Accuracy of Diagnosis Coding Based On ICD-10

Abstract

Background: Accuracy of diagnosis code in medical record is responsible for hospital medical billing. Accurate billing is crucial for the financial health of medical institutions. Billing and coding are based on what services are documented by the provider and selection of the appropriate code is most commonly done by the provider or a coding specialist. This study aims to determine inaccurate coding diagnosis at Semen Padang Hospital from January to March in 2017.Material and method: This research was conducted at Semen Padang Hospital, West Sumatera, Indonesia from January to March in 2017. The study used descriptive method with a qualitative approach. The data was collected from the medical records department. The population is overall object of research. The population is all abstraction data of medical record file from January to March in 2017, namely 2342 medical record files, used total sampling technique. Research variable is accuracy and inaccuracy diagnosis code based on ICD-10 from abstraction data inpatient patient. Accurate is compatible diagnosis code according to the code in ICD 10.Results: 95.8 % (2229) diagnosis accurate and 4.8 % (113) diagnosis inaccurate based on ICD-10. Inaccuracy diagnosis codes are acute appendicitis with generalized peritonitis (K35.2) 6.19 % (7 diagnosis), acute appendicitis, other and unspecified (K35.8) 5.3% (6 diagnosis) and chronic kidney disease stage 5 (N18.5) 88.51% (100 diagnosis).Conclusion: Accuracy code was 95,8% and inaccurate was 4,8 %. Chronic Kidney diseases is the most inaccurate code.