TEPATAN DAN KESESUAIAN ANALISIS KE PENULISAN KODE DIAGNOSIS DAN TINDAKAN KASUS OBSTETRI PASIEN SJSN DI RSUP DR.SARDJITO YOGYAKARTA

ELVIRA KUSUMASTUTI, Nuryati, S.Far., MPH

2014 | Tugas Akhir | D3 REKAM MEDIS

Latar Belakang : Pengkodean baik diagnosis maupun tindakan sangat penting dalam hal finansial terlebih lagi bagi sistem pembayaran jaminan sosial yang menggunakan klaim. Kesalahan dalam pengkodean dapat menyebabkan kerugian secara finansial bagi rumah sakit. Pada tanggal 1 Januari 2014, Indonesia mulai menerapkan sistem penjaminan sosial kesehatan baru yang dikelola oleh BPJS (Badan Pengelola Jaminan Sosial). RSUP Dr. Sardjito, Yogyakarta adalah salah satu rumah sakit rujukan terbesar yang berimbas dengan banyaknya pasien penjaminan di sana. Ketepatan dan kesesuaian kode diagnosis dan tindakan sangat menentukan besaran finansial dan pengambilan keputusan di rumah sakit tersebut. Di RSUP Dr. Sardjito salah satu kasus yang banyak dikembalikan kembali oleh verifikator BPJS adalah kasus obstetri. Tujuan Penelitian: Mengetahui tentang pelaksanaan penentuan, persentase ketepatan pengisian, persentase kesesuaian kode di berkas rekam medis dan lembar klaim serta upaya petugas rekam medis terhadap ketepatan pengisian kode diagnosis dan tindakan kasus obstetri pasien SJSN di RSUP Dr. Sardjito, Yogyakarta. Metode Penelitian : Jenis penelitian yang digunakan adalah penelitian deskriptif dengan menggunakan pendekatan kualitatif serta dengan rancangan case study. Objek penelitiannya adalah lembar ringkasan masuk keluar dan software lembar klaim INA-CBG’s selama bulan Januari 2014. Subjek penelitiannya adalah tiga orang petugas coding rawat inap pasien penjaminan dan seorang kepala Instalasi Penjaminan sebagai triangulasi. Teknik pengumpulan data menggunakan wawancara, observasi dan studi dokumentasi. Hasil Penelitian : Pelaksanaan pengkodean diagnosis dan tindakan pada ringkasan masuk keluar dan lembar klaim INA-CBG’s pasien rawat inap dilakukan oleh 9 orang petugas coding. Pengkodean diagnosis pasien berdasarkan ICD-10 versi 2005 dan tindakan berdasarkan ICD-9-CM versi 2007.. Pengkodean diagnosis dan tindakan pasien rawat inap pada lembar klaim INA CBG’s sama dengan pelaksanaan pengkodean diagnosis dan tindakan pada ringkasan masuk keluar. Persentase ketepatan kode diagnosis pada ringkasan masuk keluar adalah kriteria A sebanyak 72,77%; kriteria B sebanyak 2,12%; kriteria C sebanyak 5,93%; kriteria D sebanyak 8,90%; kriteria E sebanyak 10,17%. Persentase Ketepatan kode tindakan pada ringkasan masuk keluar adalah kriteria A sebanyak 75,34%; kriteria B sebanyak 1,37%; kriteria C sebanyak 5,94%; kriteria D sebanyak 10,50%; dan kriteria E sebanyak 6,35%. Persentase kesesuaian kode diagnosis sebanyak 9.62% dan prosentase ketidaksesuaian sebanyak 90,38%. Persentase kesesuaian kode tindakan sebanyak 11,54% dan prosentase ketidaksesuaian sebanyak 88,46%. Upaya yang dilakukan oleh petugas coding terhadap kelengkapan penulisan kode adalah selalu melakukan konfirmasi ke dokter yang bertanggungjawab apabila ada diagnosis atau tindakan yang tidak terisi atau tidak jelas.

Background: Coding is very important in financial terms even more so for the social security payment systems that use claims. Errors in coding can lead to financial losses for hospitals. On January 1, 2014, Indonesia began to implement a new health social insurance system which is managed by BPJS (Social Security Agency Business). RSUP Dr. Sardjito, Yogyakarta is one of the bigest referral hostpital that cause many guarantee’s patient. The accurancy and suitability diagnostic and procedure code very important to specify how much financial terms and to take any decision for hospital manajement. In RSUP Dr. Sardjito, Yogyakarta one of the manies case that claim give back to hospital is obstetry’s case. Objective: To know about the implementation of charging, percentage accurancy of code, suitability percentage of code in the medical record file and sheet claims and medical record staffs attempt to accurancy filling diagnosis and procedure codes of obstetric patients SJSN action cases in RSUP Dr. Sardjito, Yogyakarta. Methods: This type of research was a descriptive study used a qualitative approach and the case study design. The objek was medical record file and sheet claims in Januari 2014. The subjek was three people who coding hospitalization of guarantee’s patient and one head of guarantee instalation as triangulation The technique of collecting data used interviews, observation and documentation studies. Results: Implementation of coding diagnoses and acts on exit and entry summary sheet INA-CBG's claim inpatients 9 officers conducted by coding. Encoding patient diagnosis based on ICD-10 version of 2005 and actions based on ICD-9-CM 2007 version . The coding diagnoses and inpatient action at INA CBG's claim sheet together with the implementation of diagnosis coding and entry summary action on exit. Percentage accuracy of diagnosis codes in the summary entry exit criteria are as much as 72.77% A; criterion B as much as 2.12%; criterion C as much as 5.93%; D criteria as much as 8.90%; E criteria as much as 10.17%. Percentage accuracy of the summary action code is entered out as much as 75.34% criterion A; criterion B as much as 1.37%; criterion C as much as 5.94%; D criteria as much as 10.50%; and criterion E as much as 6.35%. Percentage suitability diagnosis codes as much as 9.62% and 90.38% as a percentage of mismatches. Percentage suitability action code as much as 11.54% and 88.46% as a percentage of mismatches. Efforts made by the officers to complete the writing of coding is always doing the confirmation code to the doctor who is responsible if there is a diagnosis or unallocated action or unclear.

Kata Kunci : Kelengkapan, ICD-10, ICD-9-CM, Pengkodean, Kesesuaian