Accuracy and Validity Outpatient Diagnosis Code Base On ICD-10 at Imogiri I Health Center Bantul Yogyakarta

2022 ◽  
Vol 2 (1) ◽  
pp. 26-31
Author(s):  
Hendra Rohman

Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.

1970 ◽  
Vol 2 (2) ◽  
pp. 12
Author(s):  
Rinda Nurul Karimah ◽  
Dony Setiawan ◽  
Puput Septining Nurmalia

Accuracy analysis of replenishment diagnosis codes on the document medical records is very important because if the diagnosis code is not right or not in accordance with the ICD-10, it can cause a decline in the quality of care in hospitals as well as the influence of data, information reporting, and accuracy rates of INA-CBG's that are currently used as a method of payment for patient care. The purpose of this study was to analyze the accuracy of diagnosis codes acute gastroenteritis disease in hospitalized patients by medical record documents in the first quarter of 2015 in the Balung Hospital Jember. This research used qualitative data. Acquisition of data from this study through interviews and observations. Results obtained from the observation of medical record documents at the inpatient unit in the first quarter 2015 in Balung Hospital Jember, there are some numbers determining the accuracy of disease diagnosis codes as many as 17 medical record documents with acute gastroenteritis illness and the determination of improper diagnosis codes as many as 63 medical records document acute gastroenteritis illness. After analyzing, the cause of the problem is the accuracy of the diagnosis that affects the accuracy of writing code, beside it has never been disseminated to physicians and medical records personnel related to the management of medical records. Therefore, it is necessary to carry out activities that can improve the accuracy of disease diagnosis code and quality of human resources, among others, include doctors and medical records personnel in training and socialization related to the management of medical records. Key Words : Diagnosis codes , medical record, acute gastroenteritis


2021 ◽  
Vol 16 (1) ◽  
pp. 55-61
Author(s):  
Nur Hayati Munawaroh ◽  
Ndari Afriyani ◽  
Sri Wahyuni ◽  
Triyo Rachmadi

Background: The disease classification system is a grouping of diseases following the International Statistical Classification of Diseases and Related Health Problems Tenth Revisions ICD-10. The coding application must be in accordance with ICD-10 to obtain a valid code in disease indexing, national, international reporting of morbidity and mortality, analysis of health care costs, and epidemiological and clinical research. The diagnosis of schizoaffective disorder is made if schizophrenia and affective disorder are symptoms based on the ICD-10 diagnostic criteria. This study aims to determine the synchronization of the codification of unspecified schizophrenia and determine the factors that influence it against the back-referral system at the Mirit Health Center. Method: This research is qualitative research with a descriptive approach. Respondents were four officers, i.e. one doctor, one medical record officer, one person holding a mental program, one pharmacy officer. The number of observed medical record documents was 96 data with research indicators of accuracy and completeness of the diagnosis code in patients referred from First Level Health Facilities (FKTP) to Advanced Health Facilities (FKTL). Result: The results showed 30 referrals, with nine referrals having the accuracy of the patient referral diagnosis code. The back-referral program (PRB) for mental illness at the Mirit Health Center, in collaboration with Mbah Marsio's mental health rehabilitation center, was carried out well. However, the implementation of the Chronic Disease Management program (Prolanis) for mental health was still not good. Conclusion: There are many unsynchronized codifications. It is recommended to conduct an evaluation where they communicate with each other about the patient's condition to supervise the implementation of Referback Patients, especially to specialists who write the back-referral form.


2008 ◽  
Vol 18 (1) ◽  
pp. 9-20 ◽  
Author(s):  
Mark Kander ◽  
Steve White

Abstract This article explains the development and use of ICD-9-CM diagnosis codes, CPT procedure codes, and HCPCS supply/device codes. Examples of appropriate coding combinations, and Coding rules adopted by most third party payers are given. Additionally, references for complete code lists on the Web and a list of voice-related CPT code edits are included. The reader is given adequate information to report an evaluation or treatment session with accurate diagnosis, procedure, and supply/device codes. Speech-language pathologists can accurately code services when given adequate resources and rules and are encouraged to insert relevant codes in the medical record rather than depend on billing personnel to accurately provide this information. Consultation is available from the Division 3 Reimbursement Committee members and from [email protected] .


2020 ◽  
Vol 7 (10) ◽  
Author(s):  
Laura R Marks ◽  
Nathanial S Nolan ◽  
Linda Jiang ◽  
Dharushana Muthulingam ◽  
Stephen Y Liang ◽  
...  

Abstract Background No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007). Conclusions Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.


BMJ ◽  
2019 ◽  
pp. k5092 ◽  
Author(s):  
Kao-Ping Chua ◽  
Michael A Fischer ◽  
Jeffrey A Linder

Abstract Objective To assess the appropriateness of outpatient antibiotic prescribing for privately insured children and non-elderly adults in the US using a comprehensive classification scheme of diagnosis codes in ICD-10-CM (international classification of diseases-clinical modification, 10th revision), which replaced ICD-9-CM in the US on 1 October 2015. Design Cross sectional study. Setting MarketScan Commercial Claims and Encounters database, 2016. Participants 19.2 million enrollees aged 0-64 years. Main outcome measures A classification scheme was developed that determined whether each of the 91 738 ICD-10-CM diagnosis codes “always,” “sometimes,” or “never” justified antibiotics. For each antibiotic prescription fill, this scheme was used to classify all diagnosis codes in claims during a look back period that began three days before antibiotic prescription fills and ended on the day fills occurred. The main outcome was the proportion of fills in each of four mutually exclusive categories: “appropriate” (associated with at least one “always” code during the look back period, “potentially appropriate” (associated with at least one “sometimes” but no “always” codes), “inappropriate” (associated only with “never” codes), and “not associated with a recent diagnosis code” (no codes during the look back period). Results The cohort (n=19 203 264) comprised 14 571 944 (75.9%) adult and 9 935 791 (51.7%) female enrollees. Among 15 455 834 outpatient antibiotic prescription fills by the cohort, the most common antibiotics were azithromycin (2 931 242, 19.0%), amoxicillin (2 818 939, 18.2%), and amoxicillin-clavulanate (1 784 921, 11.6%). Among these 15 455 834 fills, 1 973 873 (12.8%) were appropriate, 5 487 003 (35.5%) were potentially appropriate, 3 592 183 (23.2%) were inappropriate, and 4 402 775 (28.5%) were not associated with a recent diagnosis code. Among the 3 592 183 inappropriate fills, 2 541 125 (70.7%) were written in office based settings, 222 804 (6.2%) in urgent care centers, and 168 396 (4.7%) in emergency departments. In 2016, 2 697 918 (14.1%) of the 19 203 264 enrollees filled at least one inappropriate antibiotic prescription, including 490 475 out of 4 631 320 children (10.6%) and 2 207 173 out of 14 571 944 adults (15.2%). Conclusions Among all outpatient antibiotic prescription fills by 19 203 264 privately insured US children and non-elderly adults in 2016, 23.2% were inappropriate, 35.5% were potentially appropriate, and 28.5% were not associated with a recent diagnosis code. Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic prescription in 2016. The classification scheme could facilitate future efforts to comprehensively measure outpatient antibiotic appropriateness in the US, and it could be adapted for use in other countries that use ICD-10 codes.


2014 ◽  
Vol 2014 ◽  
pp. 1-4 ◽  
Author(s):  
Julia Lai-Kwon ◽  
Tracey J. Weiland ◽  
Alvin H. Chong ◽  
George A. Jelinek

Background/Objectives. There is minimal data available on the types of dermatological conditions which present to tertiary emergency departments (ED). We analysed demographic and clinical features of dermatological presentations to an Australian adult ED.Methods. The St. Vincent’s Hospital Melbourne (SVHM) ED database was searched for dermatological presentations between 1 January 2009 and 31 December 2011 by keywords and ICD-10 diagnosis codes. The lists were merged, and the ICD-10 codes were grouped into 55 categories for analysis. Demographic and clinical data for these presentations were then analysed.Results. 123 345 people presented to SVHM ED during the 3-year period. 4817 (3.9%) presented for a primarily dermatological complaint. The most common conditions by ICD-10 diagnosis code were cellulitis (n=1741, 36.1%), allergy with skin involvement (n=939, 19.5%), boils/furuncles/pilonidal sinuses (n=526, 11.1%), eczema/dermatitis (n=274, 5.7%), and varicella zoster infection (n=161, 3.3%).Conclusion. The burden of dermatological disease presenting to ED is small but not insignificant. This information may assist in designing dermatological curricula for hospital clinicians and specialty training organisations as well as informing the allocation of dermatological resources to ED.


2020 ◽  
Vol 3 (1) ◽  
pp. 29-35
Author(s):  
Hikmawan Suryanto

Human resources are an important and vital component in an organization's operations. Quality health services can not be separated from the organization of a good medical record. In order to run well, sufficient medical records are needed. In the Adan-Adan Health Center, the number of patient visits from July 2018 to July 2019 was 16,828 people. Medical records officer only numbered 1 person. The research objective is to calculate the needs of human resources in the medical record unit using the ABK method. The design of this research is descriptive observational with case study approach. Respondents in this study were medical staff at the Adan-adan Health Center in Kediri Regency with a total of 1 person. The results of the study are that there is a shortage of human resources in the Adan-Adan Health Center medical record unit which should be 3, but totaling 1 person. Suggestions for Adan-Adan Health Center are employee recruitment needs to be done so that the number of medical records officers can be fulfilled. AbstrakSumber daya manusia merupakan komponen penting dan vital dalam operasional sebuah organisasi. Pelayanan kesehatan yang bermutu tidak terlepas dari penyelenggaraan rekam medis yang baik. Agar berjalan dengan baik, maka dibutuhkan sumber daya rekam medis yang cukup. Kunjungan pasien di Puskesmas Adan-adan pada periode Juli 2018 – Juli 2019 sebesar 16.828 orang. Petugas rekam medis hanya berjumlah 1 orang. Tujuan penelitian untuk menghitung kebutuhan sumber daya manusia di unit rekam medis menggunakan metode ABK. Desain penelitian ini yaitu observasional deskriptif dengan pendekatan case study. Responden dalam penelitian ini yaitu petugas rekam medis Puskesmas Adan-adan Kabupaten Kediri yang bejumlah 1 orang. Hasil penelitian yaitu terdapat kekurangan jumlah sumber daya manusia di unit rekam medis Puskesmas Adan-adan yang seharusnya berjumlah 3, namun saat ini berjumlah 1. Saran bagi Puskesmas Adan-adan yaitu perlu dilakukan rekrutmen pegawai agar jumlah petugas rekam medis dapat terpenuhi.


2021 ◽  
Vol 8 (1) ◽  
pp. 43-46
Author(s):  
Eva Rahmawati ◽  
Tuti Herawati ◽  
Fardhoni

The implementation of coding done in the medical record should be done very thoroughly, precisely and accurately according to the diagnostic code that exists in ICD-10. If there is an error in coding, it will have a bad impact on the patient, puskesmas or hospital. But in the fact found in the field there are still problems in the implementation of the accuracy of the encoding of disease diagnosis based on ICD-10. The purpose of this research is to describe the accuracy of disease code in the medical record in Puskesmas Plumbon. The population in this study was the entire quarterly medical record document of year 2020 with a total of 1,098 medical record documents with a total sample of 92 documents using simple random sampling technique. This study was conducted in Plumbon Puskesmas Medical record unit on 20 June 2020. The method used is descriptive with a quantitative approach. The data collection procedures used are by observation and checklist sheet. The population in this study was the entire quarterly medical record document of year 2020 with a total of 1,098 medical record documents with a total sample of 92 documents using simple random sampling technique. This study was conducted in Plumbon Puskesmas Medical record unit on 20 June 2020. The results of the study obtained from 92 samples of medical record documents, the appropriate disease code in accordance with the ICD-10 as much as 39 (42.39%) and improper code of 53 (57.61%). There is still an imprecision of unsuitable disease code due to coding officers that do not include the 4th character. It is best to need a fixed procedure in accordance with WHO provisions for coding the disease to make the koder more thorough in determining the disease code.


2021 ◽  
Vol 6 (2) ◽  
pp. 108-118
Author(s):  
Esraida Simanjuntak ◽  
Fajar Insani

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.


2021 ◽  
Vol 2 (1) ◽  
pp. 1
Author(s):  
Ahmad Muchlis ◽  
Rifa Aulia Ramadhanty

Background: Completeness of patient medical information in medical records is one indicator in assessing the quality of health services. Complete and accurate medical records contribute to the accuracy of medical staff in making a diagnosis so that they can determine the correct diagnosis code according to the ICD-10 guidelines. A good medical record shows that a doctor or other medical staff has carried out their duties by the demands of their profession as stated in the Medical Practice Law No.29 of 2004. Purposes: To find out there is or not a correlation between the medical information completeness and the accuracy of the diagnosis code for upper respiratory tract infection and hypertension based on the ICD-10 in the medical record documents of outpatients at the Cibening Health Center in 2019. Method: The method used in this study is observational analytic with a cross-sectional study design. The population of this study was outpatient medical records with a diagnosis of upper respiratory tract infection and hypertension at the Cibening Health Center in 2019. The sampling technique used a simple random sampling technique with a sample size of 100. Results: Out of obtained 71 complete medical record (71%) filling in medical records, 64 medical records (64%) were accurate in giving ICD-10 codes, 63 medical records (88.7%) with complete medical information had accurate diagnosis codes in comparison with 8 medical records (11.3%) which were complete but inaccurate diagnosis code. Conclusion: With a p-value of 0.000, there is a significant correlation between the completeness of medical information and the accuracy of the diagnosis code for Upper Respiratory Tract Infection and Hypertension based on ICD-10.


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