FACTORS THAT AFFECTING THE ACCURACY OF CODING DIAGNOSIS AND MEDICAL PROCEDURES OF INPATIENT HEALTH RECORDS IN 1ST SEMESTER 2013 AT PUBLIC HOSPITAL (RSUD) OF SEMARANG DISTRICT

KRESNOWATI, LILY and ERNAWATI, DYAH (2014) FACTORS THAT AFFECTING THE ACCURACY OF CODING DIAGNOSIS AND MEDICAL PROCEDURES OF INPATIENT HEALTH RECORDS IN 1ST SEMESTER 2013 AT PUBLIC HOSPITAL (RSUD) OF SEMARANG DISTRICT. IFHIMA SEAR Conference.

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Abstract

Since the implementation of Prospective Payment Systems with Case-mix Classification based on Diagnosis Related Gmts (DRG’s) all over the World‚ the coding of main diagnosis and medical procedures has played an important role in health care reimbursement. The accuracy of coding has becoming primary conditions In claim reimbursement Many hospitals suffered loss in reimbursement due to inaccuracy of coding diagnosis and procedures. In Indonesia, the same problems occurred in many government hospitals served for Jamkesmas. One of those is RSUD Kota Semarang. In coding process, there are many factors that have roles in producing accurate codes; roles of medical staff (doctors), health information management (HIM) staff, completeness of medical records, facilities and infrastructures, and last is management policies. This research is aimed to analyze those factors affecting the accuracy of coding main diagnosis and medical procedures in health record of inpatlents during 1 semester of 2013 at RSUD (Public Hospital) Semarang District. Research is conducted quantitatively to get the status of coding accuracy. and qualItatively to know which factors affecting the coding accuracy through Focused Groups Discussion. Subjects of research are; coder specialized In handling Jamkesmas claims, head of HIM department, medical staff (doctors) as the person responsible of the main diagnosis and medical procedures written in the records. Besides, observation to completeness of the records, facilities and Infrastructure, and also management policies related to coding procedures are also obtained. The results are as follows ; Quantitatively. the status of coding accuracy are quIte good, with 37% accurate for main diagnosis codes, and 50% for medical procedure codes. Qualitative datas revealed for the factors affecting the accuracy status of coding main diagnosis an medical procedures are ; (a) The main diagnosis assigned by the doctors are not in accordance to the morbidity rules in lCD- 10. that made the coders have to do deep analysis through the records to be able to assign the right codes. But this can lead into coding error when the coders has mistakenly assuming the diagnosis or couldn’t got the appropriate infomation. (b) Despite of the educational backgrounds in HIM, coders do not have sufficient knowledge about procedures In medicine, so they may picked up the wrong codes (C) Lack of completeness of health records has contributed in the wrong assignment of codes. But (d) All facilities and infrastructures and also management policies related to Coding Procedures have been supportively enhance the coding process, only that dissemination and implementation of the policy must be re-evaluated in the aspects of discipline and enforcement. In Conclusion, improvement of coding quality in RSUD Kota Semarang must involved all doctors responsible for determining the main diagnosis and medical procedures. coders and also improvement in the quality of health records. to produce more highly status of coding accuracy of main diagnosis and medical procedures Keywords: coding accuracy, inpatient health records, factors.

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