Analisis Faktor Penyebab Ketidaktepatan Kode Kombinasi Hipertensi Dengan Penyakit Jantung (I21) Pada Rekam Medis Pasien JKN DI RS Santo Antonius Jopu

Londa, Agnes (2025) Analisis Faktor Penyebab Ketidaktepatan Kode Kombinasi Hipertensi Dengan Penyakit Jantung (I21) Pada Rekam Medis Pasien JKN DI RS Santo Antonius Jopu. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A combination code is a category of code in ICD-10 that is used for two or more interrelated conditions. At Santo Antonius Jopu Hospital, data on the inaccuracy of the combination of hypertension and heart disease diagnosis codes were found in the medical records of JKN patients, as many as 18 cases (58.06%) from 31 samples, where the coding should have reached 100% accuracy. The impact of inaccuracies in codification caused a difference in the INA-CBGs claim rate of Rp11,020,600, and there was a delay in the claim entry process. The purpose of this study is to analyze the factors that cause the inaccuracy of the combination of the diagnosis of hypertension with heart disease in the medical records of JKN patients. The type of research is qualitative research with data collection techniques, namely written tests, interviews, observations, and documentation. The research subjects consisted of 3 coders, one head of medical record and one internal verificator. The results of the study show that the cause of the inaccuracy of the combination code of hypertension with heart disease (I21) from individual factors is the lack of ability of the coder to determine the combination code because he does not understand the combination code in ICD-10, lead terms, medical terminology, diagnosis and regulation of the INA-CBGs claim code. This issue must be prioritized and resolved. Furthermore, it was reviewed based on organizational factors, namely, no evaluation related to the coder’s performance and the absence of SOPs related to codification for the medical records of JKN patients. The improvement effort is that the Head of Installation RM proposed to the DIKLAT section of Santo Antonius Jopu Hospital to hold internal training related to codification and coders are included in external training. In addition, coders must study the ICD-10 handbook in volume 2 and the INA-CBG’s claim coding regulations.

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