Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY
Abstract
The quality of diagnosis codes is an important part of the hospital management level. The impact of a lack of quality diagnosis codes is the potential to reduce hospital income. A clinical coding audit needs to be conducted to review and analyze discovered errors and attempt to trace their source. The purpose of this research is to audit the code. The research approach was carried out through a quantitative descriptive approach. The research population was inpatient medical records of BPJS Health patients. Sample calculations use Slovin, with a margin of error of 10%. In this study, the clinical coding audit involved 3 coders in each hospital, coding experts from senior practitioners from Type B Hospitals and experts from academics. The results of the clinical code audit showed that the timeliness aspect was 100%, accuracy was 92.5%, completeness was 91.0%, relevance, and legitimacy were 87.5% each, while the lowest was in the reliability aspect at 80.0%. The results of the legibility aspect are in line with the results of relevance. This shows that determining clinical codes for case mix purposes must be supported by complete documentation of the patient's medical records.
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References
. Kemenkes. Peraturan Menteri Kesehatan Nomor 76 Tahun 2016 tentang Pedoman Indonesian Case Base GroupS (INA-CBG) Dalam Pelaksanaan Jaminan Kesehatan Nasional. 2016.
. Presiden RI. Peraturan Presiden RI Nomor 111 Tahun 2013 Tentang Perubahan Atas Peraturan Presiden Nomor 12 Tahun 2013 Tentang Jaminan Kesehatan. 2013.
. Pertiwi J. Systematic Review: Faktor Yang Mempengaruhi Akurasi Koding Diagnosis Di Rumah Sakit. Smiknas [Internet]. 2019;41–50. Available from: http://ojs.udb.ac.id/index.php/smiknas/article/view/692
. Zafirah SA et al. Potential Loss Of Revenue Due To Errors In Clinical Coding During The Implementation Of The Malaysia Diagnosis Related Group (MY-DRG) Casemix System In A Teaching Hospital In Malaysia. BMC Health Serv Res. 2018;10(1).
. Oktamianiza etall. Literatur Riview Tentang Faktor Penyebab Klaim Tidak Layak Bayar BPJS Kesehatan Di Rumah Sakit Tahun 2020. J Ilm Perekam Dan Inf Kesehat Imelda. 2021;6(1):83–90.
. Ningsih. Kori Puspita etal. Accuracy aadn Confirmity Of CodingDiagnosis Case of Road Care Patients On Medical Records Using Hospital Management Information System. ISMOHIM. 2020;
. Ariyanti F, Gifari MT. Analisis Persetujuan Klaim BPJS Kesehatan pada Pasien Rawat Inap. J Ilmu Kesehat Masy. 2019;8(04):156–66.
. Ulfa HM, Octaria H, Sari TP. Analisis Ketepatan Kode Diagnosa Penyakit Antara Rumah Sakit Dan BPJS Menggunakan Icd-10 Untuk Penagihan Klaim Di Rumah Sakit Kelas C Sekota Pekanbaru Tahun 2016. J INOHIM. 2016;5(2):119–24.
. Ningtyas NK, Sugiarsi S, Wariyanti AS. Analisis Ketepatan Kode Diagnosis Utama Kasus Persalinan Sebelum dan Sesudah Verifikasi pada Pasien BPJS di Rsup Dr . Soeradji Tirtonegoro Klaten. JKESVO. 2019;4(1):1–11.
. Kurnianingsih W. Hubungan Pengetahuan Coder Dengan Keakuratan Kode Diagnosis Pasien Rawat Jalan BPJS Berdasarkan ICD – 10 Di Rumah Sakit Nirmala Suri Sukoharjo. J Manaj Inf dan Adminitrasi Kesehat. 2020;03(01):11–24.
. O’Malley, Kimberly J., Cook, Karon F., Price, Matt D., Wildes, Kimberly Raiford, Hurdle, John F., & Ashton CM. Measuring Diagnoses: ICD Code Accuracy. Health Serv Res. 2005;40(5):1620-1639.
. Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, et al. Systematic review of discharge coding accuracy. J Public Health (Bangkok). 2012;34(1):138–48.
. Dimick C. Achieving Coding Consistency. J AHIMA. 2010;81(7).
. Hatta GR. Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: Universitas Indonesia; 2017.
. Moghaddasi.H et all. Improving The Quality Of Clinical Coding: A Comprehensive Audit Model. J Heal Manag Informatics. 2014;1(2):36–40.
. Nasution KS, Hosizah H. Perancangan Instrumen Audit Pengkodean Klinis di Rumah Sakit Umum Pusat Fatmawati. J Manaj Inf Kesehat Indones. 2020;8(1):30.
. Olagundoye O, Van Boven K, Daramola O, Njoku K, Omosun A. Improving the accuracy of ICD-10 coding of morbidity/mortality data through the introduction of an electronic diagnostic terminology tool at the general hospitals in Lagos, Nigeria. BMJ Open Qual. 2021;10(1).
. Ramadhiane I, Sari I. Tinjauan Pengetahuan Perekam Medis dan Informasi Kesehatan Mengenai Aturan Penggunaan ICD 10 dalam Menentukan Diagnosa di RS Bhayangkara TK II Sartika Asih Bandung. J Heal Sains. 2021;2(8):1014–22.
. Pramono AE, Nuryati N, Santoso DB, Salim MF. Ketepatan Kodifikasi Klinis Berdasarkan ICD-10 di Puskesmas dan Rumah Sakit di Indonesia: Sebuah Studi Literatur. J Rekam Medis dan Inf Kesehat. 2021;4(2):98–106.
. Maesaroh L, Sudra RI, Arief M. Analisis Kelengkapan Kode Klasifikasi Dan Kode Morphology Pada Diagnosis Carcinoma Mammae Berdasarkan ICD-10 Di Rsud Kabupaten Karanganyar Tahun 2011. J Kesehat [Internet]. 2011;5(2):2. Available from: https://ejurnal.stikesmhk.ac.id/index.php/rm/article/viewFile/60/54
. Cindy Kusuma Dewi. Penilaian Kualitas Informasi Dokumen Rekam Medis Rawat Jalan. J Adm Kesehat Indones [Internet]. 2017;5(1):21–31. Available from: http://dx.doi.org/10.1016/j.cpc.2009.01.028%0Ahttp://dx.doi.org/10.1016/j.proeng.2015.11.146%0Ahttps://www.uio.no/studier/emner/matnat/fys/FYS4460/v17/notes/md-2016-python.pdf%0Ahttps://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePu
. WHO. Revision, The Tenth Classification, International Statistical Problems, Related Health Classification,. Vol. 1. 2010. 1–1855 p.
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