Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember

Karimah, Rinda Nurul; Setiawan, Dony; Nurmalia, Puput Septining

doi:10.19184/ams.v2i2.2775

Cited by 16 publications

(15 citation statements)

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“…Most of the quality of the diagn osis code in Dr. Moewardi hospital was good at 152 (60.80%), while the diagnosis code was not as good as 98 (39.20%) as shown in Table 3. However, the poorer percentage of the diagnosis code was still above the average compared to the average inaccuracy of diagnosis codes in other domestic hospitals, namely 31.50% [9,[13][14][15][16][17][18][19]. In addition, this percentage is still very much higher compared to overseas hospitals, which is 12.71% [3][4][5][6]11].…”

Section: Quality Of the Diagnosis Codementioning

confidence: 99%

Quality of medical information determine the quality of diagnosis code

Maryati¹,

Rahayuningrum²,

Ismayani³

2019

IJPHS

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The accuracy of the diagnosis code has implications for future patient care planning, provision of health services and patient care costs. Therefore, this study has analyzed the influence of the quality of medical information on the quality of the diagnosis code which includes the accuracy, consistency, completeness and timeliness in coding the diagnosis of inpatients at Dr. Moewardi hospital.This was an observational analytic study with a sample of 250 medical records taken using stratified random sampling. Data were analyzed by chi square test. High quality of medical information has a better diagnosis code quality (73.80%) compared to poorly quality of medical information (36.00%). High quality of medical information has a log odds of 1.54 better in the quality of diagnosis code than poorly quality of medical information (b=1.54; 95% CI=0.81-2.27, p<0.001).

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Section: Quality Of the Diagnosis Codementioning

confidence: 99%

Quality of medical information determine the quality of diagnosis code

Maryati¹,

Rahayuningrum²,

Ismayani³

2019

IJPHS

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“…Before coding the Schizophrenia Unspecified (F20.9) diagnosis, the Medical Record section must review the patient's medical record data to find deficiencies, errors, or mistakes [20][21]. Therefore, the accuracy of the medical record contents is a requirement for determining the diagnosis, so collaboration between doctors and coders plays a very important role in synchronizing disease diagnosis [22,23].…”

Section: Discussionmentioning

confidence: 99%

“…On-time (timelines). The results of in-depth interviews with informants revealed that they coded disease diagnoses on time every day; no code became homework for today or coded for tomorrow [27].…”

Section: Discussionmentioning

confidence: 99%

Synchronization of Codification of Unspecified Schizophrenia Againts Back-Referral System of Mirit Public Health Center

Wang¹,

Afriyani²,

Wahyuni³

et al. 2021

Dis.Prev.Public Heal J.

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Background: The disease classification system is a grouping of diseases following the International Statistical Classification of Diseases and Related Health Problems Tenth Revisions ICD-10. The coding application must be in accordance with ICD-10 to obtain a valid code in disease indexing, national, international reporting of morbidity and mortality, analysis of health care costs, and epidemiological and clinical research. The diagnosis of schizoaffective disorder is made if schizophrenia and affective disorder are symptoms based on the ICD-10 diagnostic criteria. This study aims to determine the synchronization of the codification of unspecified schizophrenia and determine the factors that influence it against the back-referral system at the Mirit Health Center. Method: This research is qualitative research with a descriptive approach. Respondents were four officers, i.e. one doctor, one medical record officer, one person holding a mental program, one pharmacy officer. The number of observed medical record documents was 96 data with research indicators of accuracy and completeness of the diagnosis code in patients referred from First Level Health Facilities (FKTP) to Advanced Health Facilities (FKTL). Result: The results showed 30 referrals, with nine referrals having the accuracy of the patient referral diagnosis code. The back-referral program (PRB) for mental illness at the Mirit Health Center, in collaboration with Mbah Marsio's mental health rehabilitation center, was carried out well. However, the implementation of the Chronic Disease Management program (Prolanis) for mental health was still not good. Conclusion: There are many unsynchronized codifications. It is recommended to conduct an evaluation where they communicate with each other about the patient's condition to supervise the implementation of Referback Patients, especially to specialists who write the back-referral form.

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“…Hasil penelitian terkait dengan kesalahan koding pada kasus gastroenteritis acute terdapat sebanyak 63 kasus (Karimah, Setiawan and Nurmalia, 2016). Hasil penelitian (Puspitasari and Kusumawati, 2017), didapat sebanyak 168 (33%) merupakan kode yang tidak tepat.…”

Section: Pendahuluanunclassified

Menelusuri Potensi Fraud dalam Jaminan Kesehatan Nasional melalui Rekam Medis di Rumah Sakit

Sugiarti¹,

Masturoh²,

Fadly³

2022

j. kesehat.

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Latar Belakang: Akibat fraud, BPJS (Badan Penyelenggara Jaminan Sosial Kesehatan) harus membayar klaim lebih besar, sehingga terjadi kerugian negara. Salah satu bentuk fraud yang ditemukan di kelompok provider adalah upcoding. Data koding dan rekaman pelayanan kesehatan dalam rekam medis dapat digunakan sebagai deteksi fraud.Tujuan: Menelusuri potensi fraud dalam rekam medis melalui telusur keakuratan kode diagnosis dan clinical pathway.Metode: Pendekatan kuantitatif kualitatif. Jenis penelitian case study, kasus thypoid. Subjek penelitian ditentukan dengan purposive sampling. Sampel penelitian kuantitatif menggunakan berkas rekam medis. Metode pengumpulan data menggunakan lembar observasi dan indept interview. Analisis data kuantitatif dengan analisis deskriptif dan Analisa data kualitatif dengan analisis konten.Hasil: Dari 87 dokumen, ketidaktepatan kode diagnosis 31,03%, dengan presentase ketidaksesuaian tarif klaim 26,44%. Terdapat berbagai penyebab upcoding diantaranya karena aturan pengkodean yang berbeda antara kode diagnosis berdasarkan ICD 10 dan kode untuk kepentingan klaim yang mengacu pada peraturan dari BPJS yang dituangkan dalam Berita Acara. 91,30% ketidaksesuaian merupakan tarif klaim naik. Ketidaksesuaian clinical pathway paling banyak pada item tes widal dengan presentase 21.84%.Kesimpulan: Upcoding tidak selalu disebut fraud, harus ada unsur kesengajaan untuk mendatangkan keuntungan finansial. Upcoding dapat merubah klaim menjadi lebih tinggi. Keberadaan clinical pathway penting sebagai acuan tindakan pelayanan kesehatan.

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Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember

Cited by 16 publications

References 0 publications

Quality of medical information determine the quality of diagnosis code

Quality of medical information determine the quality of diagnosis code

Synchronization of Codification of Unspecified Schizophrenia Againts Back-Referral System of Mirit Public Health Center

Menelusuri Potensi Fraud dalam Jaminan Kesehatan Nasional melalui Rekam Medis di Rumah Sakit

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