Tinjauan Peranan Koder Dalam Pengajuan Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Kota Binjai
Abstract
Submission of claim files to BPJS Health is carried out every 10th of the month, BPJS Health will provide information whether the claim file is feasible or not. If the claim file is not feasible, it needs to be corrected. The purpose of the research is to describe the role of the coder in filing claims for BPJS Health inpatients at RSUD Dr. R.M. Djoelham Binjai City. The research method used is descriptive method with a quantitative approach. The sample uses 43 claim files returned by BPJS Health in April and May 2021 and also interviews with two coders. Data is collected by using observation with a checklist instrument and interviews with interview guidelines. The result shows that the hospital does not have standard operating procedures related to the submission of BPJS Health claim files, from 276 files (100%) submitted in April and May 2021, there were 233 files (84,42%) that deserve to be claimed and 43 files (15,58%) that were returned (not eligible). The reasons for the return were due to confirmation of diagnosis (18,60%), medical support (25,58%), indications for hospitalization (16,28%), coding (11,63%), purification failure (6,98%) and other causes (20,93%). The roles of the coder in handling claim files are assembling, determining the primary diagnosis code and secondary diagnosis based on ICD-10, determining the code of action (procedure) based on the ICD-9-CM, and coordinating with various internal parties for the completeness of the BPJS Health claim file. Suggestions for hospital to make standard operating procedures related to claim files submission and coders to be more thorough in preparing the complete claim files.
Downloads
References
[2] Kemenkes RI, “Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2014 tentang Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs).” 2014.
[3] BPJS Kesehatan, “Peraturan Badan Penyelenggara Jaminan Sosial Kesehatan Nomor 3 Tahun 2017 Tentang Pengelolaan Administrasi Klaim Fasilitas Kesehatan Dalam Penyelenggaraan Jaminan Kesehatan Nasional,” 2017.
[4] T. Ardhitya and A. Perry, “Faktor-Faktor Yang Melatar Belakangi Penolakan Klaim BPJS Oleh Verifikator BPJS Di RSJD Dr. Amino Gondohutomo Provinsi Jawa Tengah Tahun 2015,” J. Univ. dian nuswantoro, vol. 12, pp. 1–10, 2015, [Online]. Available: http://eprints.dinus.ac.id/17385/1/jurnal_15985.pdf.
[5] M. E. Susanti, “Tinjauan Peran Koder Untuk Klaim BPJS Kesehatan Dalam Pelaksanaan JKN Di RSU Darmayu Ponorogo,” Glob. Heal. Sci., vol. 3, no. 3, pp. 245–251, 2018, [Online]. Available: https://jurnal.csdforum.com/index.php/GHS/article/view/266/129.
[6] L. Gouw and L. Indawati, “Tinjauan Kompetensi Koder Dalam Penentuan Kode Penyakit dan Tindakan Rawat Inap di Rumah Sakit Umum Pusat Fatmawati,” Inohim, vol. 5, no. 1, pp. 22–29, 2017, [Online]. Available: https://inohim.esaunggul.ac.id/index.php/INO/article/view/122.
[7] Supriadi and S. Rosania, “Tinjauan Berkas Klaim Tertunda Pasien JKN Rumah Sakit Hermina Ciputat 2018,” J. Vokasi Indones., vol. 7, no. 2, pp. 19–26, 2019, doi: 10.7454/jvi.v7i2.145.
[8] A. N. Kusumawati and Pujiyanto, “Faktor-Faktor Penyebab Pending Klaim Rawat Inap di RSUD Koja Rahun 2018,” CDK-282, vol. 47, no. 1, pp. 25–28, 2020, [Online]. Available: http://www.cdkjournal.com/index.php/CDK/article/view/338.
[9] R. S. Nurdiah and A. T. Iman, “Analisis Penyebab Unclaimed Berkas BPJS Rawat Inap Di RSUD Dr. Soekardjo Tasikmalaya,” J. Manaj. Inf. Kesehat. Indones., vol. 4, no. 2, pp. 23–28, 2016, doi: 10.33560/.v4i2.128.
[10] Sugiyono, Metode Penelitian Kuantitatif, Kualitatif dan R&D, 2013th ed. Bandung: CV ALFABETA, 2013.
[11] Kemenkes RI, “Peraturan Menteri Kesehatan Republik Indonesia Nomor 512 Tahun 2007 Tentang Izin Praktik dan Pelaksanaan Praktik Kedokteran,” 2007, [Online]. Available: http://www.kki.go.id/assets/data/arsip/Permenkes_512_Tahun_2007[1].pdf.
[12] Irmawati, A. Kristijono, E. Susanto, and Y. Belia, “Penyebab Pengembalian Berkas Klaim Badan Penyelenggara Jaminan Sosial (BPJS) Pasien Rawat Inap Ditinjau Dari Syarat-Syarat Pengajuan Klaim Di RSUD R.A Kartini Jepara,” J. Rekam Medis dan Inf. Kesehat., vol. 1, no. 1, pp. 45–51, 2018, doi: 10.31983/jrmik.v1i1.3594.
[13] L. Indawati, “Analisis Akurasi Koding Pada Pengembalian Klaim BPJS Rawat Inap Di RSUP Fatmawati Tahun 2016,” J. Manaj. Inf. Kesehat. Indones., vol. 7, no. 2, p. 113, 2019, doi: 10.33560/jmiki.v7i2.230.
[14] Irmawati, Sugiharto, E. Susanto, and M. Astrianingrum, “Faktor-faktor Penyebab Pengembalian Berkas Klaim Rawat Inap Oleh Verifikator BPJS Kesehatan Di RSUD Tugurejo,” Prociding Seminar Nasional Rekam Medis dan Informasi Kesehatan. Semarang: Poltekes Kemenkes Semarang, pp. 124–130, 2016, [Online]. Available: http://rmik.poltekkes-smg.ac.id/wp-content/uploads/2017/02/Faktor-Faktor-Penyebab-Pengembalian-Berkas-Klaim-Rawat-Inap-Ole.pdf.
Copyright (c) 2022 Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
