle, tendon, fascia, and232 bursa, including thatofhand
233 Otherdivisionofbone
234 Otherexcisionofjoint
235 Otherexcisionofsoft tissue
236 Otherexcisionofsoft tissueofhand
237 Otherexcisionor avulsionofcranial andperipheral nerves
238 Otherexcision, fusionand repair oftoes
Otherexplorationanddecompressionofspinal canal,239 Decompression
240Other fasciectomy
241 Other fasciectomyofhand
242 Other fusionof foot
243 Otherhandmuscletransfer or transplantation
244 Otherhandmuscletransposition
245 Otherhandtendontransferor transplantation
246Otherhandtendontransposition
247 Otherincisionofbonewithout division
248 Otherincisionofsoft tissue
249 Otherincisionofsoft tissueofhand
Otherinjectionoflocally-acting therapeuticsubstanceinto250 soft tissueofhand
251 Otherlocal excisionor destructionoflesionof joint
252 Other muscletransposition
253 Other myectomy
254 Other myectomyofhand
255 Otherneuroplasty
256 Otheroperationsonmuscle,tendon,fascia,andbursa
257 Otheroperationsonmuscle,tendon,fascia,andbursa,
Sutureof bursa
Otherpartial ostectomy(including:Bonecurretage,258 marginal resection/excision)
NOKSM/INSTALAS I/UNITTINDAKAN
259 Otherperipheral nerveor gangliondecompressionor lysisofadhesionsPeripheral nerveneurolysisNOS
260 Otherplasticoperationsonfascia
261 Otherplasticoperationsonhand
262 Otherplasticoperationson muscle
263Other repairofankle
264 Other repairofelbow
265 Other repairofhand,fingersandwrist
266 Other repairof joint
267 Other repairof knee
268 Other repairof shoulder
269 Other repairof thecollateral ligaments
270 Other repairof thecruciateligaments
271 Other repairorplasticoperationsonbone
272 Othersutureof flexor tendonofhand
273 Othersutureof muscleor fascia
274 Othersutureofother tendonofhand
275 Othersutureof tendon
276 Other tendontransposition
277 Other tenodesisofhand
278 Other tenonectomy
279 Other tenonectomyofhand
280 Other tenoplastyofhand
281 Other tenotomy
282 Other totalshoulder replacement
283 Partial hip replacement
284 Partial shoulder replacement
285 Patellarstabilization
286 Percutaneousdenervationof facet
287 Percutaneousvertebralaugmentation
288 Percutaneousvertebroplasty
289 Peripheral nerveinjection,nototherwisespecified
290 Plasticoperationonhandwithgraftof muscleor fascia
291 Plasticoperationonhandwithothergraft or implant
292 Pollicizationoperationcarryingover nervesandblood supply
293 Quadricepsplasty
294 Reattachment of muscle
295 Reattachment of muscleofhand
296 Reattachment oftendon
297 Reattachment oftendonofhand
18298Refusionofatlas-axisspine299 Refusionofdorsalanddorsolumbar spine, anterior column, anterior technique
NOKSM/INSTALASI/UNITTINDAKAN
300 Refusion of dorsalanddorsolumbar spine,posteriorcolumn,posterior technique
301 Refusion oflumbar andlumbosacral spine,anteriorcolumn,anterior technique
302 Refusion oflumbar andlumbosacral spine,anteriorcolumn,posterior technique
303 Refusion oflumbar andlumbosacral spine,posteriorcolumn,posterior technique
304 Refusion of other cervical spine, anterior column, anterior technique
305 Refusion of other cervical spine, posterior column,posterior technique
306 Refusion ofspine,notelsewhereclassified
307 Refusion ofspine,nototherwisespecified
308 Release ofcarpal tunnel
309 Release ofclubfoot,not elsewhereclassified
310 Release oftarsal tunnel
311 Removal of(cement) spacer
312 Removal of bonegrowthstimulator (invasive)
313 Removal offoreignbodyfromspinal canal
314 Removal ofimplanteddevicesfrom bone- carpalsandmetacarpals-Plate&screw
315 Removal ofimplanteddevicesfrom bone- carpalsandmetacarpals-simpleimplants(K-wire)
316 Removal ofimplanteddevicesfrom bone- Externalfixator device(invasive) (
317 Removal ofimplanteddevicesfrom bone-femur
318 Removal ofimplanteddevicesfrom bone- humerus
319 Removal ofimplanteddevicesfrom bone- radiusandulna
320 Removal ofimplanteddevicesfrom bone- scapula,clavicle, andthorax(ribs andsternum)
321 Removal ofimplanteddevicesfrom bone-unspecifiedsite(Phalanges(offoot) (of hand)) - Plate& Screw
322 Removal ofimplanteddevicesfrom bone-unspecifiedsite(Phalanges(offoot)(of hand)) - simpleimplants(K-wire)
323 Removal ofimplanteddevicesfrom bone-patella
324 Removal ofimplanteddevicesfrom bone- tarsals and metatarsals- simpleimplants(K-wire)
325 Removal ofimplanteddevicesfrom bone- tibiaandfibula
326 Removal ofimplanteddevicesfrom bone-other(Pelvic boneandVertebraae)
NOKSM/INSTALASI/UNITTINDAKAN
327 Removal ofimplanteddevicesfrom bone-tarsals and metatarsals-Plate&Screw
328 Removal ofinternal limblengtheningdevice
329 Removal of pediclescrew(s) usedinspinalfusion
330 Removal of peripheralneurostimulator lead(s)
331 Removal ofskeletal musclestimulator
332 Removal ofspinalneurostimulator lead(s)
333 Reopening oflaminectomysite
334 Repair ofclawtoe
335 Repair ofclefthand
336 Repair of hammer toe
337 Repair of hip,notelsewhereclassified
338 Repair ofmacrodactyly
339 Repair ofmalletfinger
340 Repair of oldtraumaticinjuryofcranial and peripheral nerves
341 Repair ofrecurrentdislocationofshoulder
342 Repair oftheanulusfibrosuswithgraftor prosthesis
343 Repair ofvertebralfracture, Elevationofspinal bonefragments,Reductionoffractureofvertebrae, Removal of bonyspiculesfrom spinal canal
344 Replacementofjoint offootandtoe
345 Resurfacinghip,partial, acetabulum, Hipresurfacingarthroplasty, partial, acetabulum
346 Resurfacinghip,partial,femoralhead
347 Revisionoftotal kneereplacement,tibial insert(liner),Replacementoftibial insert(liner)
348 Revisionor replacementof artificial spinal discprosthesis,cervical
349 Revisionor replacementof artificial spinal discprosthesis,lumbosacral
350 Revisionor replacementof artificial spinal discprosthesis,not otherwisespecified
351 Revisionor replacementof artificial spinal discprosthesis,thoracic
352 Rotator cuffrepair
353 Separation of equal conjoinedtwins
354 Separation of unequalconjoinedtwins
355 Sequestrectomy
356 Spinalfusion,nototherwisespecified
357 Subtalarfusion
358 Subtalar jointarthroereisis
20
359 Suture of Artery
360 Suture ofcapsuleor ligament ofankleandfoot
NOKSM/INSTALASI/UNITTINDAKAN
361 Suture ofcapsuleor ligament ofother lowerextremity
362 Suture ofcapsuleor ligament ofupper extremity
363 Suture ofcranial and peripheral nerves
364 Suture ofmuscleorfasciaof hand
365 Suture oftendonsheath
366 Suture oftendonsheathof hand
367 Suture of Vein
368 Synovectomy
369 Tarsometatarsalfusion
370 Tendongraft
371 Tendonpulleyreconstruction
372 Tendonpulleyreconstruction
373 Tendontransferor transplantation
374 Tenotomyof hand
375 Thighreattachment
376 Thumbreattachment
378 Toereattachment
379 Total anklereplacement
380 Total elbowreplacement
381 Total ostectomy
382 Total wristreplacement
383 Transplantfromcadaver
384 Transpositionofcranial andperipheral nerves -Nervetransplantation
389 Triadkneerepair
390 Triplearthrodesis
391 Unspecifiedoperationonboneinjury
392 Upper armreattachment
393 Upper limb amputation, nototherwisespecified
394 Wedgeosteotomy
21
NOKSM/INSTALASI/UNITTINDAKAN
5KSMBEDAH THORAKS DANKARDIOVASKULAR1 BiopsiTerbukaBronkhus
2 BiopsiTerbukaDiafragma
3 BiopsiTerbukaMediastinum
4 BiopsiTerbukaParu
5 BiopsiTerbukaPleura
6 BiopsiTerbukaPleuradenganVATS
7 BiopsiTerbukaTumor DindingThoraks
8 Debridement Mediastinum (Sternotomi)
9 Eksisi PadaBronkhus
10 Eksisi PadaParu (LungVolumeReduction)
11 Eksisi PadaParudenganVATS
12 Eksisi Tumor DindingDadadenganRekonstruksi DindingDada
13 Eksisi Tumor Mediastinum (Thymoma,Teratoma, Neurogenic dsb)
14 Ekstraksi CorpusAlienum di RegioToraks
15 Ekstraksi CorpusAlienum di RegioToraksdenganVATS
16 Evakuasi EfusiPleura/EmpyemasecaraTorakoskopik(VATS)
17 Fiksasi Costae(Clipp,Wire) (diluar Clipp)
18 Fiksasi Sternum(Wire,Plate) (diluar wire/plate)
19 Lobektomi Parsial (Reseksi Parusegmental)
20 Lobektomi Parsial (Reseksi Parusegmental)denganVATS
21 LumbalSimpatektomi
22 Mediastinostomy
23 Pemasanganthorakdrain/water sealeddrainage(WSD) (diluar alat)
24 Pleural window(Eloeser Flap)
25 Pleurektomi
26 Pleurodesis(Pleurosklerosis)
27 PlikaseBulae/BlebEmfisematous
28 Plikasi diafragma
29 Pneumonectomy
30 PneumonectomydenganVATS
31 PulmonaryDecortication
32 PulmonaryDecorticationdenganVATS
33 PulmonaryLobectomy/Bilobectomy
34 PulmonaryLobectomy/BilobectomydenganVATS
35 RedoTorakotomi
36 Rekonstruksi Sternum&DindingDada
37 repair deformitasPectus
2238 Repair FistulaBronkopleural39 Repair Laserasi Diafragma
NOKSM/INSTALASI/UNITTINDAKAN
40Revisi Thoraksdrain/watersealeddrainage(WSD)(diluar alat)
41 Thoracal SymphatectomydenganVideoAssisstedThoracoscopicSurgery(VATS)
42 Thoracocentesis
43 Thymectomy
44 ThymectomydenganVATS
45 Torakoplasti(AirPlumbage/MusclePlumbage)
46 Torakotomi/sternotomiEksplorasi
47 Torakotomi Eksplorasi padaTraumajantung/RepairLaserasi Jantung
48 BedahKardio(Jantung)
49 AorticValveRepair(AVR)
50 AorticValveRepair(AVR)denganBioprosthesis Valve
51 AorticValveRepair(AVR)denganMechanical Valve
52 Atrial septalDefect (ASD)Closure
53 Bidirectional Cavo-Pulmonary Shunt (BCPS)
54 Biopsi Jantung
55 Biopsi Perikardium
56 Blalock-TaussingShunt (BTShunt)
57 Coronary Artery Bypass Graft (CABG)
58 Eksisi CardiacMyxoma
59 FontanOperation(Atrium-Pulmonary Artery Conduit)
60 Internal Resusitasi/CardiacMassage(OperasiTerbuka)
61 Ligasi PatentDuctus Arteriosus (PDA)
62 Mitral valve repair (MVr)
63 Mitral ValveRepair(MVR)denganBioprosthesis Valve
64 Mitral ValveReplacement (MVR)denganMechanicalValve
65 OperasiRedoOpenHeart (ValveReplacement)
66 OperasiReopenolehKarenasebab Perdarahan, TamponadeJantung
67 PemasanganIABP
68 PemasanganPaceMakerPermanen(diluaralat)
69 Pericardiocentesis
70 Perikardiektomi
71 Perikardiotomi/PericardialWindow
72 Pulmonal ValveRepair(PVR)
73 Pulmonal ValveRepair(PVR)denganBioprosthesisValve
74 Pulmonal ValveRepair(PVR)denganMechanical Valve
75 Pulmonary Artery Banding (PA)
23
NOKSM/INSTALASI/ UNITTINDAKAN
76Rastelli Procedure(right Ventricle-PulonaryArteryConduit)
77Repair (Eksisi) AneurismaJantung
78 Repair AortaTorakalis(38.34)
79 Repair AtrioventricularSeptal Defect(35.54)
80 RepairTotalAnomalous PulmoanryVenousConnection(TAPVC) (35.82)
81 RepairTransposition ofGreatArteries(TGA)(35.84)
82 RepairTrunkusArteriosus(35.83)
83 Revisi/AffPaceMaker Permanen(diluar alat)(37.89)
84 SeptostomiTerbukaSeptum Atrium (35.41)
85 Total KoreksiTetralogyofFallot (TOF) (35.81)
86 TricuspidValveRepair(TVR) (35.14)
87 TricuspidValveRepair(TVR) denganBioprosthesisValve(35.27)
88 TricuspidValveRepair(TVR) denganMechanical Valve(35.28)
89 VentricleSeptal Defect (VSD) Closure(35.5)
90 AmputasiAboveKnee(AK) (84.17)
91 AmputasiBelowKnee (BK) (84.14)
92 Arterial Pungsi,Kanulasi, Sectie(38.91)
93 ArteriovenousShuntt(AV Shunt)Brakiosefalika(39.42)
94 ArteriovenousShuntt(AV Shunt) Radiosefalika(39.27)
95BedahVarisesInsisi Babcock(38.5)
96 Biopsi PembuluhDarah(Perifer) (38.21)
97 Debriment-NekrotomiLukaGangren(86.22)
98 Disartikulasi Sendi Ekstremitas(84.13)
6EksisiBiopsiTumor Pembuluh Darah1 EksisiTumor PembuluhDarahPerifer (Hemangioma)
2 EksplorasiVaskular (Trauma/Non trauma)
3 Embolektomi/Trombektomi Aorta
4 Embolektomi/Trombektomi Pembuluh DarahArteri Abdominal
5 Embolektomi/Trombektomi Pembuluh DarahArteriEkstremitas Bawah
6 Embolektomi/Trombektomi Pembuluh DarahEkstremitasAtas(diluaralat)
7 Embolektomi/Trombektomi Pembuluh DarahEkstremitasBawah(diluaralat)
8 Embolektomi/Trombektomi Pembuluh DarahRegioservikal(Karotis,Jugular) (diluar alat)
9EvakuasiHematom di Ekstremitas(PascaPungsi HD/ Traumatik)
10 Fasciotomy
11 Ligasi Vaskular Ekstremitas
2412 Mutilasi Digiti Ekstermitas
NOKSM/INSTALASI/UNITTINDAKAN
13 PasangDoubleLumenHemodialisis(HD) (diluar alat)
14 PasangImplantableCentral Venous Access(diluar alat:porth-a-cath,celsite)
15 PemasanganCentralVenousCatheter (CVC) (diluar alat)
16 PemasanganIntraAortic BaloonPump(IABP) (diluar alat)
17 PemasanganPeritoneal Dyalisis(PD) Catheter(diluar alat)
18 PembedahanTeleangiectasis
19 Repair Aneurisma(True/false)EkstremitasSuperior(diluar graft)
20 Repair AneurismaAortaAbdominalis(DiluarProtesa)
21 Repair PembuluhDarahRegioServikal (Karotis, Jugular)
22 Repair Ruptur PembuluhArteri Abdominal
23 Revisi ArteriovenousShunt
24 Skleroterapi Vena(Varises,Hemangioma)
25 StrippingVarisesEkstremitasInferior
26 Vascular Shunting (Splenorenal Shunt,DePalmaShunt)
27 VenaPunctie,Kanulasi, Sectie
7KSM BEDAH
DIGESTIVE1 Abdominal pull through (sfingter savingprocedure)
2Abdominoperineal resection(miles) denganpenyulit mayor
3Abdominoperineal resection(miles) denganpenyulit minor
4 Abdominoperineal resection(miles) tanpapenyulit
5 Abdominoplasty
6 Apendektomi
7 Apendektomidgnpenyulitmajor
8 Apendektomidgnpenyulitminor
9 Apendektomi laparoskopik
10 Bilio-difgestif anastomosistanpapenyulit
11 Biliodigestif denganpenyulitmayor
12 Biliodigestif denganpenyulitminor
13 Biopsi insisional,localanastesi
14 Biopsi rectum
15 Eksisi hemoroideksterna
16 Eksplorasi duktusbilier &cholangiografi intraoperatif
17 Esofagotomi
18 Fistulotomi
25
NOKSM/INSTALASI/UNITTINDAKAN
19 Fistulotomi dgnpenyulitmayor
20 Fistulotomi dgnpenyulitminor
21 Gastrostomi
22 Hemikolektomidenganpenyulitmayor
23 Hemikolektomidenganpenyulitminor
24 Hemikolektomitanpa penyulit
25 Hemoroidstapling (diluar alat)
26 Hemoroidektomi
27 Herniotomi
28 Herniotomi dgnpenyulitmayor
29 Herniotomi dgnpenyulitminor
30 Herniotomi laparoskopik
31 Jejunostomi /ileostomi
32 Laparotomi denganpenyulitminor
33 Laparotomi tanpapenyulit
34 Ligasi hemoroid(diluar alat)
35 Pankreatiko-duodenektomi cephalis(Whipple)denganpenyulitmayor
36 Peritoneal dreanse (CAPD)
37 Peritoneal lavase
38 Polipektomi
39 Potongkolostomi
40 Prosedur Heller
41 Rektopexy
42 Repairfistelusus
43 Repairfistel vesicorectal
44 Repair herniacicatricalis
45 Repair herniacicatricalis dgnpenyulitmayor (diluar alat)
46 Repair herniacicatricalis dgnpenyulitminor (diluar alat)
47 Repair HerniaDiafragmatika (diluar alat)
48 Reseksi anterior denganpenyulitmayor
49 Reseksi anterior denganpenyulitminor
50 Reseksi anterior tanpapenyulit
51 Reseksi esofagus-colon/ileumtransposisi
52 Reseksi esofagus-endtoend
53 Reseksi esofagus-esofago-gastrectomy
54 Reseksi hati
55 Secondlooklaparoscopy
56 Splenektomi /splenoraphytraumatika
57 Splenektomi nontrauma
58 Terminalesofagus proksimal gastrektomi (TEPG)
26
59 Total gastrektomi
NOKSM/INSTALASI/UNITTINDAKAN
60 Total pantreaktomi
61 Total prokto-kolektomi
62 Tutupburstabdomen (tanpaalat)
63 Tutupburstabdomendenganpenyulitmayor
64 Tutupburstabdomendenganpenyulitminor
65 Tutupkolostomi/ileostomi
66 Tutupkolostomi/ileostomi denganpenyulitmayor
67 Tutupkolostomi/ileostomi denganpenyulitminor
68 Repair AortaTorakalis(38.34)
69 Repair AtrioventricularSeptal Defect(35.54)
8KSM BEDAHUROLOGI1 Adrenalektomi
2 Adrenalektomi (Abdominotorakal)
3 Anastomosis endtoendUreter
4 Augmentasi Buli
5 Biopsi Ginjalperkutan
6 Biopsi GinjalTerbuka
7 Biopsi Penis
8 Biopsi Prostat
9 BiopsiTestis
10 Bladder NeckRekonstruksi
11 BuriedPenis
12 Businasi/Dilatasi Uretra
13 CabutDJStent
14 DefooringKistaGinjalper Laparoskopi
15 Deroofing/UnroofingKista
16 Diseksi Kelenjar GetahBeningInguinal
17 Diseksi Kelenjar GetahBening pelvis
18 Diseksi Kelenjar GetahBeningPelvis perLaparoskopi
19 Divertikulektomi Buli
20 DivertikulumUretra
21 Dorsumsisi
22 DrainasePeriureter
23 Eksisi Chordae/Chordektomi
24 Eksisi Fibroma/Rekonstruksi Penis
25 Eksisi Plaque(PeyronieDisease)
26 EksisiWebbedPenis
27 Eksplorasi testis(Microsurgery)
28 Ekstraksi Batu
29 Ekstrofi Buli Rekonstruksi
30 Epispadia
31 Evakuasi BekuanDarah(Clot)
32 ExtendedPyelolithotomy
2733 Fistulektomi/Repair Fistel Uretra
NOKSM/INSTALASI/UNITTINDAKAN
34 Funikokelektomi
35 Ganti Nefrostomy
36 Hidrokel per Inguinal/Ligasi Tinggi
37 Hidrokel per Skrotal
38 HipospadiaSubkoronal
39 Holmium YaGLaser (Sewa)
40 Ileal Conduit(Bricker)
41 Insersi DJ Stent
42 Insisi AbsesPerineum
43 Insisi AbsesSkrotum
44 Insisi Posterior Urethral Valve
45 Johanson
46 JohansonI
47 JohansonII
48 Kalibrasi Uretra
49 Kauterisasi
50 Koreksi HorseshoeKidney
51 Koreksi Priapismus
52 LaparoskopiAdrenalektomi
53 Laparotomi Eksplorasi
54 Ligasi V.SpermatikaInterna(Microsurgery)
55 Limfadenektomi Ilioinguinal
56 Limfadenektomi Retroperitoneal/RPLND
57 Litholapaksi
58 Lithotripsi
59 MasaseProstat
60 Meatoplasti
61 Meatotomi
62 MMK/SlingUretra
63 Nefrektomi
64 Nefrektomi Donor Transplant
65 Nefrektomi Parsial
66 Nefrektomi perLaparoskopi
67 Nefrektomi Radial
68 Nefropeksi/Renopeksi
69 Nefrostomi Perkutan/Temporer
70 NefrostomiTerbuka/Permanen
71 Nefroureterektomi
72 Neobladder
73 Operasi Priapismus(prosedurWinter)
74 Operasi Repair BuliTrauma
75 Operasi Sistokel
28
NOKSM/INSTALASI/UNITTINDAKAN
76 OperasiTraumaGinjal
77 Operasi Urakhus/Reseksi urakhus
78 Orkhidektomi
79 Orkhidektomi extended
80 Orkhidektomi LigasiTinggi
81 Orkhidektomi Subkapsuler
82 Orkhidopeksi (TorsioTestis)
83 Orkhidopeksi (UDT)
84 Orkhidopeksi perLaparoskopi
85 PasangKateter
86 PasangKateter denganMandrain
87 PasangKateterTenckhoff untukCAPD
88 PCNL/PNL
89 Penektomi Parsial
90 PenektomiTotal/Amputasi Penis
91 PER (PrimaryEndoscopicRealignment)
92 Pielokalikotomi
93 Pielolitotomi
94 Pieloplasti
95 Pieloplastiper Laparoskopi
96 Prostatektomi Radikal
97 Prostatektomi Retropubik
98 ProstatektomiTerbuka
99 ProstatektomiTerbukadanSectioAlta
100 PsoasHitch/Boari Flap
101 Punksi dansklerosingKistaGinjal
102 Railroading RuptureUretra
103 Reimplantasi Ureter Bilateral
104 Reimplantasi UreterUnilateral/Ureteroneosistostomi
105 Rekontruksi Renovaskuler
106 Repair Fistel Enterovesika
107 Repair Fistel Vesikokutan
108 Repair Fistel Vesikorektal
109 Repair Fistel Vesikovagina
110 Repair Fistel VesikovaginaKompleks
111 Reparasi Penis
112 Reseksi-anastomosisUretra
113 RPG
114 SectioAlta/Vesikolithotomi
115 Sirkumsisi
115 Sistektomi Parsial/Sistoplasti Reduksi
116 Sistektomi Per Laparoskopi
117 SistektomiTotal/Radikal
29118 Sistoskopi119 SistoskopiODS
NOKSM/INSTALASI/UNITTINDAKAN
120 Sistostomi perkutan
121 SistostomiTerbuka
122 Skrotoplasti
123 Spermatokelektomi
124TailoringUreter
125 TransplanResipien
126 Transuretero-ureterostomi
127 TUR Prostat/TUIP/BNI
128 TURTumor Buli
129 TVP/TMP
130 Ureterokutaneostomi
131 Ureterolisis
132 Ureterolithotomi
133 Ureterolithotomi Distal
134 UreterolithotomiProksimal
135 Ureterosigmoidostomi(Caffey)
136 Ureterostomi
137 Ureterouretostomi
138 Uretroplasti Hipospadia
139 Uretroskopi/Uretrosistoskopi
140 UretrotomiInterna(Sachse)
141 URS/Lithotripsi
142 Varikokelektomi (Palomo)
143 Vasektomi (anestesi lokal)
144 Vasektomi (narkose)
145 Vasoepididimostomi
146 Vasografi
147 Vasovasostomi
9KSM ILMUKESEHATAN MATA1 AngkatJahitan
2AngkatJahitandenganGA
3 Anterior ChamberTap/Parasintesis
4 Aspirasi MassaLensa
5 Blefaroplasty(2KelopakMata)
6 ClawLens
7 CryopexyKornea
8 CycloCryo
9 Dacryocystorinostomi (Without SiliconTube)
10 Dekompresi Orbital/Lateral Orbitotomi
11 Disisi Aspirasi &IOL
12 ECCE
13 ECCE&IOL
14 Eksenterasi
15 Eksisi Hordeolum/Chalazion
30
3737
16 Ekstirpasi CorpusAlienum di Kornea17 Ekstirpasi Pterygium+ GraftKonjungtiva
NOKSM/INSTALASI/UNITTINDAKAN
18 Ekstripasi CorpusAlienum di BilikMataDepan
19 Enukleasi/Eviscerasi (DFG/Bonegraft)
20 Evakuasi SilikonOil
21 FornixRepair
22 ICCE
23 ICCE&IOL
24 Injeksi IntraVitreal
25 Injeksi PeriokulerTerapetik
26 IOLExplant
27 Iridectomi
28 JahitKelopakMataFull Thickness&LidMargin
29 JahitKornea
30 Keratoplasti (CornealTransplantation)
31 Konjungtival Flap/AmnionGraft
32 PiggyBackIOL
33 Pneumoretinopexy
34 Repair Canalis Lacrimalis(Without SiliconTube)
35 Repair ColobomaPalpebra(Skin/Mucosal Graft)
36 Reposisi IOL
37 Reposisi Iris
38 Resesi &Reseksi 2Otot
39 Resesi &Reseksi 3Otot
40 Resesi &Reseksi 4Otot
41 Resesi/Reseksi 1Otot
42 Sekunder Implant(Posterior Chamber)
43 Sekunder ImplantClawLens/Fiksasi Sulcus
44 SICS
45 SICS&IOL
46 Simpel Vitrektomi
47 Skleral Buckle
48 SocketRepair (ContractedSocket)
49 Trabekulektomi
50 Trabekuletomi &Ollogen
51 Trabulektomi &Goniotomi padaPediatricGlaucoma
52 TubeShunt(Express)
53 Viscocanulostomy
54 Vitrektomi +++
55 Vitrektomi Lengkap&Skleral Buckle
56 WideEksisi Tumor KelopakMata
57 WideEksisi Tumor KelopakMata+ Flap+ graft
NOKSM/INSTALASI/UNITTINDAKAN
10DivisiOnkologi1 Aspirasi KistaMammaSingledan Multiple
2 Biopsi CoreLokalAnestesi
3 Biopsi Eksisi Lokal
4 Biopsi Eksisi Narkose
5 Biopsi InsisiLokal
6 Biopsi Narkose
7 BreastConservingSurgery(BCS)
8 BreastConservingSurgery+ LD Flap
9 DebrimentMamma
10 Diseksi Axilla
11 Eksisi Fibroadenoma Lokal AnestesiSingleSatuSisi
12 Eksisi Fibroadenoma MultipleNarkose
13 Eksisi Tumor MetastaseLoco-regional
14 Eksplorasi DuktusMama
15 Eksplorasi DuktusMama+VC
16 Insisi AbscesMastitisLokal
17 LD Flap+ EksisiTumor
18 Mastectomy+ TramFlap
19 ModifiedRadical Mastectomy+ Flap/SingleGrafting
20 ModifiedRadical MastectomySingle
21 Quadrantectomy/ Partial Mastectomy
22 Simple Mastektomy+ Flap/SkinGrafting
23 Simple MastektomySingle
24 TramFlap+ Eksisi Tumor
25 OperasiTumorKulit
26 Biopsi InsisiTumor Kulit Lokal
27 Biopsi EksisiTumor KulitNarcose
28 Eksisi Tumor Jinak 3cm
29 Eksisi Tumor Jinak+ Flap/SkinGraft
30 Eksisi Tumor JinakKulit>3cm
31 WideEksisi + Diseksi KGB
32 WideEksisi Tumor GanasKulit
33 WideEksisi Tumor GanasKulit+Flap/ SkinGraft
34 Operasi SoftTissueTumor
35 Amputasi + Diseksi KGB
36 Amputasi Jari + Flap/SkinGraft
37 AmputasiTungkai /Lengan
38 Biopsi CoresoftTissue
39 Biopsi InsisiTumor SofTissuedenganNarcose
40 Biopsi InsisiTumor SoftTissueLokalAnestesi
41 Eksisi Tumor Jinak>3cm
42 Eksisi Tumor Jinak1
8 Amputasi jari single
9 Augmentasimamae
10 Blefaroplasty(2kelopakmata)
11 Blefaroplastypadakasussulit
3612 Blefaroptosis
NOKSM/INSTALASI/UNITTINDAKAN
13 Bone rekonstruksifacial cleft
14 Bone rekonstruksifacial cleft
15 Cheilonasoraphy
16 Chordectomy
17 Chordectomy+urethroplasty
18 ClosedReductionFr.Nasal
19 Comisuroplasty
20 Eksmammaaberanbilateral
21 Eksisi neoplasmajinak(lipoma, atheromadll)
22 Eksisi luas+ Deltopectoralflap
23 Eksisi luas+ Foreheadflap
24 Eksisi luas+ Muskulocutanflap
25 Eksisi luas+ rekonstruksi dengan bedah mikrovaskular
26 Eksisi malformasi lymphatik/vaskuler
27 Ekstraksi ateroma/keloid
28 Ekstraksi korpusalienum
29 Elevasi ear rimcartilago
30Excisehemangioma+rekonstruksi
31 Exciseintrakeloid
32 Excisepolydactyly
33 Excisereduksi lymedema
34 Facial slingdenganallograft
35 Fasciotomyburninjury
36 Fasciotomywithcomplication
37 Flaplokal sederhana
38 Fr.Condylusmandibulaopenred
39 Fr.Maksilasuspensi (IOID)
40 Fr.Nasal openreduction
41 Fraktur Prosesus alveolaris denganinterdental wiring (IDW) (per rahang)
42 Fraktur Prosesus alveolarisluasdenganIDW(per rahang)
43 Fraktur rahang reduksiterbuka&inter oseuswiring(IOW)
37
NOKSM/INSTALASI/UNITTINDAKAN
44 LDflap
45 LefortIosteotomy
46 Liposuction
47 Lobuloplasti
48 Malarplasty
49 Mammaaberanunilateral
50 Mandibular distraksi
51 Mandibular rekonstruksi dengancostochondral graft
52 Mastopexi
53 Mentoplasty
54 Microsurgery
55 Multiplefacialfraktur +implant
56 Muskulokutaneusflap
57 Myokutaneusflap/pectoralismayorflap
58 Nasal repair danrekonstruksi
59 Neovagina
60 Operasi bedahmikro
61 Oriffraktur zygoma
62 Oriffraktur hand
63 Oriffrakturmandibula
64 Oriffrakturmaxilla
65 Orifmaksilaplating
66 Orifmandibulaplating
67 Orifmandibulawiring
68 Oriforbital wall
69 Oriforbital wall
70 Orifzygomawiring
71 Osteotomycraniosynostosisreconstruction
72 Osteotomyfacial rekonstruksi
73 Osteotomygenioplastitanpatarif bahan
74 OsteotomymaksilaLefortI
75 OsteotomymaksilaLefortII
76 Palatoplastibilateral komplit
77 Palatoplastibilateral takkomplit
78 Palatoplastiunilateralkomplit
79 Palatoplastiunilateral takkomplit
80 Palatoraphy
81 Pasangarchbar
82 Pasang backslab/foreslab
83 Pasangcast/gipstanpareposisi
84 Recheiloraphy
85 Rekonstruksidengan alloplasticmaterial
38
4444
86 Rekonstruksifacial cleft87 Rekonstruksinasal
NOKSM/INSTALASI/UNITTINDAKAN
88 Rekonstruksipalpebra
89 Releasedburiedpenis
90 Releasedsyndactylykompleks
91 Repair canalislacrimalis(withoutsilicontube)
92 Repair colobomapalpebra(skin/mucosal graft)
93 Repair ductusnasolacrimalis
94 Repairfingertipinjury
95 Repairfistelurethra
96 Replantation
97 Reposisifraktur nasalsederhana
98 Reposisifraktur osnasalis(complicated)
99 Reseksi mandibula+ bonegraft
100 Rhinoplasty
101 Rotationflap
102 Sagital Split osteotomimandibula
103 Simplebonegrafting
104 Simpleskingrafting
105 Skinflap
106 Skingraft>5cm
107 Skingraftsedang5cm
108 Skingraftingkecil
109 Skingraftingluas
110 Skingraftingsedang
111 Skingraftingwithcomplication
112 Tendonreconstruction
113 Tendontransfer
114 Tendontransfer withcomplication
115 Tennoraphy
116 Tennoraphywithcomplication
117 TMJ arthroplasty
118 TMJ arthrostomy
119 Tram flap
120 WoundDressing
121 WoundRepair
NOKSM/INSTALASI/UNITTINDAKAN
13KSM OBGYN1 Cauter serviks
2 Cordosentesis
3 Debulkingtumor ovarium
4 Eksplorasi vagina
5 Embryotomi
6 Extirpasi + kuret polipendoserviks
7 Extirpasi geborenmioma
8 Extirpasi geborenmioma+kuiretasi
9 Histeroctomypada mola/chorioCa
10 Histeroctomyradikal
11 Kistektomi
12 Konisasi serviks
13 Kuretabortusincompletes
14 Lapop:myomektomi
15 Laparoskopi (Kistektomi Ovarium,Salphingektomi, Adhesiolisis)
16 Laparoskopi Histerektomi
17 Laparoskopi steril
18 LaparoskopikDiagnostik
19 Laparotomi denganpenyulitmayor
20 Laparotomi denganpenyulitminor
21 Laparotomi tanpapenyulit
22 LEEP
23 MicrokuretaseDUB
24 Mikrokuret
25 Miomectomy
26 Neovagina
27 Operasi Cavagina
28 Operasi kanker corpusuteri
29 Operasi tumor ganasovarium
4030 Operativehisteroscopy/Ablasi endometrium
31 Overectomi
NOKSM/INSTALASI/UNITTINDAKAN
32 Painlesslabor
33 Persalinannormal
34 Persalinannormaldenganpenyulit
35 Persalinanpervaginam tindakanoperatif
36 Persalinansungsang
37 Rekanalisasi
38 Rekanalisasituba
39 Salfingektomi unilateral
40 Salvingoovarectomi unilateral
41 SecoundlooksurgeryCaovarium
42 Seksiosesaria
43 Seksiosesariadenganpenyulit penyulit
44 Sirklaseserviks
45 Seksiosesariadenganpenyulit penyulit
46 Sirklaseserviks
47 Supravaginal hyterectomy
48 Surgical staging
49 TAH+BSOdenganPenyulit
50 TAH+BSOdenganPenyulit PemasanganTamponAbdomen
51 Total abdominal hysterectomy+bilateral salfingektomi
52 Tubektomi klinik
53 Tutupburstabdomen
4343
NOKSM/INSTALASI/UNITTINDAKAN
14KSM GIGIdanMULUT1 AugmentasiTulangPer Regio(Belum TermasukBahan)2 DebrimentMukosadanPengelolaanLukaSayat3 Dislokasi Sendi Mandibula4 Eksisi EpulisPer Rahang
5 Eksisi KelenjarLudahSubmandibula
6 Eksisi KistaOdontogenik Keratosis+ Ostektomi
7 Eksisi NeoplasmaJinak ExtraOral UkuranKecil
8 Eksisi Parsial + Marsupialisasi Ranula
9 Eksisi PlungingRanula
10 Eksisional Biopsi NeoplasmaJinak
11 Enukleasi KistaDentigerous+ Extraksi Gigi Impaksi12 Enukleasi Kistaradikuler Per Rahang+ Extraksi GigiPenyebab13 Extirpasi KistaDermoid
14Extirpasi Sialolith
15 Extraksi Corpus AlienumdenganTeknik Lindorf16 Extraksi Gigi Anak denganKelainanJantungPerRahang17 Extraksi Gigi Anak PerRahang
18 Extraksi Gigi DewasaPer Rahang
19 FissureSealantpadaAutis
20 Fraktur DentoalveolarDenganarchBar
21 Fraktur DentoalveolarDenganBracket(belum termasukbahan)22 fraktur DentoAlveolardenganEyelet
23 Fraktur MaksiladenganSuspensiWiring
24 Fraktur Nasal closeReduksi
25 Fraktur Nasal OpenReduksi26 Fraktur RahangReduksi TertutupdenganIntermaksilaFiksasi27 Frenektomi Per Rahang
28 Genioplasty
29 Gingivektomi Per Rahang
42
NOKSM/INSTALASI/UNITTINDAKAN
30 Hemi MaksilektomiTanpaRekonstruksi
31 Insisi Abses/Phlegmon
32 InsisionalBiopsi NeoplasmaJinak
33 Mandibular Distraksi
34 OdontektomiPer Gigi
35 ORIF Maksila+ Zygoma+ Mandibula (belum termasukimplant)
36 ORIF MaksilaPlating(belumtermasukimplant)
37 ORIF MandibulaPlating (belumtermasukimplant)
38 ORIF ZygomaPlating (belumtermasukimplant)
39 Osteotomi MaksilaleFortI
40 Osteotomi MaksilaleFortII
41 PelepasanArchBar (IntermaksilaFiksasi)
15DIVISIPEDIATRI GAWAT DARURAT ILMU KESEHATAN ANAK1 Intubasi Endotrakea
2 Krikotirotomi
3 Kanulasi venaperifer
4 Venasectie
5 Pungsi lumbal
6 PungsivPleura
16KSM PENYAKIT JANTUNG&PEMBULUH DARAH1 Diagnostik KateterisasiJantung
2 PTMC
3 PTCA/Stenting
4 Pacemaker Temporer&Permanen
5 IABP
6 Perikardiosintesis
7 PemasanganSwanGanzKateter
8 PemasanganAmplatzer/ADO/Coilling
9 CVC
10 PelepasanArchBar (IntermaksilaFiksasi)
17KSM PENYAKIT DALAMEndoscopy
43
B.TindakanAnestesi&Sedasi ( Sedang danDalam),tindakan yang memerlukan informed consenttersebut antaralain:a. Semuatindakananestesi dansedasi didalamkamaroperasi b. Semuatindakananestesi dansedasi di ICU
TindakanAnestesidiICU
Pemasanganintubasiventilator
Pemasanganvenacentral
PemasanganCRRT
PemasanganSwanGanz(KateterArteriPulmonal)
PemasanganIntraArterialCatheher(KateterIntraArterial)
PemasanganPercutaneousDilatationalTracheostomy
PemasanganDrainIntraThorakal/PunksiThorax
PemasanganIABP
PemasanganDrainIntraAbdominal
PemasanganGemo
Cardioversi
Bronchoskopi-FOB
TEE
C.TindakanPemberianProdukDarah dan Komponen Darah,tindakanyang memerlukan informed consenttersebut antaralain:Transfusi darah: a. Plasma sel b. PRCc. WholeBloodCell d. Trombositee. Albumin
f. lainlain
44
D.SemuaTindakan Yang Berisiko Tinggi:
NoKSM /INSTALASINAMATINDAKAN
1
KSMAnak1Chesttube
2Tindakan kemotherapi
3PemasanganVentilator
4Intubasi Endotrakea
5PemasanganLaryngeal mask
6Krikotirotomi
7Infusintraosseus
8Kanulasi venaperifer
9Venasectie
10Pengambilandarahintravenadanintraarteri
11Pungsi lumbal
12PungsivPleura
13Pemasangankateterurine
14Pemasanganketeter rectal
15Pemasanganorogastriktube
16Pemasangannasogastriktube
2
THT-KL1PemeriksaanAudiometri
2PemeriksaanTimpanometri
3PemeriksaanAudiometri Tutur
4PemeriksaanSisi&ToreDecay
5PemeriksaanPendengaranPadaAnak
6PemeriksaanBrainstemEvokedResponseAudiometry
3KSM Patologi
AnatomiFNAB(FineNeedleAspirationBiopsy)
4Inst.
RadiotherapiTindakanRadiotherapi
5
KSM Neurologi1Cerebral Angiografi
2AVM&Embolisasi
3AneurismaCoiling
4Embolisasi preoperasi
5DiagnosisDSA
6LumbalPunksi
7PainIntervention
8InjeksiTriger point
9InjeksiTriger Fringer
10Injeksi CTS
11SubOptical Functional
12Injeksi botox
13EMG
6KSM PatologiPhlebotomi
45
Klinik
7
KSM Gigidan
Mulut1Scaling
2Curettage/root planning(jikadiperlukananestesi)
3Gingivektomi
4Frenektomi
5Flapoperasi(bonegraft/membrance/GTR/interseptif)
6Implant
7Vital pulpektomi dan Partial Nekrose
8Cauter
9RetraksiGingivapadaprep.crown
8PoliAndrologiSuntikIntraCavernosal Penis
9KSM Kardiologi dan Kedokteran Vaskular1DobutaminStressEkhokardiografi
2Transophegal Ekhokardiografi
3TreadmillTes
4ExerciseStress Ekhokardiografi
10
KSM Pulmonologi dan Ilmu Kedokteran Respirasi1Bronchoscopy/FOB
2Tindakan kemotherapi
3Thoracoscopy
4ContraVentil/WSD
5PunctiePleura
6FNAB
7ScaleneBiopsy
8Reposisi
9Pleurodesis
10AFFWSD
11PerawatanLukaWSD
12USGThoraxMarker
11
KSM Radiologi1TindakanRadiologi Injecteecontrast
2TindakanRadiologi padapasiendengankelainancardiovaskuler
3TindakanRadiologi padapasiendenganalergiberat
4TindakanRadiologi padapasiendenganKU yang menurun
5TindakanRadiologi yangmemerlukanFNABGuiding MSCT pada pasiendengankelainanyang berdekatandenganorganvital
6TindakanRadiologi padaIbuhamil yangmemerlukanfoto
12KSM Neurologi1Cerebral Angiografi
2AVM&Embolisasi
3AneurismaCoiling
4Embolisasi preoperasi
5DiagnosisDSA
46
6LumbalPunksi
7PainIntervention
8InjeksiTriger point
9InjeksiTriger Fringer
10Injeksi CTS
11SubOptical Functional
12Injeksi botox
13EMG
14Neuroendovaskuler:Coiling,Embolisasi,DSA
13InstalasiHemodialisisSetiapkalimelakukantindakanHemodialisis
14KSM Rehabilitasi Medik
ElektromiografidanKecepatanHantarSaraf
16
IRNAJiwa1 PsychoAnalisa
2 PsychoTherapyDalam
3 PemeriksaanCalonPimpinanPublik
4 Aborsi ProvocatusMedicinalis
5 Tindakanterapi elektroconfusi
6 Pemeriksaankandunganzatnarkotika
7 Restraint/Fiksasi :mekanikdanpsikotropika
8 Pemeriksaansengketa/konflikdalamkeluarga
15Semuainjeksi denganobat risikotinggi
47