Analysis of Medical Procedures Codes Accuracy Based on ICD-9 CM Cases of Bacterial Infection at Hospital X in Padang

Abstract

Background: Based on a preliminary survey at X Padang hospital, the writing of a diagnosis code for a procedures medical caused by a bacterial infection found a discrepancy between the diagnosis in cases of bacterial infection and the written code. In 15 samples of medical record files at hospital X in Padang, only 33.33% of the code writing was correct. Based on the Decree of the Minister of Health Number 377/MenKes/SK/III/2007 concerning Professional Standards for Medical Recorders and Health Information, it states that one or the competencies that a medical recorder must have is the classification and coding of diseases, problems related to health and actions medical. Medical recorders are capable of defining disease and action codes precisely according to the international classification of diseases and medical practices in health care and management. The impact of losses from inaccurate clinical data codes has an effect on the financing of health services, such as submitting financing claims to health insurers. The aim of this study was to determine the accuracy of the medical procedure code based on ICD-9 CM at Hospital X in Padang.Methods: The kind of this research is a descriptive study with the retrospective method. The variables is the accuracy of the medical procedures codes bacterial infection. The population is all medical records of bacterial infection inpatients in January 2019 and the sample with sampling techniques saturated is 33 documents. The collection of data is interviews and observation in July 2020 at Hospital X in Padang.Results: Accurate medical procedures codes based on the ICD-9 CM is 22 (66.66%), and an inaccurate 11 (66.66%) of 33 diagnoses in the medical record file.Conclusions: The coding inaccuracy at Hospital X in Padang was partly due to the inaccuracy in selecting sub-category for determining the causes of bacterial infection.