Review Ketepatan Kode Diagnosis Dan Pending Klaim Rekam Medis Pasien Covid-19 Tahun 2021
Abstract
A complete of medical record and the accuracy of clinical coding is reflect to the quality of medical record documentation. In 2021, the number of pending claim for medical record patient’s covid-19 is 41%, as cause the quality of medical record incomplete. The research aim is to measure the quality of medical records by covid-19 documentation for pending claims and the accuracy of coding Covid-19. The research method is mixed-method sequential explanatory. We used the checklist observation to measure the quality of clinical coding for patient covid-19 and interview guideline to explore the factors of pending claims. The total sampling are 889 of medical records as secondary data was analyze with STATA Version 13. The characteristic of administrative data by gender is man 571 (64,45%), woman 315 (35,35%). the number of classification covid-19 case is probable 25 cases (2,71%), suspected 214(24,15%) and confirmed 648 cases (73,14%). In another hand, the quality of accuracy coding covid-10 use code B34.2 is 377 (42,55%), use code U07.1 is 295(33,30%) and use code Z20.8 is 215 (24.14%). The accuracy of coding covid-19 is 295 (33,30%) and inaccurate 591 (66,70%). we observe the number of pending claims is 222 due to incomplete of signature and full name of physician items in discharge summary form.
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[2] U. Zellweger, C. Junker, And M. Bopp, “Cause Of Death Coding In Switzerland : Evaluation Based On A Nationwide Individual Linkage Of Mortality And Hospital In-Patient Records,” Vol. 2, Pp. 1–15, 2019.
[3] B. Singh, “International Comparisons Of Covid-19 Deaths In The Presence Of Comorbidities Require Uniform Mortality Coding Guidelines,” Int. J. Epidemiol., Vol. 50, No. 2, Pp. 373–377, 2021, Doi: 10.1093/Ije/Dyaa276.
[4] World Health Organization, “Medical Certification, Icd Mortality Coding, And Reporting Mortality Associated With Covid-19,” Tech. Note, Vol. 19, No. June, Pp. 1–13, 2020, [Online]. Available: Https://Www.Who.Int/Publications/I/Item/Who-2019-Ncov-Mortality-Reporting-2020-1.
[5] A. J. Walker Et Al., “ Clinical Coding Of Long Covid In English Primary Care: A Federated Analysis Of 58 Million Patient Records In Situ Using Opensafely ,” Br. J. Gen. Pract., Vol. 71, No. 712, Pp. E806–E814, 2021, Doi: 10.3399/Bjgp.2021.0301.
[6] B. Garret And Gangopadhyaya, “How The Covid-19 Recession Could Affect Health Insurance Coverage,” 2020.
[7] N. K. Ningtyas, S. Sugiarsi, And A. S. Wariyanti, “Analisis Ketepatan Kode Diagnosis Utama Kasus Persalinan Sebelum Dan Sesudah Verifikasi Pada Pasien Bpjs Di Rsup Dr . Soeradji Tirtonegoro Klaten,” Vol. 4, No. 1, Pp. 1–11, 2019.
[8] G. Alfiansyah, P. N. Jember, P. N. Jember, M. W. Santi, And P. N. Jember, “Optimalisasi Manajemen Penanganan Klaim Pending Pasien Bpjs Rawat Inap Di Rumah Sakit Citra Husada Jember Bpjs Rawat Inap Di Rumah Sakit Citra Husada Jember Optimizing Of Management Pending Claims For Bpjs ’ S Prodi Rekam Medis , Jurusan Kesehatan , Polit,” No. January, 2019, Doi: 10.20884/1.Ki.2019.11.1.1314.
[9] World Health Organization, “The Coronavirus Disease 2019 (Covid-19):Situation Report-36,” Who, Vol. 36, No. 3, Pp. E99–E100, 2020, Doi: 10.3928/19382359-20200219-01.
[10] X. Jin Et Al., “Epidemiological, Clinical And Virological Characteristics Of 74 Cases Of Coronavirus-Infected Disease 2019 (Covid-19) With Gastrointestinal Symptoms,” Gut, Pp. 1–8, 2020, Doi: 10.1136/Gutjnl-2020-320926.
[11] S. Molani Et Al., “Risk Factors For Severe Covid-19 Differ By Age For Hospitalized Adults,” Sci. Rep., Vol. 12, No. 1, Pp. 1–9, 2022, Doi: 10.1038/S41598-022-10344-3.
[12] C. Opitasari And A. Nurwahyuni, “The Completeness And Accuracy Of Clinical Coding For Diagnosis And Medical Procedure On The Ina-Cbgs Claim Amounts At A Hospital In South Jakarta,” Vol. 9, No. 1, Pp. 14–18, 2018, Doi: 10.22435/Hsji.V9i1.464.
[13] J. J. Reeves Et Al., “Rapid Response To Covid-19: Health Informatics Support For Outbreak Management In An Academic Health System,” J. Am. Med. Informatics Assoc., Vol. 27, No. 6, Pp. 853–859, 2020, Doi: 10.1093/Jamia/Ocaa037.
[14] Cdc, “Infection Prevention And Control In The Household Management Of People With Suspected Or Confirmed Target Audience Self-Isolation Infection Prevention And Control For Suspected Or Confirmed Covid-19 Cases Self- Isolating At Home General Infection Preventi,” 2020.
[15] R. M. Burke Et Al., “Active Monitoring Of Persons Exposed To Patients With Confirmed Covid-19 - United States, January-February 2020,” Mmwr. Morb. Mortal. Wkly. Rep., Vol. 69, No. 9, Pp. 245–246, 2020, Doi: 10.15585/Mmwr.Mm6909e1.
[16] D. J. Wake Et Al., “Endocrinology In The Time Of Covid-19: Remodelling Diabetes Services And Emerging Innovation,” Eur. J. Endocrinol., Vol. 183, No. 2, Pp. G67–G77, 2020, Doi: 10.1530/Eje-20-0377.
[17] M. W. Davis Et Al., “Re-Purposing Antimicrobial Stewardship Tools In The Electronic Medical Record For The Management Of Covid-19 Patients,” Infect. Control Hosp. Epidemiol., Pp. 1–3, 2020, Doi: 10.1017/Ice.2020.281.
[18] L. R. Ilmi, “Cause Of Death Reported And Administrative Code With Sepsis And Trend In Panembahan Senopati General Hospital,” Proceeding- 2nd Ismohim, Vol. 5, No. 1, Pp. 82–86, 2020.
[19] H. Asari, L. R. Ilmi, And N. Intan, “Kelengkapan Dan Keakuratan Pemberian Kode Diagnosis Kasus Neoplasma,” Pros. Semin. Rekam Medis Dan Inf. Kesehat. “Inovasi Teknol. Inf. Untuk Mendukung Kerja Pmik Dalam Rangka Kendali Biaya Di Fasilitas Pelayanan Kesehatan,” Vol. 80, Pp. 39–43, 2020, [Online]. Available: Https://Publikasi.Aptirmik.Or.Id/Index.Php/Procinovasiti/Article/View/75.
[20] L. R. Ilmi And I. R. Sayekti, “The Design Of Discharge Summary For Patients Of Continuous Care,” Vol. 514, No. Icoship 2020, Pp. 210–215, 2021, Doi: 10.2991/Assehr.K.210101.046.
[21] X. He, L. Cai, S. Huang, X. Ma, And X. Zhou, “The Design Of Electronic Medical Records For Patients Of Continuous Care,” J. Infect. Public Health, 2019, Doi: 10.1016/J.Jiph.2019.07.013.
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