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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: nur3yati@yahoo.com
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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