Factors Causing Inaccuracy in Disease Diagnosis Codes in Outpatient BPJS Patients Based on the ICD-10 Book

Abstract

Coding of disease diagnosis is an important process in the health care system that aims to classify and record patient disease information accurately. The purpose of this study was to identify the implementation of disease diagnosis coding and the factors causing inaccuracy of disease diagnosis codes in outpatient BPJS patients at the Siompu Barat Health Center, this study used a descriptive quantitative approach method with a sample of 89 medical record files of outpatient BPJS patients. Data collection methods were interviews, observations, and documentation studies, data analysis using source triangulation techniques. The results of the study showed that the coding process was carried out by searching for disease diagnosis codes using a book containing a list of previously existing patient diagnosis codes, which were recorded by coding officers as a guide, and by searching for the diagnosis code using Google. The accuracy of the disease diagnosis code was 45 diagnosis codes that were in accordance with ICD-10, while 44 others were not in accordance with the ICD-10 book. Factors that influence code inaccuracy include human factors, namely lack of knowledge and training of coding officers, material factors, namely non-specific diagnosis writing and unavailability of ICD-10 books, money factors, namely no budget related to coding training and budget for procuring ICD-10 books. It is expected that the Siompu Barat Health Center will hold routine training for officers, ensure the availability of a budget related to training and a budget related to procuring ICD-10 books so that the accuracy of disease diagnosis codes can be achieved as expected.