evaluation of diagnosis and procedures accuracy in panti rapih hospital yogyakarta in the...

Australian Journal of Asian Country Studies

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Australian Society for Commerce Industry & Engineering

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35

Evaluation of Diagnosis and Procedures Accuracy in Panti

Rapih Hospital Yogyakarta in the Implementation of

National Health Coverage Insurance

Nuryati

Vocational College of Medical Records, Gadjah Mada University, Bulaksumur Yogyakarta

55281, Indonesia

* E-mail of the corresponding author: [email protected]

Abstract

Background: Coding, costing, clinical pathway and information technology become essential elements

in health care in the National Health Coverage Insurance. Encoding is a code determining activity of

the disease and procedure with appropriate measures of classification in Indonesian (ICD-10) on

diseases and medical procedures in the healthcare management. Based on The Ministry of Health of

The Republic of Indonesia Number 377/Menkes/SK/III/2007 on Medical Record and Health

Information‘s Professional Standards, stated that the classification and diseases code, problems related

to health and medical treatment is the first competence of medical record and information management

professions. It shows that they should have the competencies to perform the coding activity. This

reinforces the role and functions of the medical record and health information profession in The

National Health Coverage Insurance. Panti Rapih Hospital Yogyakarta has five medical record and

health information staffs that are responsible for carrying out such activities in healthcare coding on

National Health Coverage Insurance. There is also one independent verifier of the BPJS which verifies

the codes specified by the staffs.

Objective: To ascertain the implementation and evaluation the accuracy of diagnosis and procedures as

well as the factors that lead to the inaccuracies of codes in Panti Rapih Hospital Yogyakarta on the

implementation of National Health Coverage Insurance.

Research Methodology: This type of research was a qualitative study. Objects used by researchers

were inpatient medical records of obstetrics and gynecology in 2012 as many as 339 files and all data

of the existing measures in the datasheet of surgery activity (Operations Report) in 2012 as many as

4925 procedures. The techniques used to collect the data were done by interviewing doctors, nurses,

medical record staffs, and independent verifier. Other data collection techniques were the study

documentation in the medical records and observations related to the implementation of coding.

Results: Implementation of coding diagnoses and procedures in Panti Rapih Hospital Yogyakarta is

computerized using the Hospital Information System (HIRS). Inpatient coding was done by the staffs at

the data processing unit. The processes of coding were done by looking at the discharge summary and

the datasheet of surgery activity (Operations Report). The accuracy of the diagnosis codes entered on

the inpatient obstetrics and gynecology records was 44.56% based on ICD-10 and the procedure codes

was 57.12%. Factors affecting the inaccuracies of diagnosis codes and procedures were lack of coding

comprehension, the ICD-10 database was not updated in the Inpatient HIRS, also coding audits have

not been conducted.

Keywords : Coding, ICD-10, accuracy, diagnosis, procedures, national health coverage insurance.

1. Introduction

Based on the Decree of the President of the Republic of Indonesia Number 12 Year 2013 concerning

health insurance, is a form of health insurance is a guarantee of health coverage for participants to

obtain health care benefits and protection to meet the basic needs of health care given to every person

who has paid dues or dues paid by the government. To organize Health Insurance program, then formed

a legal entity called the Social Security Agency, hereinafter abbreviated BPJS. While the parties who

operate health care effort is called the Health Facility. Health facilities are health care facilities that are

used to hold individual health care efforts, both promotive, preventive, curative and rehabilitative

undertaken by the Government, Local Government, and / or Community. Health facilities consist of a

first-level health facilities and advanced level referral health facilities.

Panti Rapih Hospital of Yogyakarta as advanced level referral health facilities in collaboration with the

BPJS as Social Security Agency of Health in implementing health care in the National Health

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Insurance. Based on the Ministry of Health of the Republic of Indonesia Number 71 Year 2013

concerning health care in the National Health Insurance, that one of service form that given by the

government is attendant administration. Administration services consisting of patient enrollment fee

and other administrative costs that occur during the process of patient care or health care.

According to the American Health Information Management Association in Hatta (2008), the officer is

able to assign codes coding disease and appropriate action in accordance with the classification in force

in Indonesia (ICD 10 and ICD-9-CM) on diseases and medical procedures in the care and health

management. The standard classification code used in the determination of the action is the

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Volume 3.

According HCIA (1992), ICD-9-CM Volume 3 consists of a number of numerical codes without the use

of character alphabet. Classification procedure published as itself volume as volume 3 of ICD-9-CM

classification procedures and contain of Tabular List and Alphabetic Index.

According to Hatta (2008), refer to ethics of coding and the desire to achieve high quality, encoded data

that is helpful publishing details of the bill appropriate care costs and reduce the risk of related health

care facility management. In designing the program in coding compliance (compliance in coding), one

of which held the activities of internal auditing and monitoring. Every health care organization must

have policies and procedures to create a guideline, set the encoding process and ensure the consistency

of the coding results. Every health care organization should establish an audit program / monitoring to

review the coding accuracy based on existing rules.

Coding, Costing, Clinical Pathway and Information Technology become essential elements in health

care in the National Health Insurance. Coding is a set of activities and measures of disease codes with

appropriate classification applied in Indonesia (ICD-10) on diseases and medical procedures in the care

and health management. Based on the Ministry of Health of the Republic of Indonesia Number

377/Menkes/SK/III/2007 on Professional Standards Medical Record and Health Information, stated

that the classification and code diseases, problems related to health and medical treatment is the first

competence Professions and Medical Record and Health Information. It shows that Profession Medical

Record and Health Information have the competencies to perform the coding activity. There are no

other professions of all types of health professionals who have competence to carry out activities of

coding, in addition Professions Medical Record and Health Information. This reinforces the role and

functions of the Professions Medical Record and Health Information Recorder in health care in the

National Health Insurance.

Panti Rapih Hospital of Yogyakarta has five staff Medical Record and Health Information that is

responsible for carrying out activities in health care coding on National Health Insurance. There is one

independent verifier of the BPJS which verifies the code specified by trained Medical Record and

Health Information conducting the coding. Therefore, more research needs to be done to ascertain the

implementation of diagnosis coding in Panti Rapih Hospital of Yogyakarta on the implementation of

National Health Insurance.

This study aims to ascertain the implementation and evaluation the accuracy of diagnosis and

procedures as well as the factors that lead to inaccuracies in coding in Panti Rapih Hospital of

Yogyakarta on the implementation of National Health Insurance.

This type of research is a qualitative descriptive. Objects used by researchers were inpatient medical

records of obstetrics and gynecology in 2012 as many as 339 files and all data of the existing measures

in the datasheet of surgery activity (Operations Report) in 2012 as many as 4925 procedures. The

techniques used to collect the data were done by interviewing doctors, nurses, medical record staffs,

and independent verifier. Other data collection techniques were the study documentation in the medical

records and observations related to the implementation of coding.

2. The Implementation of Coding Diagnosis and Procedures in Panti Rapih Hospital

The implementation of coding in Panti Rapih Hospital be reviewed based on the five elements of

management, including man, money, material, machine, and method.

1. Man

a. The parties involved in the encoding in Panti Rapih Hospital of Yogyakarta include

patients, physicians, medical records personnel and health information coding part, internal

verifier and independent verifier.

b. Patients who were all patients referred to the BPJS health services on the condition


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he suffered in Panti Rapih Hospital of Yogyakarta. Patients served BPJS Health Hospital

Nursing Neat Yogyakarta at 20% of the total patients.

c. The doctor is all the doctors who performed patient services in the BPJS in Panti

Rapih Hospital of Yogyakarta.

d. Officers medical records and health information in question is the officer conducting

patient diagnosis coding BPJS Health in Panti Rapih Hospital of Yogyakarta. There are five

officers involved coding. The entire coding clerk is D3 Medical Record, pass the test

credentials, and attended training coding and there are already certified.

e. Independent verifier is the party that verifies the diagnosis code generated for any

diagnosis coding officer upheld by physicians who serve patients. Independent verifier is from

BPJS Health. There is an independent verifier for Panti Rapih Hospital of Yogyakarta, which

is a doctor.

f. Internal verifier is the party that verifies the diagnosis code specified by the coding

clerk before reported to the independent verifier. There is an internal verifier derived from

Panti Rapih Hospital of Yogyakarta, which is a doctor.

2. Money

a. Installation Medical Record of Panti Rapih Hospital of Yogyakarta is not experience

problems related to money. The financial arrangements in Panti Rapih hospital is done

centrally.

b. The financial arrangements of the center have been set up payroll clerk overall

coding. The amount of the salary received by the clerk coding has been adjusted to the

workload. That is, there is no special treatment (wage increase) related to income received by

each officer encoding even though they have strong roles and functions in the health services

in the National Health Insurance.

3. Material

a. Diagnosis was established by doctors who provide care to patients is a matter that is

encoded by the coding clerk.

b. In the implementation, the officer encoding encodes in accordance with established

diagnosis by the doctor who examined the patient. But in certain circumstances, the officer

does not necessarily encode encoding in accordance with established diagnosis by the doctor.

For example, when the diagnosis is less completed, any determination of the primary

diagnosis and additional diagnoses, and in the event of over-coding.

c. To overcome the problem of encoding time of diagnosis is less complete, coding

officer may recommend to the physician by means of consultations related conditions that

have not been included in the diagnosis established by the physician after a review of the

patient's medical record file. If the proposal is accepted, then the doctor is responsible for the

added diagnostic and coding clerk adds the added diagnosis codes. Problems incomplete

diagnosis is established, usually caused by the diagnosis delivered to the clerk of encoding is

not a final result yet. So that after the file reached the Medical Record Installation and further

studied, it still found some things that have not been included in the diagnosis had been

established previously.

d. To overcome the problem of incorrect determination of the primary diagnosis and

additional diagnoses, coding clerk re-applying the selection rules contained in the ICD-10.

However, the officer does not necessarily apply coding rules are re-selection. Discussion with

the doctor who did the examination of these patients remains to be done first. If the proposal is

accepted, then the doctor is responsible for the added diagnostic and coding clerk adds the

added diagnosis codes. One of the main problems of determining diagnosis and additional

diagnoses are usually caused by the lack of physician carefulness put (write) a diagnosis of

primary diagnosis in the appropriate fields and an additional diagnosis. Doctors also do not

have enough time to write in the appropriate fields accordingly, so that all of diagnosis is put

(written) in the appropriate fields.

e. To solve the problem when there is over-coding, coding officer gave a warning to the

physician. Since the beginning of every patient who comes to Panti Rapih Hospital, has


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estimated the amount of resources that would be spent to serve each of these patients. Estimate

the amount of resources that would be spent if the thresholds that have occurred over coding.

If the limit has been exceeded, it has happened over coding. When there is over-coding, the

coding officer gave a warning to the doctor in order to make improvements to the

effectiveness and efficiency of service. This problem usually occurs due to some condition of

the patient, the doctor just look at the patient's clinical symptoms to determine the diagnosis,

without the need to use the investigation. So long as the doctor is still seeing patients clinical

symptoms have not improved, then the service will continue to be provided. It is also a

separate issue related to the interests of the diagnosis BPJS Health. Doctors only make a

diagnosis based on clinical symptoms, without the use of investigations. On the other hand,

independent verifier requires information related investigation. As a consequence, often

frequent rejection of an independent verifier claims.

4. Machine

a. Equipment that used in the process of diagnosis coding in Panti Rapih Hospital of

Yogyakarta include computing devices equipped with INA-CBGs grouper applications,

programs consist of coding the ICD-10 and ICD-9-CM electronic, and SIMRS

b. There are two computers that are used for coding diagnoses in Panti Rapih Hospital

of Yogyakarta.

c. Application grouper used for coding diagnoses in Panti Rapih Hospital of Yogyakarta

INA-CBG's is 4.0.

d. Application grouper and SIMRS not integrated, so it must work twice.

5. Methods

a. Cooperation between Hospital Panti Rapih Yogyakarta with BPJS started date of

January 1, 2014.

b. In general, there is no difference between before and after the encoding process

Hospitals Nursing cooperation with Panti Rapih Hospital of Yogyakarta with BPJS Health.

The difference lies in the presence of process efficiency that occurs, both the efficiency of the

examination and the efficiency of the drug.

c. There is related Standard Procedure Operational (SPO) Medical BPJS patient

diagnosis coding. SPO has not set the associated reward and punishment.

d. Yet there (still in the drafting process) associated coding guide patients BPJS Health

3. Evaluation of Accuracy codification Diagnosis and Action

Encoding conducted by four officers who were in the medical record data section. Three of the

officers of each coding have responsibility, which is in charge of encoding the ER (IGD), outpatient,

inpatient, a data processing clerk to help the work of all officers encoding. Hospital coding clerk in

charge of implementing encoding only in accordance with the existing organizational structure, so

there is no double duty in the execution of the work.

There are two officers coding inpatient in Panti Rapih Hospital of Yogyakarta, one educational

background D3 Medical Record and have training of trainers ICD-10. Officers coding educational

background is not D3 Medical Record also attended training seminars or seminars but in general the

medical record management.

Human resources are responsible officers who are able to work optimally to achieve organizational

goals. The paradigm shift profession of medical records into the health information management

profession has brought changes to the importance of human resource development particularly the

profession that has been going out for the job.

Based on the Decree of the Minister of Health number 377/Menkes/SK/III/2007 on Professional

Standards Medical Record and Health Information, medical and health information recording is a

person who has completed formal education of Medical Records and Health Information that has

competence recognized by the government and the profession as well as has duties, responsibilities,

authority, and full rights to perform service activities of medical records and health information in

healthcare facilities.

Based on the Decree of the Minister of Health number 377/Menkes/SK/III/2007 which states that the


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qualifications of medical record education is set in the education of medical and Health Information.

But there is official in Panti Rapih Hospital that has not a graduate of Medical Records and Health

Information, although the officers have completed training to support job. This is consistent with the

statement of Hatta (2008) human resources personnel, especially during this profession to pursue that

field must follow the training, coaching, and development first.

Based on the results of observations conducted by researchers at the Medical Records Installation in

Panti Rapih Hospital of Yogyakarta, the facilities used to support the implementation of coding in

Panti Rapih Hospital is by using the SIRS program menu coding, ICD-10 volumes 1 and 3, ICD-9

CM, Dictionary medicine, standardized list of abbreviations, dictionary stands for International, and

English dictionaries.

According to Abdelhak, et al (2001), "computer software called an encoder is available to assist in the

coding-process". Based on the study of the documentation to the SPO number RSPR/S5P2/SPO.24

Panti Rapih Hospital of Yogyakarta (2009), about coding and Indexing, diagnosis codes and coding

implementation measures have been hospitalized patients is computerized. The SPO is mentioned in

the code where the disease has been no search code using ICD-10 disease manually and immediately

put the code into the computer. In the Panti Rapih Hospital of Yogyakarta coding implementation is

using a useful facility to support the encoding process, which is in line with SPO

RSPRS/S5P2/SPO.24 numbers, and in accordance with the theory of Abdelhak, et al (2001).

Encoding process is done by using a program that is already contained in the computer. If there is a

diagnosis that is shortened, then the officer will look at the list of abbreviations that have been

standardized by the hospital or look it up in the list of abbreviations International.

The implementation of the encoding is done after the completion of medical record file in

assembling. If the file is found incomplete medical records in the diagnosis and act charge, or found a

diagnosis and action is not clearly legible, medical records clerk will restore files and medical records

pertinent to ask the doctor about diagnosis and action.

According to Abdelhak, et al (2001), medical records personnel in performing coding must use ICD-

10. Panti Rapih Hospital of Yogyakarta implementation of coding implemented using SIMRS

encoding menu. This is consistent with the theory Abdelhak, et al (2001) which states "computer

software called an encoder is available to assist in the coding-process".

According to Abdelhak, et al (2001), the coding should be done in sequence to avoid mistakes in

doing so. Before performing the encoding process, the officer must check the completeness of the

medical record medical record sheets and completeness of physician records, especially records of the

diagnosis written on the summary sheet in and out and already there is a doctor's signature.

Panti Rapih Hospital of Yogyakarta encoding performed after complete medical record file in

assembling is by checking the completeness of the medical record sheets and completeness of

records, especially records of physician diagnosis written in the summary sheet in and out. This is

consistent with the theory Abdelhak, et al (2001) prior to the encoding process, the officer must check

the completeness of the medical record medical record sheets and completeness of physician records,

especially records of the diagnosis written in the summary sheet entry and exit of existing physician

signature.

After checking the completeness of the medical records clerk medical record sheets and completeness

of physician notes. If the doctor does not understand writing, medical records clerk at Panti Rapih

Hospital of Yogyakarta ask the doctor who acts as a conduit of diagnosis. This is in accordance with

Abdelhak, et al (2001) when the officer confronted with obstacles in the medical record coding or

found a diagnosis, the doctor responsible for helping.

In the Installation Medical Record Panti Rapih Hospital of Yogyakarta, policies governing the coding

procedure already contained in the SPO and RSPR/S5P2/SPO.24 numbers, but the procedure remains

the coding between the coding procedure inpatient, outpatient, and emergency care.

With the procedure remains the work can be carried out according to the correct rules efficiently

(Sabarguna, 2008). Based on the results of the study indicate that the procedure remains in Panti

Rapih Hospital of Yogyakarta set of coding and Indexing already exists, it is appropriate theory

(Sabarguna, 2008), but the procedure is still the one encoding the encoding procedure inpatient,

outpatient, and emergency department. Procedure still remains to be one and the revision process for

accreditation prepare.


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3.1 The Accuracy of Diagnosis Codes and Action on Inpatient Panti Rapih Hospital of

Yogyakarta

To determine the percentage of accuracy of diagnosis codes and procedures, researchers conducted a

study of the documentation of the medical record and Files 339 to 469 in the diagnosis entry

summary sheet out and act on the data sheet 4925 operations.

Below are the results data coding diagnoses and inpatient measures, for more detail can be seen in the

table below:

Table 1Results of Analysis the Accuracy of Diagnosis Code and Action

No Criteria Diagnosis Procedures

Total % Total %

1 A 209 44,56 377 57,12

2 B 16 3,41 62 9,39

3 C 44 8,95 63 9,55

4 D 88 18,76 68 10,30

5 E 114 24,30 90 13,64

Total 469 100,00 660 100,00

From Table 1 it can be seen above the percentage of inaccuracy in determining the diagnosis code

entered on the summary sheet out inpatient obstetrics and gynecology. From 339 files it can be

obtained 469 in the diagnosis entry summary sheet out who analyzed contained 44.56% of patients

disease corresponding code / specific to the ICD-10 disease code which only consists of 3 characters

as much as 4 3.41%, disease code wrong the fourth character as much as 8.95%, the disease code

does not match the ICD-10 as much as 18.76%, and the code is not coded as disease 24.30%.

Criterion A (code appropriate procedures / specific) action code 377 or as much of 57.12% of the total

number, while for criterion B (right up to the second digit code) code as much as 62% of procedures

or at 9:39, criterion C (right up to the third digit code) code or as much as 63% by 9:55. Criterion D

(improper procedures code) code as much as 68% or as much as 10:30 and criterion E (no code

procedures) or as many as 90 codes of 13.64%.

Criteria "A", according to the WHO (2004) that the four-character subcategories used for

identification of the most appropriate, for example where different variations on the three categories

of characters for a single illness or disease that stands alone in the category of three characters for the

group condition. According to WHO (2002), medical records personnel are required to use a three-

digit code or four digits of the ICD-10.

The accuracy of diagnosis codes with the criteria "A" on the entry summary sheet out inpatient

obstetrics and gynecology amounted to 44.56%. The accuracy of diagnosis codes to ICD-10 needs to

be improved because by Hatta (2008), the implementation of ICD-10 coding system is used for:

a. Index listing of disease and actions in health means service.

b. Input for medical diagnosis reporting systems

c. Facilitate the storage and retrieval of data related of characteristics diagnosis patient

and service providers

d. The basic ingredients in the grouping DRGs (diagnosis-related groups) for payment

of a service charge billing system

e. National and international reporting morbidity and mortality

f. Tabulation of data for the evaluation of health services planning medical services.

g. Determine the type of services that should be planned and developed according to the

needs of the times

h. Analysis of health care financing

i. For epidemiological and clinical research

Criteria "B", the code included in this category is used in the reporting process requires only three


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characters. For inpatient morbidity itself, reporting to the health department uses three character

categories. Three categories characters are characters that must be reported to the WHO from each

country (WHO, 2002).

In Panti Rapih Hospital of Yogyakarta, there are several criteria "C" code is written to a disease that

only these three characters do not affect the reporting of morbidity diagnosis codes are three

characters that must be reported to WHO. However, this is not it an issue for the purposes of research

and education regarding the disease, since both require specificity (specification).

Criteria "E", the code included in this category are dual diagnosis, but a few copies in the diagnosis

entry summary sheet out not coded. By Hatta (2008), for a reporting group of the analysis is the

single cause of morbidity are taken is the main condition code, while the indexing code for all of

these conditions should be recorded, encoded and then stored in order to meet local needs wider.

According to Abdelhak (2001), the suitability of the data and information presented in the required

information was instrumental in the decision-making process. To be able to produce good data and

information and can be used as a basis for management decision making, it takes an active role in the

officer doing data processing.

From the calculation accuracy of the researchers associated with the action code, still found a code

that is not appropriate and not filled. The highest percentage of accuracy lies in the procedures code

―A‖ criteria (code appropriate actions / specific) action code 377 or as much of 57.12% of the total.

Based on the accuracy of analysis procedures code in Panti Rapih Hospital of Yogyakarta there are

actions that are not appropriate for criterion ―D‖(not exact code) as much as 68% or improper 10:30.

There are also procedures that are not encoded code for criterion ―E‖ (unallocated procedures code)

as much as 90 or 13.64%. Medical records officer should strive to minimize inaccuracies procedures

code is the responsibility of the medical records officer acts as a coder.

Based on Farzandipour (2009), the accuracy is divided over the accuracy of the main digit and the

fourth digit, the accuracy of the comparison between coding personnel who have had experience with

that yet, the comparison code using the database by using the book ICD-9-CM and re-checking code

in the list table by using the alphabetical index only. The difference in the present study conducted in

Panti Rapih Hospital of Yogyakarta is researchers split criterion to 5 criteria in determining the

accuracy of the code of procedures, the criterion A (specific code / right), criterion B (two-digit code

on the right), criterion C (three- digit code on the right ), criterion D (not exact code), and the

criterion E (code not filled).

Medical records personnel responsible for the accuracy of a diagnosis code that has been established

by medical personnel (Budi, 2011). Panti Rapih Hospital of Yogyakarta there are not yet accurate

diagnosis corresponding ICD-10, medical records officers should seek to minimize inaccuracies due

to the accuracy of diagnosis codes is the responsibility of the medical records officer as giving a

diagnosis code.

4. Conclusion

a. Implementation of coding diagnoses and procedures in the Installation Medical Record Panti

Rapih Hospital of Yogyakarta done by coding 2 officers, one officer act as inpatient coding

JAMKESNAS patients, and the other act as clerk for inpatient coding. Background D3 Medical

Record and outside of medical records. The encoding process of Panti Rapih Hospital of

Yogyakarta has been computerized.

b. Analysis of the accuracy of the diagnosis code and the procedures has not reached its full

potential, the results of the analysis of the accuracy of 44.56% diagnosis codes are codes that are

in accordance with the ICD-10 and there are 377 or 57.12% of code procedures are in

accordance with the ICD-9-CM.

c. Factors causing inaccurate coding and diagnosis codes and procedures inpatient surgical cases

in Panti Rapih Hospital of Yogyakarta are the Human Resources (HR), database update ICD-10

and ICD-9-CM, and have not done an evaluation / audit of diagnosis codes and procedures.

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