Daftar Tindakan Dan Pengobatan Yang Memerlukan Informed Consent Jadi

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(1)

DAFTAR TINDAKAN MEDIS 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 SMF TINDAKAN

1 Bedah 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

(2)

16 Elevasi Kraniotomi Fraktur Impresi,Dengan Robekan 17 Dura

18 Elevasi Kraniotomi Fraktur Impresi,Tanpa Robekan

NO SMF TINDAKAN

19 Dura

20 Extirpasi Tumor Jinak Saraf Kulit Kepala 21 Fusi Stabilisasi Corpus Vertebra

22 Graft/Transposisi Saraf Tepi 23 Hemisferektomi (Epilepsi) 24 Hemisferoktomi (Epilepsi)

25 Injeksi saraf perifer (dengan radiofrekuensi) 26 Injeksi spinal (Pain)

27 Insersi Elektrode Intradural (Epilepsi,movement,psikiatrik) 28 Kordotomi Perkutan

29 Kordotomi Servikal Open (Pain) 30 Kordotomi Servikal Perkutan (Pain) 31 Kranioplasti dua sisi

32 Kranioplasti satu sisi 33 Kraniotomi Biopsi otak

34 Laminektomi Eksisi Tumor Spinal 35 Laminoplasti

36 Laminotomi Biopsi Mielum

37 Laminotomi Diskektomi HNP/Stenosis>1 level 38 Laminotomi Diskektomi HNP/Stenosis 1 level 39 Lesionectomy (Epilepsi)

40 Lobektomi (Epilepsi) 41 Mesencephalectomy (Pain) 42 Mikrodisekktomi HNP

(3)

44 Neurektomi/Neurolise

45 Neuroendoskopi (Otak,Spinal) 46 Neuroplasti

47 Omaya drain

NO SMF TINDAKAN

48 Pallidotomi (movement Disorder) 49 Paravertebral Blok Perkutan 50 Pemasangan Traksi Servikal 51 Penjahitan Saraf Tepi

52 Punksi Cairan Otak

53 Reseksi Extra-Temporal (Epilepsi) 54 Revisi VP Shunt

55 Rhizotomi Selektif (Spastisitas) 56 Rhizotomy (Pain)

57 Selective Nerve Root Block

58 Selective Thalamotomi (Movement Disorder) 59 Simpatektomi Open (Pain)

60 Simpatektomi Perkutan

61 SLTH

62 Stereotactic Ablative Procedure (Psichiatric) 63 Subthalamotomy (Movement Disorder) 64 Suturektomi Kraniostenosis

65 Thalomotomy (Pain)

66 Transposisi kraniostenosis,dengan orbital advancement

67 Transposisi kraniostenosis,tanpa orbital advancement

68 Trepanasi Cedera Kepala (<4jam) 69 Trepanasi Cedera Kepala (>4jam)

(4)

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 76 VP Shunt Satu Sisi

NO SMF TINDAKAN

1 Aff Arch Barr

2 Aff Arch Barr dan suspensi maksila 3 Biopsy Insisional dengan anastesi lokal 4 Deseksi submandibula

5 Diseksi leher radikal/radikal neck dissection 6 Eksisi gld submandibula

7 Eksisi higroma leher 8 Eksisi kista tiroglosus

9 Eksisi luas tumor ganas bibir dengan rekontruksi 10 flap lokal

11 Eksisi luas tumor ganas dengan rekontruksi flap jauh 12 Eksisi luas tumor ganas kulit dengan rekontruksi 13 flap lokal

14 Eksisi luas tumor ganas rongga mulut dengan 15 rekontruksi flap lokal

16 Eksisi parsial+marsupialisasi Ranula

17 Eksisi tumor ganas kulit dengan flap local atau graft 18 Kulit

19 Eksisi tumor ganas kulit dengan flap local jauh 20 Eksisi tumor ganas kulit tanpa rekontruksi 21 Eksisi tumor jinak dengan anastesi lokal

(5)

22 Ekskokleasi epulis

23 Ekskokleasi kista folikuler 24 Ekskokleasi kista radikuler

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

26 Ekstirpasi kista dermoid 27 Endoscopic thyroidectomy

28 Fiksasi interna fraktur maksilofasial 1-2 tempat patahan

No 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 2 THT 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

(6)

15 Ekstraksi Polip

16 Esofagoskopi Rigid & Fleksibel 17 Ethmoidektomi (Intranasal)

18 Ekstraksi Korpus Alienum Kavum Nasi

NO 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 48 Laringoskopi Rigid

(7)

NO 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

(8)

85 Terapi Wicara Tuna Laring

NO SMF TINDAKAN

3 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

7 Amputation and disarticulation of finger- general anaesthesia

8 Amputation and disarticulation of finger -local anaesthesia

9 Amputation and disarticulation of thumb-general anaesthesia

10 Amputation and disarticulation of finger- general anaesthesia

11 Amputation and disarticulation of finger -local anaesthesia

12 Amputation and disarticulation of thumb-general anaesthesia

13 Amputation and disarticulation of thumb-local anaesthesia

14 Amputation of ankle through malleoli of tibia and fibula

15 Amputation of toe-general anaesthesia 16 Amputation of toe-local anaesthesia 17 Amputation through foot

18 Amputation through forearm

19 Amputation through hand, Amputation through carpals

20 Amputation through humerus, Upper arm amputation

(9)

22 Ankle fusion

23 Application of external fixator device

24 Application of external fixator device, monoplanar system

25 Application of external fixator device, ring system 26 Application of hybrid external fixator device

27 Arthrocentesis

NO SMF TINDAKAN

28 Arthrodesis of elbow 29 Arthrodesis of hip 30 Arthrodesis of knee

31 Arthrodesis of other specified joints 32 Arthrodesis of shoulder

33 Arthrodesis of unspecified joint

34 Arthroplasty of carpocarpal or carpometacarpal joint with implant

35 Arthroplasty of carpocarpal or carpometacarpal joint without implant

36 Arthroplasty of metacarpophalangeal and interphalangeal joint with implant

37 Arthroplasty of metacarpophalangeal and interphalangeal joint without implant 38 Arthroscopy

39 Arthrotomy for removal of prosthesis without replacement

40 Aspiration of bursa

41 Aspiration of bursa of hand 42 Aspiration of other soft tissue

43 Aspiration of other soft tissue of hand 44 Atlas-axis spinal fusion

45 Biopsy of bone

(10)

47 Biopsy of spinal cord or spinal meninges 48 Bone graft

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

50 Bunionectomy with soft tissue correction and arthrodesis

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

52 Bursectomy 53 Bursectomy of hand 54 Bursotomy NO SMF TINDAKAN 55 Bursotomy of hand 56 Carporadial fusion

57 Closed reduction of dislocation -General anaesthesia

58 Closed reduction of dislocation of ankle 59 Closed reduction of dislocation of elbow 60 Closed reduction of dislocation of foot and

toe-general anaesthesia

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

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

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

64 Closed reduction of dislocation of hip 65 Closed reduction of dislocation of knee

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

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

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

(11)

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

73 Closed reduction of fracture with internal fixation - Femur (Including : MIPO, interlocking nail, TEN) 74 Closed reduction of fracture with internal fixation -

Humerus (including : Interlocking nail, TEN, MIPO)

NO SMF TINDAKAN

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

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

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

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

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

84 Excision of bone for graft 85 Excision of intervertebral disc 86 Excision of lesion of muscle

87 Excision of lesion of muscle of hand 88 Excision of lesion of other soft tissue

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

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

91 Excision of bone for graft 92 Excision of intervertebral disc 93 Excision of lesion of muscle

94 Excision of lesion of muscle of hand 95 Excision of lesion of other soft tissue

(12)

96 Excision of lesion of tendon sheath 97

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

98

Excision 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 101 Excision of other lesion of soft tissue of hand

NO SMF TINDAKAN

102 Excision of semilunar cartilage of knee 103 Excision of tendon for graft

104 Excision of tendon of hand for graft

105 Excision or correction of bunionette, That with osteotomy

106 Excision or destruction of intervertebral disc, unspecified

107 Exploration of tendon sheath

108 Exploration of tendon sheath of hand 109 Exploratory thoracotomy

110 Fasciotomy

111 Fasciotomy of hand 112 Finger reattachment 113 Five-in-one repair of knee 114 Foot reattachment

115 Forearm, wrist, or hand reattachment 116 Fusion or refusion of 2-3 vertebrae

(13)

117 Fusion or refusion of 4- 8 vertebrae 118 Fusion or refusion of 9 or more vertebrae 119 Graft of muscle or fascia

120 Hip bearing surface, ceramic-on-ceramic

121 Hip bearing surface, ceramic-on-polyethylene, Hip bearing surface, oxidized zirconium-on-polyethylene 122 Hip bearing surface, metal-on-metal

123 Hip bearing surface, metal-on-polyethylene

124 Implantation of internal limb lengthening device with kinetic distraction

125 Implantation of other internal limb lengthening device

126 Implantation or replacement of peripheral neurostimulator lead (s)

127 Implantation or replacement of spinal neurostimulator lead(s)

128 Incision and drainage of palmar or thenar space 129 Injection of anesthetic into peripheral nerve for

analgesia

NO SMF TINDAKAN

130 Injection of anesthetic into spinal canal for analgesia 131 Injection of destructive agent into spinal canal 132 Injection of locally-acting therapeutic substance into

other soft tissue 133

Injection 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 136 Injection of therapeutic substance into joint or

ligament

137 Injection of therapeutic substance into tendon 138 Injection of therapeutic substance into tendon of

(14)

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 145 Insertion of partial spinal disc prosthesis,

lumbosacral

146 Insertion of recombinant bone morphogenetic protein

147 Insertion of spinal disc prosthesis, not otherwise specified, Replacement of spinal disc, NOS 148 Insertion of spinal disc prosthesis, thoracic

149 Insertion of sternal fixation device with rigid plates 150 Insertion of total spinal disc prosthesis, cervical 152 Insertion of total spinal disc prosthesis, lumbosacral 153 Insertion or replacement of (cement) spacer

154 Insertion or replacement of facet replacement device(s)

NO SMF TINDAKAN

155 Insertion or replacement of interspinous process device(s)

156 Insertion or replacement of pedicle-based dynamic 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

(15)

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 179 Myotomy

180 Myotomy of hand 181 Neurectasis

NO SMF 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

(16)

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

187 Open reduction of dislocation of hip - Fresh dislocation 188 Open reduction of dislocation of hip - Neglected

dislocation

189 Open reduction of dislocation of knee - Neglected dislocation

190 Open reduction of dislocation of knee -Fresh dislocation 191 Open reduction of dislocation of other specified sites 192 Open reduction of dislocation of shoulder -Fresh

dislocation

193 Open reduction of dislocation of shoulder -Neglected dislocation

194 Open reduction of dislocation of unspecified site-Fresh dislocation

195 Open reduction of dislocation of unspecified site-Neglected dislocation

196 Open reduction of dislocation of wrist -Fresh dislocation 197 Open reduction of fracture with internal fixation- radius

and ulna-Simple fracture

198 Open reduction of fracture with internal fixation- unspecified site (Periarticular Major Bone ) 199

Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws

Hand NOS -Plate & Screw 200

Open reduction of fracture with internal fixation-carpals and metacarpals - plate & screws

Hand NOS -Plate & Screw 201

Open reduction of fracture with internal fixation-carpals and metacarpals - simple implants (K-wire)

Hand NOS -implant sederhana (K-wire)

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

203 Open reduction of fracture with internal fixation-femur-Simple fracture

NO SMF TINDAKAN

(17)

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 metafixation-tarsals- Plate & Screws 212 Open reduction of fracture with internal

fixation-tarsals and metafixation-tarsals- 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

215

Open reduction of fracture without internal fixation 216 Open reduction of separated epiphysis

217 Osteoclasis (correction of bone deformity) 218 Other

219

Other (peripheral) vascular shunt or bypass 220

Other amputation below knee

221 Other anastomosis of cranial or peripheral nerve 222 Other and unspecified repair of the anulus fibrosus 223 Other arthrotomy

224

Other bunionectomy 225

Other bunionectomy with soft tissue correction 226 Other cervical fusion of the anterior column, anterior

technique

227 Other cervical fusion of the posterior column, posterior technique

228

(18)

229

Other change in muscle or tendon length 230

Other destruction of intervertebral disc

NO SMF TINDAKAN

231 Other diagnostic procedures on joint structures

232 Other 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

239 Other 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

250 Other 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

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

Suture of bursa

258 Other partial ostectomy (including : Bone curretage, marginal resection/excision)

NO SMF TINDAKAN

(19)

lysis of adhesions Peripheral nerve neurolysis NOS 260 Other plastic operations on fascia

261 Other plastic operations on hand 262 Other plastic operations on muscle 263 Other repair of ankle

264 Other repair of elbow

265 Other repair of hand, fingers and wrist 266 Other repair of joint

267 Other repair of knee 268 Other repair of shoulder

269 Other repair of the collateral ligaments 270 Other repair of the cruciate ligaments 271 Other repair or plastic operations on bone 272 Other suture of flexor tendon of hand 273 Other suture of muscle or fascia 274 Other suture of other tendon of hand 275 Other suture of tendon

276 Other tendon transposition 277 Other tenodesis of hand 278 Other tenonectomy

279 Other tenonectomy of hand 280 Other tenoplasty of hand 281 Other tenotomy

282 Other total shoulder replacement 283 Partial hip replacement

284 Partial shoulder replacement 285 Patellar stabilization

286 Percutaneous denervation of facet 287 Percutaneous vertebral augmentation 288 Percutaneous vertebroplasty

289 Peripheral nerve injection, not otherwise specified 290 Plastic operation on hand with graft of muscle or fascia 291 Plastic operation on hand with other graft or implant 292 Pollicization operation carrying over nerves and blood

supply

293 Quadricepsplasty 294 Reattachment of muscle

295 Reattachment of muscle of hand 296 Reattachment of tendon

297 Reattachment of tendon of hand 298 Refusion of atlas-axis spine

299 Refusion of dorsal and dorsolumbar spine, anterior column, anterior technique

(20)

NO SMF 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

(21)

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)

NO SMF TINDAKAN

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

328 Removal of internal limb lengthening device 329 Removal of pedicle screw(s) used in spinal fusion 330 Removal of peripheral neurostimulator lead(s) 331 Removal of skeletal muscle stimulator

332 Removal of spinal neurostimulator lead(s) 333 Reopening of laminectomy site

334 Repair of claw toe 335 Repair of cleft hand 336 Repair of hammer toe

337 Repair of hip, not elsewhere classified 338 Repair of macrodactyly

339 Repair of mallet finger

340 Repair of old traumatic injury of cranial and peripheral nerves

341 Repair of recurrent dislocation of shoulder

342 Repair of the anulus fibrosus with graft or prosthesis 343 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 toe

345 Resurfacing hip, partial, acetabulum, Hip resurfacing arthroplasty, partial, acetabulum

346 Resurfacing hip, partial, femoral head

347 Revision of total knee replacement, tibial insert (liner), Replacement of tibial insert(liner)

348 Revision or replacement of artificial spinal disc prosthesis, cervical

349 Revision or replacement of artificial spinal disc prosthesis, lumbosacral

350 Revision or replacement of artificial spinal disc prosthesis, not otherwise specified

(22)

prosthesis, thoracic 352 Rotator cuff repair

353 Separation of equal conjoined twins 354 Separation of unequal conjoined twins 355 Sequestrectomy

356 Spinal fusion, not otherwise specified 357 Subtalar fusion

358 Subtalar joint arthroereisis 359 Suture of Artery

360 Suture of capsule or ligament of ankle and foot

NO SMF 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 Upper arm reattachment

(23)

394 Wedge osteotomy

NO SMF TINDAKAN

4 BEDAH 1 Biopsi Terbuka Bronkhus THORAKS 2 Biopsi Terbuka Diafragma

DAN 3 Biopsi Terbuka Mediastinum KARDIOVASKULAR 4 Biopsi Terbuka Paru

5 Biopsi Terbuka Pleura

6 Biopsi Terbuka Pleura dengan VATS 7 Biopsi Terbuka Tumor Dinding Thoraks 8 Debridement Mediastinum (Sternotomi) 9 Eksisi Pada Bronkhus

10 Eksisi Pada Paru (Lung Volume Reduction) 11 Eksisi Pada Paru dengan VATS

12 Eksisi Tumor Dinding Dada dengan Rekonstruksi Dinding Dada

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

14 Ekstraksi Corpus Alienum di Regio Toraks

15 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS 16 Evakuasi Efusi Pleura/Empyema secara Torakoskopik

(VATS)

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

20 Lobektomi Parsial (Reseksi Paru segmental) dengan VATS

21 Lumbal Simpatektomi 22 Mediastinostomy

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

24 Pleural window (Eloeser Flap) 25 Pleurektomi

26 Pleurodesis (Pleurosklerosis) 27 Plikase Bulae / Bleb Emfisematous 28 Plikasi diafragma

(24)

30 Pneumonectomy dengan VATS 31 Pulmonary Decortication

32 Pulmonary Decortication dengan VATS 33 Pulmonary Lobectomy/Bilobectomy

34 Pulmonary Lobectomy/Bilobectomy dengan VATS 35 Redo Torakotomi

36 Rekonstruksi Sternum&Dinding Dada 37 repair deformitas Pectus

38 Repair Fistula Bronkopleural 39 Repair Laserasi Diafragma

NO SMF TINDAKAN

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

41 Thoracal Symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS)

42 Thoracocentesis 43 Thymectomy

44 Thymectomy dengan VATS

45 Torakoplasti (Air Plumbage/Muscle Plumbage) 46 Torakotomi / sternotomi Eksplorasi

47 Torakotomi Eksplorasi pada Trauma jantung/Repair Laserasi Jantung

48 Bedah Kardio (Jantung) 49 Aortic Valve Repair (AVR)

50 Aortic Valve Repair (AVR) dengan Bioprosthesis Valve 51 Aortic Valve Repair (AVR) dengan Mechanical Valve 52 Atrial septal Defect (ASD) Closure

53 Bidirectional Cavo-Pulmonary Shunt (BCPS) 54 Biopsi Jantung

55 Biopsi Perikardium

56 Blalock-Taussing Shunt (BT Shunt) 57 Coronary Artery Bypass Graft (CABG) 58 Eksisi Cardiac Myxoma

59 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

(25)

66 Operasi Reopen oleh Karena sebab Perdarahan, Tamponade Jantung

67 Pemasangan IABP

68 Pemasangan Pace Maker Permanen (diluar alat) 69 Pericardiocentesis

70 Perikardiektomi

71 Perikardiotomi/Pericardial Window 72 Pulmonal Valve Repair (PVR)

73 Pulmonal Valve Repair (PVR) dengan Bioprosthesis Valve 74 Pulmonal Valve Repair (PVR) dengan Mechanical Valve

75 Pulmonary Artery Banding (PA)

NO SMF 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)

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

81 Repair Transposition of Great Arteries (TGA) (35.84) 82 Repair Trunkus Arteriosus (35.83)

83 Revisi/Aff Pace Maker Permanen (diluar alat) (37.89) 84 Septostomi Terbuka Septum Atrium (35.41)

85 Total Koreksi Tetralogy of Fallot (TOF) (35.81) 86 Tricuspid Valve Repair (TVR) (35.14)

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

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

89 Ventricle Septal Defect (VSD) Closure (35.5) 90 Amputasi Above Knee (AK) (84.17)

91 Amputasi Below Knee (BK) (84.14) 92 Arterial Pungsi, Kanulasi, Sectie (38.91)

93 Arteriovenous Shuntt (AV Shunt) Brakiosefalika (39.42) 94 Arteriovenous Shuntt (AV Shunt) Radiosefalika (39.27) 95 Bedah Varises Insisi Babcock (38.5)

96 Biopsi Pembuluh Darah (Perifer) (38.21) 97 Debriment-Nekrotomi Luka Gangren (86.22) 98 Disartikulasi Sendi Ekstremitas (84.13)

Eksisi Biopsi 1 Eksisi Tumor Pembuluh Darah Perifer (Hemangioma) Tumor Pembuluh 2 Eksplorasi Vaskular (Trauma/Non trauma)

(26)

Darah 3 Embolektomi/Trombektomi Aorta

4 Embolektomi/Trombektomi Pembuluh Darah Arteri Abdominal 5 Embolektomi/Trombektomi Pembuluh Darah Arteri Ekstremitas

Bawah

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

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

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

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

10 Fasciotomy

11 Ligasi Vaskular Ekstremitas 12 Mutilasi Digiti Ekstermitas

NO SMF TINDAKAN

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

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

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

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

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

18 Pembedahan Teleangiectasis

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

20 Repair Aneurisma Aorta Abdominalis (Diluar Protesa) 21 Repair Pembuluh Darah Regio Servikal (Karotis,

Jugular)

22 Repair Ruptur Pembuluh Arteri Abdominal 23 Revisi Arteriovenous Shunt

24 Skleroterapi Vena (Varises, Hemangioma) 25 Stripping Varises Ekstremitas Inferior

26 Vascular Shunting (Splenorenal Shunt, De Palma Shunt)

27 Vena Punctie, Kanulasi, Sectie

(27)

DIGESTIVE 2 Abdominoperineal resection (miles) dengan penyulit mayor

3 Abdominoperineal resection (miles) dengan penyulit minor

4 Abdominoperineal resection (miles) tanpa penyulit 5 Abdominoplasty

6 Apendektomi

7 Apendektomi dgn penyulit major 8 Apendektomi dgn penyulit minor 9 Apendektomi laparoskopik

10 Bilio-difgestif anastomosis tanpa penyulit 11 Biliodigestif dengan penyulit mayor 12 Biliodigestif dengan penyulit minor 13 Biopsi insisional, local anastesi 14 Biopsi rectum

15 Eksisi hemoroid eksterna

16 Eksplorasi duktus bilier & cholangiografi intra operatif 17 Esofagotomi

18 Fistulotomi

NO SMF TINDAKAN

19 Fistulotomi dgn penyulit mayor 20 Fistulotomi dgn penyulit minor 21 Gastrostomi

22 Hemikolektomi dengan penyulit mayor 23 Hemikolektomi dengan penyulit minor 24 Hemikolektomi tanpa penyulit

25 Hemoroid stapling (diluar alat) 26 Hemoroidektomi

27 Herniotomi

28 Herniotomi dgn penyulit mayor 29 Herniotomi dgn penyulit minor 30 Herniotomi laparoskopik 31 Jejunostomi / ileostomi

32 Laparotomi dengan penyulit minor 33 Laparotomi tanpa penyulit

34 Ligasi hemoroid (diluar alat)

35 Pankreatiko-duodenektomi cephalis (Whipple) dengan penyulit mayor

36 Peritoneal dreanse (CAPD) 37 Peritoneal lavase

38 Polipektomi 39 Potong kolostomi

(28)

40 Prosedur Heller 41 Rektopexy

42 Repair fistel usus

43 Repair fistel vesicorectal 44 Repair hernia cicatricalis

45 Repair hernia cicatricalis dgn penyulit mayor (diluar alat)

46 Repair hernia cicatricalis dgn penyulit minor (diluar alat)

47 Repair Hernia Diafragmatika (diluar alat) 48 Reseksi anterior dengan penyulit mayor 49 Reseksi anterior dengan penyulit minor 50 Reseksi anterior tanpa penyulit

51 Reseksi esofagus-colon / ileum transposisi 52 Reseksi esofagus-end to end

53 Reseksi esofagus-esofago-gastrectomy 54 Reseksi hati

55 Second look laparoscopy

56 Splenektomi / splenoraphy traumatika 57 Splenektomi non trauma

58 Terminal esofagus proksimal gastrektomi (TEPG) 59 Total gastrektomi

NO SMF TINDAKAN

60 Total pantreaktomi 61 Total prokto-kolektomi

62 Tutup burst abdomen (tanpa alat)

63 Tutup burst abdomen dengan penyulit mayor 64 Tutup burst abdomen dengan penyulit minor 65 Tutup kolostomi / ileostomi

66 Tutup kolostomi / ileostomi dengan penyulit mayor 67 Tutup kolostomi / ileostomi dengan penyulit minor 68 Repair Aorta Torakalis (38.34)

69 Repair Atrioventricular Septal Defect (35.54) 6 BEDAH 1 Adrenalektomi

UROLOGI 2 Adrenalektomi (Abdominotorakal) 3 Anastomosis end to end Ureter 4 Augmentasi Buli

5 Biopsi Ginjal perkutan 6 Biopsi Ginjal Terbuka 7 Biopsi Penis

(29)

9 Biopsi Testis

10 Bladder Neck Rekonstruksi 11 Buried Penis

12 Businasi/Dilatasi Uretra 13 Cabut DJ Stent

14 Defooring Kista Ginjal per Laparoskopi 15 Deroofing/Unroofing Kista

16 Diseksi Kelenjar Getah Bening Inguinal 17 Diseksi Kelenjar Getah Bening pelvis 18 Diseksi Kelenjar Getah Bening Pelvis per

Laparoskopi 19 Divertikulektomi Buli 20 Divertikulum Uretra 21 Dorsumsisi 22 Drainase Periureter 23 Eksisi Chordae/Chordektomi 24 Eksisi Fibroma/Rekonstruksi Penis 25 Eksisi Plaque (Peyronie Disease) 26 Eksisi Webbed Penis

27 Eksplorasi testis (Microsurgery) 28 Ekstraksi Batu

29 Ekstrofi Buli Rekonstruksi 30 Epispadia

31 Evakuasi Bekuan Darah (Clot) 32 Extended Pyelolithotomy

33 Fistulektomi/Repair Fistel Uretra

NO SMF TINDAKAN

34 Funikokelektomi 35 Ganti Nefrostomy

36 Hidrokel per Inguinal/Ligasi Tinggi 37 Hidrokel per Skrotal

38 Hipospadia Subkoronal 39 Holmium YaG Laser (Sewa) 40 Ileal Conduit (Bricker) 41 Insersi DJ Stent 42 Insisi Abses Perineum 43 Insisi Abses Skrotum

44 Insisi Posterior Urethral Valve 45 Johanson

46 Johanson I 47 Johanson II 48 Kalibrasi Uretra

(30)

49 Kauterisasi

50 Koreksi Horseshoe Kidney 51 Koreksi Priapismus

52 Laparoskopi Adrenalektomi 53 Laparotomi Eksplorasi

54 Ligasi V.Spermatika Interna (Microsurgery) 55 Limfadenektomi Ilioinguinal 56 Limfadenektomi Retroperitoneal/RPLND 57 Litholapaksi 58 Lithotripsi 59 Masase Prostat 60 Meatoplasti 61 Meatotomi 62 MMK/Sling Uretra 63 Nefrektomi

64 Nefrektomi Donor Transplant 65 Nefrektomi Parsial

66 Nefrektomi per Laparoskopi 67 Nefrektomi Radial 68 Nefropeksi/Renopeksi 69 Nefrostomi Perkutan/Temporer 70 Nefrostomi Terbuka/Permanen 71 Nefroureterektomi 72 Neobladder

73 Operasi Priapismus (prosedur Winter) 74 Operasi Repair Buli Trauma

75 Operasi Sistokel

NO SMF TINDAKAN

76 Operasi Trauma Ginjal

77 Operasi Urakhus/Reseksi urakhus 78 Orkhidektomi

79 Orkhidektomi extended 80 Orkhidektomi Ligasi Tinggi 81 Orkhidektomi Subkapsuler 82 Orkhidopeksi (Torsio Testis) 83 Orkhidopeksi (UDT)

84 Orkhidopeksi per Laparoskopi 85 Pasang Kateter

86 Pasang Kateter dengan Mandrain 87 Pasang Kateter Tenckhoff untuk CAPD

(31)

89 Penektomi Parsial

90 Penektomi Total/Amputasi Penis

91 PER (Primary Endoscopic Realignment) 92 Pielokalikotomi

93 Pielolitotomi 94 Pieloplasti

95 Pieloplasti per Laparoskopi 96 Prostatektomi Radikal 97 Prostatektomi Retropubik 98 Prostatektomi Terbuka

99 Prostatektomi Terbuka dan Sectio Alta 100 Psoas Hitch/Boari Flap

101 Punksi dan sklerosing Kista Ginjal 102 Railroading Rupture Uretra

103 Reimplantasi Ureter Bilateral 104 Reimplantasi Ureter

Unilateral/Ureteroneosistostomi 105 Rekontruksi Renovaskuler 106 Repair Fistel Enterovesika 107 Repair Fistel Vesikokutan 108 Repair Fistel Vesikorektal 109 Repair Fistel Vesikovagina

110 Repair Fistel Vesikovagina Kompleks 111 Reparasi Penis

112 Reseksi-anastomosis Uretra

113 RPG

114 Sectio Alta/Vesikolithotomi 115 Sirkumsisi

115 Sistektomi Parsial/Sistoplasti Reduksi 116 Sistektomi Per Laparoskopi

117 Sistektomi Total/Radikal 118 Sistoskopi 119 Sistoskopi ODS NO SMF TINDAKAN 120 Sistostomi perkutan 121 Sistostomi Terbuka 122 Skrotoplasti 123 Spermatokelektomi 124 Tailoring Ureter 125 Transplan Resipien 126 Transuretero-ureterostomi 127 TUR Prostat/TUIP/BNI

(32)

128 TUR Tumor Buli 129 TVP/TMP 130 Ureterokutaneostomi 131 Ureterolisis 132 Ureterolithotomi 133 Ureterolithotomi Distal 134 Ureterolithotomi Proksimal 135 Ureterosigmoidostomi (Caffey) 136 Ureterostomi 137 Ureterouretostomi 138 Uretroplasti Hipospadia 139 Uretroskopi/Uretrosistoskopi 140 Uretrotomi Interna (Sachse) 141 URS/Lithotripsi

142 Varikokelektomi (Palomo) 143 Vasektomi (anestesi lokal) 144 Vasektomi (narkose) 145 Vasoepididimostomi 146 Vasografi

147 Vasovasostomi 7 KSM ILMU 1 Angkat Jahitan

KESEHATAN 2 Angkat Jahitan dengan GA

MATA 3 Anterior Chamber Tap/Parasintesis 4 Aspirasi Massa Lensa

5 Blefaroplasty (2 Kelopak Mata) 6 Claw Lens

7 Cryopexy Kornea 8 Cyclo Cryo

9 Dacryocystorinostomi (Without Silicon Tube) 10 Dekompresi Orbital/Lateral Orbitotomi

11 Disisi Aspirasi & IOL

12 ECCE

13 ECCE & IOL 14 Eksenterasi

15 Eksisi Hordeolum / Chalazion

16 Ekstirpasi Corpus Alienum di Kornea 17 Ekstirpasi Pterygium + Graft Konjungtiva

NO SMF TINDAKAN

18 Ekstripasi Corpus Alienum di Bilik Mata Depan 19 Enukleasi/Eviscerasi (DFG/Bonegraft)

20 Evakuasi Silikon Oil 21 Fornix Repair

(33)

22 ICCE

23 ICCE & IOL

24 Injeksi Intra Vitreal

25 Injeksi Periokuler Terapetik 26 IOL Explant

27 Iridectomi

28 Jahit Kelopak Mata Full Thickness & Lid Margin 29 Jahit Kornea

30 Keratoplasti (Corneal Transplantation) 31 Konjungtival Flap/Amnion Graft

32 Piggy Back IOL 33 Pneumoretinopexy

34 Repair Canalis Lacrimalis (Without Silicon Tube) 35 Repair Coloboma Palpebra (Skin/Mucosal Graft) 36 Reposisi IOL

37 Reposisi Iris

38 Resesi & Reseksi 2 Otot 39 Resesi & Reseksi 3 Otot 40 Resesi & Reseksi 4 Otot 41 Resesi/Reseksi 1 Otot

42 Sekunder Implant (Posterior Chamber)

43 Sekunder Implant Claw Lens / Fiksasi Sulcus

44 SICS

45 SICS & IOL 46 Simpel Vitrektomi 47 Skleral Buckle

48 Socket Repair (Contracted Socket) 49 Trabekulektomi

50 Trabekuletomi & Ollogen

51 Trabulektomi & Goniotomi pada Pediatric Glaucoma

52 Tube Shunt (Express) 53 Viscocanulostomy 54 Vitrektomi +++

55 Vitrektomi Lengkap & Skleral Buckle 56 Wide Eksisi Tumor Kelopak Mata

57 Wide Eksisi Tumor Kelopak Mata + Flap + graft

NO SMF TINDAKAN

8 Onkologi 1 Aspirasi Kista Mamma Single dan Multiple 2 Biopsi Core Lokal Anestesi

(34)

3 Biopsi Eksisi Lokal 4 Biopsi Eksisi Narkose 5 Biopsi Insisi Lokal 6 Biopsi Narkose

7 Breast Conserving Surgery (BCS) 8 Breast Conserving Surgery + LD Flap 9 Debriment Mamma

10 Diseksi Axilla

11 Eksisi Fibroadenoma Lokal Anestesi Single Satu Sisi 12 Eksisi Fibroadenoma Multiple Narkose

13 Eksisi Tumor Metastase Loco-regional 14 Eksplorasi Duktus Mama

15 Eksplorasi Duktus Mama+VC 16 Insisi Absces Mastitis Lokal 17 LD Flap + Eksisi Tumor 18 Mastectomy + Tram Flap

19 Modified Radical Mastectomy + Flap/Single Grafting 20 Modified Radical Mastectomy Single

21 Quadrantectomy / Partial Mastectomy 22 Simple Mastektomy + Flap/Skin Grafting 23 Simple Mastektomy Single

24 Tram Flap + Eksisi Tumor 25 Operasi Tumor Kulit

26 Biopsi Insisi Tumor Kulit Lokal 27 Biopsi Eksisi Tumor Kulit Narcose 28 Eksisi Tumor Jinak ≤ 3cm

29 Eksisi Tumor Jinak + Flap/Skin Graft 30 Eksisi Tumor Jinak Kulit >3cm

31 Wide Eksisi + Diseksi KGB 32 Wide Eksisi Tumor Ganas Kulit

33 Wide Eksisi Tumor Ganas Kulit+Flap / Skin Graft 34 Operasi Soft Tissue Tumor

35 Amputasi + Diseksi KGB

36 Amputasi Jari + Flap / Skin Graft 37 Amputasi Tungkai / Lengan 38 Biopsi Core soft Tissue

39 Biopsi Insisi Tumor Sof Tissue dengan Narcose 40 Biopsi Insisi Tumor Soft Tissue Lokal Anestesi 41 Eksisi Tumor Jinak > 3cm

42 Eksisi Tumor Jinak Ø<3cm

43 Wide Eksisi + Compartement Procedure 44 Wide Eksisi + Diseksi KGB

(35)

46 Wide Eksisi Tumor Jinak + Flap/Skin Graft

NO SMF 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

(36)

73 Total Thyyroidectomy

74 Transversus-Rectus Abdominis Flap (Tram Flap)

NO SMF TINDAKAN

9 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

7 Biliodigestif 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

(37)

25 Ekstirpasiranula

26 Endoskopik diagnostik 27 Endoskopik terapeutik 28 Gastrostomi

29 Hemikolektomi

30 Herniotomi elektif tanpa penyulit 31 Herniotomi laparoskopik

NO SMF 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)

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

50 Polipektomi (48.36)

(38)

52 Posterosagital anorectoplasty urethro vaginoplasty (70.79) 53 Potong kolostomi (46.14) 54 Potong Stump (84.3) 55 Prosedur Heller (44.6) 56 Prosedur Kasai (51.37)

57 Repair atresia esofagus (42.5) 58 Repair defek diafragma (53.8) 59 Repair ekstrofia buli (57.8)

60 Repair hernia diafragma (53.7/53.8)

NO SMF TINDAKAN

61 Repair of Gastrochisis (54.71) 62 RPLND (40.59)

63 Separasi conjoined twin (84.9)

64 Sirkumsisi dengan general anesthesia (64.0) 65 Sirkumsisi dengan local anesthesia (64.0) 66 Splenektomi (41.5)

67 Splenorenal shunt (39.1)

68 Transnasal endorectal pullthrough laparascopic assisted (48.42)

69 Transplantasi organ

70 Tutup burst abdomen dengan penyulit (54.61) 71 Tutup burst abdomen tanpa penyulit (54.61) 72 Tutup ileostomi dengan penyulit (46.5) 73 Tutup kolostomi / ileostomi (46.5) 74 Tutup Stoma (46.5)

75 Urethroplasty / chordectomy (64.42) 76 Vena Sectie Aksilaris (38.94)

77 Vena sectie Femoralis / saphena magna (38.94) 78 Wound repair (86.8)

(39)

10 BEDAH 1 Abdominoplasty

PLASTIK 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

NO SMF TINDAKAN

13 Bone rekonstruksi facial cleft 14 Bone rekonstruksi facial cleft 15 Cheilonasoraphy

16 Chordectomy

17 Chordectomy+urethroplasty 18 Closed Reduction Fr. Nasal 19 Comisuroplasty

20 Eks mamma aberan bilateral

21 Eksisi neoplasma jinak (lipoma, atheroma dll) 22 Eksisi luas + Deltopectoral flap

23 Eksisi luas + Fore head flap 24 Eksisi luas + Muskulocutan flap

25 Eksisi luas + rekonstruksi dengan bedah mikrovaskular

26 Eksisi malformasi lymphatik / vaskuler 27 Ekstraksi ateroma / keloid

(40)

29 Elevasi ear rim cartilago

30 Excise hemangioma + rekonstruksi 31 Excise intra keloid

32 Excise polydactyly

33 Excise reduksi lymedema 34 Facial sling dengan allograft 35 Fasciotomy burn injury

36 Fasciotomy with complication 37 Flap lokal sederhana

38 Fr. Condylus mandibula open red 39 Fr. Maksila suspensi (IOID) 40 Fr. Nasal open reduction

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

42 Fraktur Prosesus alveolaris luas dengan IDW (per rahang)

43 Fraktur rahang reduksi terbuka & inter oseus wiring (IOW) NO SMF TINDAKAN 44 LD flap 45 Le fort I osteotomy 46 Liposuction 47 Lobuloplasti 48 Malarplasty

49 Mamma aberan unilateral 50 Mandibular distraksi

51 Mandibular rekonstruksi dengan costochondral graft 52 Mastopexi

53 Mentoplasty 54 Microsurgery

55 Multiple facial fraktur + implant 56 Muskulokutaneus flap

57 Myokutaneus flap/pectoralis mayor flap 58 Nasal repair dan rekonstruksi

59 Neo vagina

60 Operasi bedah mikro 61 Orif fraktur zygoma 62 Orif fraktur hand

(41)

63 Orif fraktur mandibula 64 Orif fraktur maxilla 65 Orif maksila plating 66 Orif mandibula plating 67 Orif mandibula wiring 68 Orif orbital wall 69 Orif orbital wall 70 Orif zygoma wiring

71 Osteotomy craniosynostosis reconstruction 72 Osteotomy facial rekonstruksi

73 Osteotomy genioplasti tanpa tarif bahan 74 Osteotomy maksila Le fort I

75 Osteotomy maksila Le fort II 76 Palatoplasti bilateral komplit 77 Palatoplasti bilateral tak komplit 78 Palatoplasti unilateral komplit 79 Palatoplasti unilateral tak komplit 80 Palatoraphy

81 Pasang archbar

82 Pasang back slab/fore slab 83 Pasang cast/gips tanpa reposisi 84 Recheiloraphy

85 Rekonstruksi dengan alloplastic material 86 Rekonstruksi facial cleft

87 Rekonstruksi nasal

NO SMF TINDAKAN

88 Rekonstruksi palpebra 89 Released buried penis

90 Released syndactyly kompleks

91 Repair canalis lacrimalis (without silicon tube) 92 Repair coloboma palpebra (skin/mucosal graft) 93 Repair ductus nasolacrimalis

94 Repair fingertip injury 95 Repair fistel urethra 96 Replantation

97 Reposisi fraktur nasal sederhana

98 Reposisi fraktur os nasalis (complicated) 99 Reseksi mandibula + bone graft

100 Rhinoplasty 101 Rotation flap

102 Sagital Split osteotomi mandibula 103 Simple bone grafting

(42)

104 Simple skin grafting 105 Skin flap

106 Skin graft >5 cm

107 Skin graft sedang 5 cm 108 Skin grafting kecil 109 Skin grafting luas 110 Skin grafting sedang

111 Skin grafting with complication 112 Tendon reconstruction

113 Tendon transfer

114 Tendon transfer with complication 115 Tennoraphy

116 Tennoraphy with complication 117 TMJ arthroplasty 118 TMJ arthrostomy 119 Tram flap 120 Wound Dressing 121 Wound Repair NO SMF TINDAKAN 11 1 Cauter serviks OBGYN 2 Cordosentesis

3 Debulking tumor ovarium 4 Eksplorasi vagina

5 Embryotomi

6 Extirpasi + kuret polip endoserviks 7 Extirpasi geboren mioma

8 Extirpasi geboren mioma+kuiretasi 9 Histeroctomy pada mola / chorio Ca

(43)

10 Histeroctomy radikal 11 Kistektomi

12 Konisasi serviks

13 Kuret abortus incompletes 14 Lap op: myomektomi

15 Laparoskopi (Kistektomi Ovarium, Salphingektomi, Adhesiolisis)

16 Laparoskopi Histerektomi 17 Laparoskopi steril

18 Laparoskopik Diagnostik

19 Laparotomi dengan penyulit mayor 20 Laparotomi dengan penyulit minor 21 Laparotomi tanpa penyulit

22 LEEP

23 Micro kuretase DUB 24 Mikrokuret

25 Miomectomy 26 Neovagina

27 Operasi Ca vagina

28 Operasi kanker corpus uteri 29 Operasi tumor ganas ovarium

30 Operative histeroscopy/Ablasi endometrium 31 Overectomi

NO SMF TINDAKAN

32 Painless labor 33 Persalinan normal

34 Persalinan normal dengan penyulit 35 Persalinan pervaginam tindakan operatif 36 Persalinan sungsang

(44)

37 Rekanalisasi 38 Rekanalisasi tuba 39 Salfingektomi unilateral 40 Salvingoovarectomi unilateral 41 Secound look surgery Ca ovarium 42 Seksio sesaria

43 Seksio sesaria dengan penyulit penyulit 44 Sirklase serviks

45 Seksio sesaria dengan penyulit penyulit 46 Sirklase serviks

47 Supra vaginal hyterectomy 48 Surgical staging

49 TAH+BSO dengan Penyulit

50 TAH+BSO dengan Penyulit Pemasangan Tampon Abdomen

51 Total abdominal hysterectomy+bilateral salfingektomi 52 Tubektomi klinik

53 Tutup burst abdomen

NO SMF TINDAKAN

12 1 Augmentasi Tulang Per Regio (Belum Termasuk

Bahan)

GIGI dan 2 Debriment Mukosa dan Pengelolaan Luka Sayat MULUT 3 Dislokasi Sendi Mandibula

(45)

5 Eksisi Kelenjar Ludah Submandibula

6 Eksisi Kista Odontogenik Keratosis + Ostektomi 7 Eksisi Neoplasma Jinak Extra Oral Ukuran Kecil 8 Eksisi Parsial + Marsupialisasi Ranula

9 Eksisi Plunging Ranula

10 Eksisional Biopsi Neoplasma Jinak

11 Enukleasi Kista Dentigerous + Extraksi Gigi Impaksi 12 Enukleasi Kista radikuler Per Rahang + Extraksi Gigi

Penyebab

13 Extirpasi Kista Dermoid 14 Extirpasi Sialolith

15 Extraksi Corpus Alienum dengan Teknik Lindorf 16 Extraksi 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

21 Fraktur Dento alveolar Dengan Bracket (belum termasuk bahan)

22 fraktur Dento Alveolar dengan Eyelet 23 Fraktur Maksila dengan Suspensi Wiring 24 Fraktur Nasal close Reduksi

25 Fraktur Nasal Open Reduksi

26 Fraktur Rahang Reduksi Tertutup dengan Intermaksila Fiksasi

27 Frenektomi Per Rahang 28 Genioplasty

29 Gingivektomi Per Rahang

NO SMF TINDAKAN

(46)

31 Insisi Abses / Phlegmon

32 Insisional Biopsi Neoplasma Jinak 33 Mandibular Distraksi

34 Odontektomi Per Gigi

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

36 ORIF Maksila Plating (belum termasuk implant) 37 ORIF Mandibula Plating (belum termasuk implant) 38 ORIF Zygoma Plating (belum termasuk implant) 39 Osteotomi Maksila le Fort I

40 Osteotomi Maksila le Fort II

41 Pelepasan Arch Bar (Intermaksila Fiksasi)

13 1 Intubasi Endotrakea

GAWAT 2 Krikotirotomi

DARURAT 3 Kanulasi vena perifer

ILMU 4 Vena sectie

KESEHATAN 5 Pungsi lumbal

ANAK 6 Pungsiv Pleura

14 PENYAKIT 1 Diagnostik Kateterisasi Jantung JANTUNG & 2 PTMC

PEMBULUH 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) 15 PENYAKIT

DALAM

(47)

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

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

D. Semua Tindakan Yang Berisiko Tinggi :

No SMF NAMA TINDAKAN

1 ANAK 1 Chest tube

2 Tindakan kemotherapi 3 Pemasangan Ventilator

(48)

4 Intubasi Endotrakea

5 Pemasangan Laryngeal mask 6 Krikotirotomi

7 Infus intraosseus 8 Kanulasi vena perifer 9 Vena sectie

1

0 Pengambilan darah intra vena dan intra arteri 11 Pungsi lumbal

1

2 Pungsiv Pleura 1

3 Pemasangan kateter urine 1

4 Pemasangan keteter rectal 1

5 Pemasangan orogastrik tube 1

6 Pemasangan nasogastrik tube

2 THT

1 Pemeriksaan Audiometri 2 Pemeriksaan Timpanometri 3 Pemeriksaan Audiometri Tutur 4 Pemeriksaan Sisi&Tore Decay

5 Pemeriksaan Pendengaran Pada Anak 6 Pemeriksaan Brainstem Evoked Response

Audiometry 3 Patologi

Anatomi FNAB (Fine Needle Aspiration Biopsy) 4 Radiotherapi Tindakan Radiotherapi

5 Neorologi 1 Cerebral Angiografi 2 AVM&Embolisasi 3 Aneurisma Coiling 4 Embolisasi pre operasi 5 Diagnosis DSA

6 Lumbal Punksi 7 Pain Intervention 8 Injeksi Triger point 9 Injeksi Triger Fringer 1

0 Injeksi CTS

11 Sub Optical Functional 1 Injeksi botox

(49)

2 1

3 EMG

6 Patologi

Klinik Phlebotomi

7 Gigi & Mulut

1 Scaling

2 Curettage/root planning (jika diperlukan anestesi) 3 Gingivektomi

4 Frenektomi

5 Flap operasi (bone graft/membrance/GTR/interseptif) 6 Implant

7 Vital pulpektomi dan Partial Nekrose 8 Cauter

9 Retraksi Gingiva pada prep.crown 8 Andrologi Suntik Intra Cavernosal Penis

9

Kardiologi dan Kedokteran

Vaskular

1 Dobutamin Stress Ekhokardiografi 2 Transophegal Ekhokardiografi 3 Treadmill Tes

4 Exercise Stress Ekhokardiografi

10 Pulmonologi dan Ilmu Kedokteran Respirasi 1 Bronchoscopy/FOB 2 Tindakan kemotherapi 3 Thoracoscopy 4 Contra Ventil/WSD 5 Punctie Pleura 6 FNAB 7 Scalene Biopsy 8 Reposisi 9 Pleurodesis 1 0 AFF WSD 11 Perawatan Luka WSD 1

2 USG Thorax Marker

11 Radiologi

1 Tindakan Radiologi Injectee contrast

2 Tindakan Radiologi pada pasien dengan kelainan cardiovaskuler

3 Tindakan Radiologi pada pasien dengan alergi berat

4 Tindakan Radiologi pada pasien dengan KU yang menurun

5 Tindakan Radiologi yang memerlukan FNAB Guiding MSCT pada pasien dengan kelainan yang

(50)

berdekatan dengan organ vital

6 Tindakan Radiologi pada Ibu hamil yang memerlukan foto

12 Neurologi

1 Cerebral Angiografi 2 AVM&Embolisasi 3 Aneurisma Coiling 4 Embolisasi pre operasi 5 Diagnosis DSA

6 Lumbal Punksi 7 Pain Intervention 8 Injeksi Triger point 9 Injeksi Triger Fringer 1

0 Injeksi CTS

11 Sub Optical Functional 1

2 Injeksi botox 1

3 EMG

1

4 Neuro endovaskuler: Coiling,Embolisasi,DSA 13 Hemodialisis Setiap kali melakukan tindakan Hemodialisis 14 Rehabilitasi

Medik Elektromiografi dan Kecepatan Hantar Saraf

16 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

(51)

DIREKTUR RSUD MAJALENGKA

Dr. H. ASEP SUANDI,M.Epid

Pembina Tk.I

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