TABEL PEMBEDAHAN

Tabel Pembedahan ini adalah sebagai dasar pembayaran atau klaim Biaya Pembedahan, Biaya Kamar Operasi dan Biaya
Pembiusan. Tindakan Pembedahan ini dikelompokan menjadi "COMPLEX", "MAJOR", "INTERMEDIATE" dan "MINOR".
Jika terjadi tindakan pembedahan yang tidak tercantum pada Daftar Pembedahan, Perusahaan akan menentukan
kelompok pembedahan tersebut berdasarkan tindakan yang memiliki tingkat keparahan sebanding.
1. ABDOMEN AND DIGESTIVE SYSTEM Surgical Category

Abdomen, exploratory laparatomy, celiotomy Major

exploration, retroperitoneal intermediate
Peritoneum, Abscess, drainage intermediate
Anus, Abscess, incision and drainage Minor
Fistulectomy, Subcutaneous Minor
Submuscular intermediate
Fissurectomy, with/without sphincterotomy intermediate
Hemorroidectomy, external, complete intermediate
Internal and external, simple intermediate
By Laser, Stapler intermediate
Appendix, Abscess, incision and drainage Major
Appendectomy intermediate
Biliary tract, excision of Major
choledochotomy / choledochostomy with / without cholecystotomy Major
Cholecystectomy Major
With open exploration of common duct Major
Cholecystotomy or cholecystostomy intermediate
Endoscopy : Anoscopy, with collection specimen Minor
Colonoscopy, beyond splenic flexure intermediate
with removel polyp intermediate
Esophagoscopy with collection specimen intermediate
with biopsy, one or more intermediate
Esophagogastoroscopy, with collection specimen intermediate
with biopsy, one or more intermediate
Gastroscopy, with collection specimen intermediate
with biopsy, one or more intermediate
Endoscopic Retrograde Cholangio Pancreatography (ERCP) intermediate
with insertion of tube / stent Major
Esophagus,Esophagotomy, cervical approach, with/without removal foreign body intermediate
Esophagectomy, recection with gastric anastomosis Major
Diverticulectomy, esophagus or hypopharynx cervical approach intermediate
Esophagoplasty with repair of tracheo-esophagal fistula Major
Intestines, Duodenotomy intermediate
Enterolysis, with acute bowel obstruction intermediate
Enterotomy, with exploration/ removal foreign body, small bowel intermediate
Excision, one or more lesions small/large bowel, single enterotomy intermediate
Enterectomy, resection small intestines Major
Colectomy, partial, with anastomosis Major
with colostomy Major
Tube enterostomy or cecostomy Major
Ileostomy Major
Repair of inguinal/ femoral/ scrotal/ umbilical/ diaphragmatic hernia intermediate
Incarcerata / strangulated hernia Major
Liver, needle biopsy, percutaneous Minor
wedge biopsy intermediate
Hepatectomy, partial lobectomy Major
Cyst or abscess, marsupialization of intermediate
Hepatorrhaphy-suture wound, simple intermediate
Mouth and tongue, glossectomy, partial, with unilateral radical dissection Major
total, with unilateral radical nect dissection Major

SURGERY SCHEDULE 1 of 11
Pancreas, Biopsy pancreas intermediate
Excision lesion of pancreas Major
Pancreatectomy, with pancreatico-jejunostomy Major
Whipple type Major
Marsupialization, cyst of pancreas intermediate
Rectum, incision and drainage, deep supra levator/perirectal/retrorectal abscess Minor
Biopsy, incision, ano-rectal wall, anal approach Minor
Dilation of rectal/ anorectal stricture Minor
Proctectomy, complete, combined abdominoperineal Major
Proctoplasty, for prolapse mucous membrane intermediate
Proctopexy for prolapse, with sigmoid resection Major
Closure, reclovesical, rectourethral fistula, with colostomy Major
Stomatch, Gastrotomy, with exploration of foreign body removal intermediate
Pyloromyotomy intermediate
Gastric biopsy, by laparatomy intermediate
Local excision ulcer or tumor intermediate
Total gastrectomy, with repair by intestinal transplant Major
Sub-total or hemi gastrectomy, with vagotomy Major
Vagotomy and pyloroplasty, with or without gastrostomy Major
Pyloroplasty intermediate

2. AMPUTATIONS AND DISARTICULATIONS Surgical Category

Arms, through humerus, with implant intermediate
Ankle, disarticulation/amputation, through malleoli, tibia and fibula intermediate
Finger or thumb, amputation at any joint, single, including neurectomies Minor
Foot, amputation, mid-tarsal or transmetatarsal intermediate
Forearm, through radius and ulna intermediate
Hand, transmetacarpal intermediate
Hip, interpelviabdominal amputattion Complex
disarticulation Major
Leg through tibia and fibula with immediate fitting technique intermediate
Shoulder, amputation, inter thoracoscapular Major
disarticulation Major
Thigh, amputation through femur,any level intermediate
disarticulation at knee intermediate
Toe, Amputatation, meta-tarsophalangeal joint Minor
Wrist, amputation intermediate
Interpelviabdominal amputation (hind quarter amputation) Complex

3. BRAIN, NERVOUS SYSTEM Surgical Category

Skull, burr holes, not followed by other surgery intermediate
burr hole or trephine for drainage intracanial abscess or cyst Major
crainectomy or crainiotomy, exploratory supratentorial infratentorial Major
exploration of orbit or decompression Major
unilateral Major
Elevation of depressed fracture, simple, extradural Major
Compound or comminuted Major
with debridement brain and repair of dura Major
BRAIN, lobotomy, including cingulotomy Complex
bilateral Complex
Brain tumor, excision of supratentorial, except meningioma Complex
menigioma Complex
Brain abscess, excision of Complex
Cyst, excision of fenestration, supratentorial Complex
Brain tumor, intratentorial or posterior fossa Complex
meningioma, intratentorial or posterior fossa Complex
Lobectomy, partial or total Complex
Hemispherectomy Complex

SURGERY SCHEDULE 2 of 11
Craniectomy for craniostenosis, multiple sutures Complex
Foraminotomy Major
Foreign body, excision of from brain Major
SPINE, spinal puncture, lumbar, diagnostic Minor
for decompression Minor
Laminectomy for exploration intraspinal canal.
one or two segments cervical or thoracic Major
lumbar Major
for decompression spinal cord and/or cauda Major
equina, one or two segments, cervical, thoracic lumbar Major
Laminotomy, one interspace, for herniated disc
and/or decompression root nerve, cervical Major
bilateral Major
lumbar Major
Laminectomy, for herniated disc. Thoracic, posterior approach Major
Discetomy, single interspace, cervical Major
Laminectomy, for intraspinal lesion, cervical / thoracic Major
lumbar Major
Creation of Shunt-ventriculo peritoneal Complex
Transpedicular approach with decompression of spinal cord, equina and/or nerve roots Major

4. DISLOCATIONS Surgical Category

ANKLE, closed, manipulative reduction with anaesthesia Minor
closed or open, open reduction intermediate
distal tibio-fibular joint, closed or open, open reduction intermediate
ELBOW closed, manipulative reduction, with anaesthesia Minor
closed or open, open reduction intermediate
FINGERS, Metacarpophalangeal, closed.
requiring anaesthesia Minor
open, uncomplicated, manipulative Minor
closed or open, open reduction intermediate
intraphalangeal joint, closed manipulative Minor
open, uncomplicated, manipulative Minor
closed or open, open reduction Minor
HIP traumatic dislocation, manipulative with anaesthesia Minor
closed or open, with acetabular hip fixation Major
JAW temporo-mandibular, simple, closed reduction Minor
open reduction with interdental fixation Major
KNEE closed, manipulative reduction, with anaesthesia Minor
closed or open, open reduction intermediate
KNEE CAP closed manipulative reduction with anaesthesia Minor
closed or open reduction with/without patellectomy intermediate
SHOULDER sternoclavicular, manipulative reduction Minor
closed or open, acute or chronic, open reduction/repair intermediate
with fascial graft, includes obtaining graft intermediate
acromioclavicular, with fascial graft incl. obtaining graft intermediate
TOES tarsal bone, closed, manipulative, with anaesthesia Minor
open, uncomplicated, manipulative Minor
closed or open, open reduction intermediate
astragalo-tarsal joint, closed, manipulative.
without anaesthesia Minor
with anaesthesia Minor
open, uncomplicated, manipulative Minor
closed or open, open reduction intermediate
tarso-metatarsal, closed manipulative, with anaesthesia Minor
with percutaneous skeletal fixation Minor
open uncomplicated, manipulative Minor
closed or open, open reduction intermediate

SURGERY SCHEDULE 3 of 11
 metatarsophalangeal, closed, manipulative with anaesthesia Minor
open, uncomplicated,manipulative Minor
closed or open, open reduction Minor
interphalangeal joint, closed, manipulative with anaesthesia Minor
open, uncomplicated, manipulative Minor
closed or open, open reduction Minor
WRIST, radio-carpal or intercarpal closed manipulative reduction Minor
closed or open, open reduction intermediate
distal radio-ulnar, closed, manipulative Minor
closed or open, open reduction or repair intermediate

5. EAR, NOSE, THROAT Surgical Category

EAR: excision aural polyp Minor
Fenestration , unilateral Major
Myringotomy by needle, with/without aspiration/eustachian inflamation Minor
Tympanostomy (requires of ventilating tube) with opening microscope office Minor
in surgical suite Minor
Transmastoid antrotomy intermediate
Mastoidectomy modified radial or radical unilateral Major
Myringoplasty confined to drummed and donor area intermediate
Tympanoplasty intermediate
with mastoidectomy Major
with ossicular chain reconstruction Major
Tympanic membrane repair intermediate
Stapes mobilization intermediate
Removal foreign body from external auditory canal Minor
with general anesthesia intermediate
Removal impacted cerumen, one/both ears Minor
Clearance of middle ear for granuloma, cholesteatoma & polyp Major
Middle ear exploration through postauricular/ear canal incision Minor
Drainage external ear, abcess/hematoma; simple Minor
NOSE: excision polyp(s), simple Minor
excision or surgical planning, for rhinophyma intermediate
excision, dermoid cyst, simple Minor
turbinate, partial/complete Minor
submucous resection, turbinate, partial/complete Intermediete
removal foreign body, intranasal, requiring general anaesthesia Minor
Sinuses; lavage by cannulation ( antrum puncture or natural ostium ) each Minor
sphenoid sinus Minor
sinusotomy maxillary, intranasal, unilateral intermediate
radical, (Caldwell-Luc) unilateral Major
combined, three or more sinuses Major
Control nasal hemorrhage anterior, simple Minor
Control nasal hemorrhage posterior with posterior nasal pack intermediate
THROAT
Larynx: laryngotomy, with removal tumor/laryngocele, cordectomy Major
Laryngectomy, total without radical nect dissection Major
with radical nect dissection Major
Laryngoscopy with removal foreign body, excision of tumor
and/or stripping of vocal cord/epiglottis intermediate
Pharyngolaryngectomy with radical nect dissection and/reconstruction Complex
Pharynx,Adenoids,Tonsils, Drainage,Abscess, Peritonsillar Minor
retropharyngeal/parapharyngeal, intra oral Minor
Tonsillectomy, with or without adenoidectomy intermediate
Uvulectomy intermediate
Adenoidectomy intermediate
Marsupialization of sublingual salivary cyst intermediate
Excision of parotid gland/tumor, total

SURGERY SCHEDULE 4 of 11
 with dissection & preservation of facial Major
with unilateral radical neck dissection Complex

6. ENDOCRINE SYSTEM Surgical Category

THYROID : Thyro-glossal cyst, incision and drainage Minor
biopsy, needle Minor
cyst or adenoma, small excision of, or transection of isthimus intermediate
Lobectomy, total, unilateral, with contralateral subtotal lobectomy intermediate
Thyroidectomy, total or complete intermediate
total or sub-total with radical neck resection Major
Endolymphatic sac operation with shunt Complex
Vestibular nerve section, translabjrinthine Complex
Total facial nerve decompression and/or repair, may include graft Complex
Decompression, internal auditory canal Complex
Tympanic neurectomy Complex
Radical excision, external auditory canal lesion, with neck dissection Complex

7. EXCISION, FIXATION OR REPAIR BY CUTTING OPERATIONS Surgical Category

ANKLE : Achilles Tendon repair ; primary intermediate
lengthening or shortening of tendon, single Intermedate
repair, primary, torn or severed collateral ligament intermediate
both collateral ligaments intermediate
ELBOW: tendon lengthening, single intermediate
Flexorplasty intermediate
Arthroplasty, radial head, with implant intermediate
FEMUR, excision bone cyst/benign tumor intermediate
with autogenous graft (includes obtaining graft) intermediate
HAND and FINGERS, excision/curettage bone cyst/benign tumors, metacarpal ,
with autogenous graft (includes obtaining graft) intermediate
phalanx intermediate
with autogenous graft (includes obtaining graft) intermediate
HIP: external oblique muscle transfer to greater trochanter, including graft intermediate
iliopsoas transfer to greater trochanter Major
muscle release, complete Major
arthroplasty with acetabuloplasty Major
actelabular and proximal femoral prosthetic replacement Major
osteotomy iliac or acetabular Major
arthrodesis, hip joint, with subtrochanteric osteotomy Major
HUMERUS, excision/curettage bone cyst/benign tumor intermediate
KNEE: suture intrapatellar tendon, primary intermediate
lengthening hamstring tendon, multiple one leg intermediate
repair, primary , torn/severed collateral ligament with or without menisectomy intermediate
collateral and cruciate ligaments Major
capsulotomy, posterior capsular release intermediate
PELVIS, excision bone cyst/benign tumor, superficial pelvis; with or without graft Minor
Arthroscopy Diagnostic Minor
Biopsy, bone, trocar/needle; superficial (eg. Ilium, sternum,ribs) Minor
Biopsy, bone, excisional; superficial (eg. Ilium, sternum,ribs) intermediate
Incision, extensor tendon sheath, wrist (eg. de Quervains's desease) Minor

8. EYE Surgical Category

EYEBALL : evisceration occular contents, with implant intermediate
enucleation, with implant, muscles attched to implant intermediate
exenteration of orbit, with temporalis muscle transfer Major
removal foreign body, conjungtival, superficial Minor
embedded, subconjunctival Minor
corneal, with slit lamp Minor
Trabeculoplasty by laser surgery, one/more sessions (defined treatment series) Major

SURGERY SCHEDULE 5 of 11
 Severing adhesions of anterior segment of eye Incisional technique, Goniosynechiae Major
EXTRAOCULAR MUSCLE, repair wound Minor
Blepharoplasty, lower eyelid intermediate
Repair of blepharoptosis; frontalis muscle technique with suture/ other material Major
CORNEA : excision of lesion intermediate
excision or transposition of pterygium Minor
Destruct. of lesion of cornea by cryotherapy intermediate
Keratoplasty Major
SCLERA : fistulization for glaucoma, trephine, with iridectomy intermediate
repair scleral staphyloma, with graft Major
IRIS : Iridotomy, stab incision intermediate
Iridotomy, with cycletomy Major
Iridotomy/Iridectomy by laser surgery intermediate
LENS: removal after cataract or membranous cataract Major
removal lens material, aspiration technique Major
expression of cataract, linear Major
repositioning of intraocular lens prothesis, requiring an incision Major
RETINA: repair retinal datachment Major
with vitrectomy, with/without air tamponade Major
prophylaxis, retinal datachement, diathermy or cryotherapy Major
destruction, localized lesion, retina or choroid Major
CONJUNGTIVA : incision and drainage cyst, stye Minor
Biopsy of conjungtiva Minor
LACRIMAL SYSTEM : incision and drainage lacrimal gland Minor
lacrimal sac, dilation Minor
excision of lacrimal sac or gland-total or partial intermediate
Closure of the lacrimal punctum intermediate
CILIARY BODY DESTRUCT : Cyclodialysis intermediate
Cyclophotocoagulation intermediate

9. FRACTURES Surgical Category

ANKLE : single malleolus, closed, manipulative reduction Minor
closed or open, open reduction with skeletal fixation intermediate
bi-malleolar, closed, with manipulative reduction Minor
closed or open reduction with/without skeletal fixation intermediate
tri-malleolar, closed, manipulative reduction, with anaesthesia intermediate
closed or open, open reduction, with skeletal fixation posterior lip (malleolus) intermediate
CLAVICLE closed, manipulative reduction Minor
closed or open, open reduction, with/without skeletal fixation intermediate
ELBOW: comminuted, closed, manipulative reduction intermediate
closed or open, open reduction, with/without skeletal fixation Major
FEMUR shaft, clossed, manipulative reduction, age 12 and over intermediate
closed or open , reduction with/without skeletal fixation, over 12 Major
distal end, medial or lateral condyle, closed,manipulative reduction intermediate
closed or open, open reduction with/without skeletal fixation Major
FIBULA, proximal end, open, uncomplicated soft-tissue closure, manipulative Minor
closed or open, open reduction, with skeletal fixation posterior lip (malleolus) intermediate
distal end, closed, manipulative reduction with anaesthesia Minor
closed or open, open reduction with skeletal fixation intermediate
FINGERS : metacarpal single, closed, manipulative reduction Minor
closed/open, open reduction with/without skeletal fixation intermediate
carpometacarpal , closed, manipulative reduction Minor
with skeletal fixation Minor
closed/open, open reduction, with/without skeletal fixation intermediate
phalangeal, closed, manipulative reduction Minor
closed/open, open reduction, with/without skeletal fixation Minor
intra-articular, complex, open reduction, with/without skeletal fixation intermediate
FOOT : Tarsal, closed, manipulative Minor

SURGERY SCHEDULE 6 of 11
 Metatarsal, closed, manipulative Minor
HUMERUS : shaft, closed manipulative reduction Minor
closed/open reduction, with/without skeletal fixation intermediate
supracondylar or transcondylar, closed, manipulative reduction Minor
with traction, pin or skin intermediate
with percutaneous skeletal fixation intermediate
closed/open , open reduction, with/without skeletal fixation intermediate
epicondylar, medial or lateral, closed, manipulative reduction Minor
closed/open, open reduction with/without skeletal fixation intermediate
condylar, radial or lateral, closed, manipulative reduction Minor
closed/open , open reduction, with/without skeletal fixation intermediate
JAW: mandibular, closed, manipulative reduction with interdental fixation intermediate
open reduction with interdental fixation Major
KNEE CAP : open reduction Minor
RADIUS, shaft, closed manipulative reduction age12 and over Minor
closed/open. Open r4eduction, with skeletal fixation, age 12 and over intermediate
RIBS, simple, 1 rib Minor
SCAPULA ; closed manipulative reduction Minor
closed/open; juxta-articular, open reduction, with/without skeletal fixation intermediate
SPINE : vertebral process, one/more, manipulative reduction with anaesthesia
cervical, open reduction and fusion, posterior approach, with local Major
anterior approach with iliac or other bone graft Major
TIBIA : shaft, closed, manipulative reduction, age 12 and over intermediate
clossed/open, open reduction, with skeletal fixation intermediate
TIBIA and FIBULA : shaft closed, manipulative, with/without external pinning intermediate
closed/open, open reduction, with/without skeletal fixation, age 12 and over intermediate
ULNA, shaft, closed, manipulative reduction, age 12 and over Minor
closed/open, open reduction with skeletal fixation, age 12 and over intermediate
ULNA and RADIUS: shaft, closed, manipulative reduction age 12 and over intermediate
closed/open, open reduction, with skeletal fixation, age 12 and over intermediate
WRIST: Colles or Smith type: closed manipulative reduction: age 12 and over Minor
closed, complex, with external skeletal fixation/percutaneous pinning intermediate
Removal of implant; deep (eg. buried wire, pin, screw, metal band, nail, rod/plate) Minor

10. GENITAL SYSTEM Surgical Category

MALE
PENIS, biopsy, cutaneous Minor
deep Minor
excision penile plaque intermediate
amputation, partial intermediate
radical Major
circumcision Minor
TESTIS; biopsy, needle Minor
incision, bilateral Minor
excision, local lesion Minor
orchiectomy, simple, unilateral Minor
radical intermediate
epididymectomy intermediate
Exploration for undescended testis intermediate
with abdominal exploration Major
Excision of spermatocele intermediate
Excision of hydrocele; unilateral/bilateral intermediate
PROSTATE; biopsy, needle or punch Minor
incisional intermediate
prostatectomy, external drainage of abscess, complicated intermediate
prostatectomy, sub-total or total, including TUR Major
radical Major

SURGERY SCHEDULE 7 of 11
FEMALE
PERINEUM abscess, incision and drainage, or biopsy Minor
VULVA and INTROITUS Bartholin`s cyst, incision and drainage Minor
marsupialization Minor
Vulvectomy, complete, bilateral intermediate
Radical, excluding skin graft Major
Excision Bartholin`s tumor or cyst Minor
VAGINA, Colpotomy with exploration Minor
biopsy, vaginal mucosa Minor
Colpectomy, complete obliteration intermediate
Anterior colporhaphy, repair cystocele with/without repair urethrocele intermediate
Posterior colporrhaphy, repair of rectocele Minor
Combined anterior/posterior colporhaphy intermediate
Repair of enterocele, abdominal approach intermediate
CERVIX UTERI biopsy or local excision of lession, or cauterization Minor
trachelectomy, cervicectomy, amputation of cervix Minor
Removal of polyp Minor
CORPUS UTERI endometrical biopsy suction Minor
dilation and curettage ( non-obstertrical ) Minor
Myomectomy, single or multiple, abdominal approach Major
Hysterectomy total abdominal approach Major
OVIDUCT transection fallopian tube unilateral/bilateral independent intermediate
Salpingo-oophorectomy complete partial, unilateral/bilateral intermediate
OVARY drainage of cyst(s) vaginal approach, unilateral/bilateral Minor
abdominal approach intermediate
drainage of ovarium abscess vaginal approach Minor
oophorectomy with total omentectomy (Cystectomy) intermediate

11. HEMIC AND LYMPHATIC SYSTEMS Surgical Category

SPLEEN splenectomy Major

12. HEART AND CIRCULATORY SYSTEMS Surgical Category

PERICARDIUM Pericardiotomy for removal clot or foreign body intermediate
partial resection for chronic constructive pericarditis, with bypass Major
HEART intracardiac tumor, resection with bypass Major
pacemaker insertion with epicardial electrode intermediate
repair, cardiac wound, with bypass Major
cardiotomy and removal foreign body with bypass Major
Insertion/replacement of implantable cardioverter-defibrillator intermediate
AORTA and GREAT VESSELS suture repair with bypass Major
Myocardial Resection Major
Repair post infarction venticular spetal detect Major
Ascending arch graft, with valve replacement Complex
VALVES Aortic, commissu rotomy with bypass Major
valvuloplasty, with bypass Major
Mitral, commissurotomy open ,with bypass Major
valvuloplasty, with bypass Major
Tricuspid commissurotomy open with bypass Major
valvuloplasty or valvectomy with bypass Major
Pulmonary, commissurotomy with bypass Major
Replacement single valve Major
double valve with commissurotomy valvuloplasty one valve Complex
triple valve Complex
CORONARY ARTERY anomalous ligation Major
with bypass Major
PTCA with/without stent Major
CORONARY ARTERY BYPASS ; autogenous on two coronary arteries Complex
on three or more coronary arteries Complex

SURGERY SCHEDULE 8 of 11
Angiography & coronary catheterization intermediate
PULMONARY ARTERY embolectomy with bypass Major
ARTERIES and VEINS Arterial embolectomy, carotid intermediate
renal Major
femoral poplilial, unilateral intermediate
Venous thrombectomy, iliac-femoral, unilateral intermediate
bilateral intermediate
Varicose, ligation/division/stripping, long saphenous, complete, complete unilateral intermediate
bilateral intermediate
short or lesser saphenous unilateral Minor
bilateral intermediate
long and short saphenous, unilateral intermediate
bilateral intermediate
ligation and excision-minor veins Minor
Venesection Minor
Endarterectomy & arterial patch Major
Ligation, exploration, dissection, decompresion elective repair for artery/vein/arteriovenous fistula Major
Arterial/venous catheterisation Minor

13. MATERNITY Surgical Category

Hysterotomy, abdominal for removal hydatidiform mole intermediate
Hydatidiform Mole evacuation by dilation and curettage intermediate
Ectopic pregnancy, tubal, abdominal/vaginal approach intermediate
Ovarium pregnancy intermediate
Interstitial, hysterectomy for uterine pregnancy, total/sub-total intermediate
Dilation & Curettage, postpartum henorrhage, same admissin as delivery Minor
Vaginal Delivery; with/without forceps intermediate
Caesarian section , low cervical or classic intermediate
Abortion, completed by dilation and curettage intermediate
induced by dilation and curettage intermediate

14. CHEST, RESPIRATORY SYSTEM Surgical Category

LUNGS & PLEURA; thoracostomy, tube with waterseal Minor
with rib resection for empyma intermediate
thoracotomy ; limited, with biopsy lung/pleura intermediate
major, with exploration and biopsy intermediate
with excision-plication bullae, with/without pleural procedure Major
with removal intrapleural/intrapulmonary foreign/fibrin body intermediate
pnemonostomy with open drainage abscess/cyst intermediate
decoratication, pulmonary Major
pleurectomy, parietal Major
pneumonectomy, total Major
lobectomy, total or segmental Major
with bronchoplasty or decortication Major
Wedge resection/enucleation of lession, single or multiple Major
resection, pulmonary, with thoracoplasty or resection/reconstruction, chest wall Major
enucleation of empyema cavity, extra pleural Major
with lobectomy Major
thoracoplasty extrapleural resection ribs, first stage intermediate
second stage intermediate
third stage Minor
pneumothorax Minor
Sternotomy/ Thoracotomy Major
TRACHEA and BRONCHI: tracheostomy Minor
bronchoscopy, diagnostic Minor
with biopsy Minor

15. SKIN, INTEGUMENTARY, BREAST Surgical Category

SURGERY SCHEDULE 9 of 11
Wound management, wound of soft tissue, debridement of Minor
ABSCESS ; carbuncle or furuncle, incision and drainage/puncture aspiration Minor
complicated, hematom Minor
ACNE: marsupialization or removal multiple milia, comedones, cyst, pustules Minor
BENIGN LESIONS; skin tags excision, including anaesthesia, up to 15 Minor
each additional 10 Minor
other, up to 0,5 cm diameter Minor
1 cm to 2 cm Minor
paring or curettement, with/without cauterization Minor
each additional , up to 0,5 cm Minor
MALIGNANT LESIONS:up to 0,5 cm Minor
0,5 cm to 1 cm Minor
1 cm to 2 cm Minor
Biopsy, skin or subcutaneous tissue, including closure, first Minor
Incision & drainage of hematome, seroma/fluid collection Minor
Excision of skin & subcutan tissue Minor
Destruct. by any method incl. laser, all benign/premalignant lesions Minor
Removal of foreign body in subcutan Minor
Destruct. by any method of flat warts, molluscum contagiosum Minor
Dermabrasion Minor
Excision, excessive skin & subcutan tissue (incl. lipectomy); abdomen (abdominoplasty) intermediate
CYST; infected or non-infected, incision and drainage, first lesion Minor
second lesion Minor
each additional Minor
excision with removal sac and treatment of cavity Minor
PILONIDAL SINUS or CYST: incision and drainage Minor
excision, sample Minor
GANGLION: excision Minor
LYMPH NODE: biopsy or excision, superficial Minor
deep intermediate
NAILS: avulsion, nail plate, partial or complete, first second Minor
each additional Minor
excision, nail and matrix, partial or complete Minor
REPAIRS, simple, sum of length of repairs; up to 2,5 cm Minor
2,50 cm to 7,50 cm Minor
7,50 cm to 12,50 cm Minor
12,50 cm to 20 cm Minor
20 cm to 30 cm Minor
intermediate
up to 2,5 cm Minor
2,5 cm to 7,5 cm Minor
7,5 cm to 12,5 cm Minor
12,50 cm to 20 cm Minor
complex
1 cm to 2,5 cm Minor
2,5 cm to 7,5 cm Minor
TISSUE TRANSFER or RE-ARRANGEMENT
Trunk, up to 10, sq cm Minor
10 sq, cm to 30 sq cm intermediate
Scalp Arms, Legs up to 10 sq cm intermediate
10 sq, cm to 30 sq, cm intermediate
Forehead, cheeks, chin, mouth, neck, axillae,genitalia, hands or feet-up to 10 sq, cm intermediate
10 sq, cm to 30 sq, cm intermediate
Eyelids, nose, ears, or lips up to 10 sq, cm intermediate
FREE SKIN GRAFTS,pinch, single or multiple Minor
Split skin, Trunk, scalp, arms, legs, hand, feet up to 100 sq, cm Minor
each additional 100 sq, cm Minor
Face, mouth, neck, ears, eyelids, orbit, genitalia up to 100 sq, cm

SURGERY SCHEDULE 10 of 11
Full thickness; free, including closure donorsite; Trunk up to 20 sq cm Minor
each additional 20 sq, cm Minor
Scalp, arms, legs up to 20 sq cm intermediate
each additional 20 sq, cm Minor
Forehead, cheeks, chin, mouth,genitalia, neck, axillae, hands, feet up to 20 sq cm intermediate
each additional 20 sq, cm Minor
Eyelids, nose, ears and lips up to 20 sq, cm intermediate
each additional 20 sq, cm Minor
PEDICLE FLAPS; skin and deep tissue
tube pedicle without transfer or major `delay` a large flap intermediate
primary attachment, open/tubed flap to recipient site intermediate
Intermediate `delay` any flap, primry `delay` small flap or sectioning of pedicle or tubed
or direct trunk flap; Trunk intermediate
Scalp; arms, legs intermediate
Forehead, cheek, chin, mouth, neck axillae, genitalia, eyelids, nose, hands or feet Major
BREAST : puncture aspiration of cyst, single Minor
Mastotomy with exploration/drainage of deep abscess Minor
biopsy, needle Minor
incisional Minor
excision, cyst/fibro-adenomal/benign tumor/aberrant tissue/
duct lesion/nipple lession, male or female, 1 or more, unilateral intermediate
mastectomy, complete, unilateral Major
bilateral Major
partial, unilateral Major
subcutaneous unilateral intermediate
radical, incl. breast, pectorl muscles, axillary and lymph nodes Major

16. URINARY SYSTEM Surgical Category

KIDNEY : exploration intermediate
drainage perirenal or renal abscess Intermadiate
Nephrostomy, nephrotomy with drainage Major
Nephrolithotomy (removal of calculus) Major
large staghorn claculus Major
biopsy, percutaneous Minor
by surgical exposure intermediate
Nephrolithotripsy (ESWL) intermediate
Nephrectomy, including partical ureterectomy Major
radical, with regional lymphadenectomy Major
Cysts, excision of Major
aspiration or injection of, percutaneous Minor
Nephropexy, fixation or suspension of kidney intermediate
URETER: ureterotomy, with exploration or drainage Major
ureterlithotomy, upper one third of ureter Major
Dilation of urethral stricture Minor
BLADDER: aspiration by needle Minor
by trochar or inter catheter Minor
by insertion suprapublic catheter Minor
Cystotomy or cystostomy with fulguration intermediate
Cystotomy with insertion ureteral catheter intermediate
Cystolithotomy Major
Cystourethroscopy, with biopsy Minor
Excision, cystectomy, complete Major
with bilateral pelvic lymphadenectomy, including external Complex
iliac hypogastric and abturator nodes Complex
with ureteroileal conduit or sigmoid bladder including bowel anastomosis Complex
Litholapaxy; crushing/fragmentation of calculus in bladder & removal of fragments (over 2.6 cm) Major
URETHRA: dilation of urethral stricture Minor

SURGERY SCHEDULE 11 of 11