Abstract
Background: the accuracy of a diagnosis code is essential in financing health services and diseases and procedure indexing and hospital management information. Based on the results of the preliminary study, diabetes mellitus is among the top 10 diseases. While coding 10 medical record documents, three consisted of 30% which were accurate, and the seven recorded 70% were found to be accurate. The four-character of the code was predominantly the character with many inaccuracies. Therefore, the researchers conducted a study on the accuracy of a diagnosis code at Dr. Soekardjo Regional General Hospital specifically on inpatient cases of diabetes mellitus in 2022. Methods: A quantitative type of study with a descriptive research design was implied in the study. The study object is data coding of diabetes mellitus cases. Data are collected by observation and interviews Results: According to the research results, diabetes mellitus is one of the top 10 diseases, while 40 medical record documents were coded, 20 (50%) were inaccurate and 20 (50%) were accurate, while the highest percentage of unaccuracy occurs in the fourth character of the code. The alignment of codes based on ICD-11 revealed that 10 documents (25%) were not aligned due to lack of specificity regarding ulcer complications and gastropathy.The alignment of codes based on SNOMED CT showed that 40 documents were aligned with the SNOMED CT clinical phrase standards. Conclusion: The inaccuracies in diabetes mellitus diagnosis coding at Dr. Soekardjo Regional General Hospital are attributed to less specific diagnoses, unclear handwriting by doctors in patient medical records, and coding personnel still facing difficulties in determining complication coding. The researchers suggest solutions such as involving coders and medical personnel in training and socialization activities related to diagnosis codes, particularly for Diabetes Mellitus.
Published Version
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