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
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
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
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)
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)
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
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
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
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
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
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
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
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
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
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
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
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
DIREKTUR RSUD MAJALENGKA
Dr. H. ASEP SUANDI,M.Epid
Pembina Tk.I
