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

PROCEEDING INTERNATIONAL CONFERENCE ON MEDICAL RECORD (ICMR) 2020 E-ISSN: 2775-8680 DOI: https://doi.org/10.47387/icmr.v1i1.17

Yastori, M.Si1*

1Department of Medical Record and Health Management, Apikes Iris, Padang, Indonesia [email protected]

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. Keywords: Accuracy, coding, ICD-9 CM

INTRODUCTION 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. Over the years, the use of different procedures and terms of disease has resulted in inaccurate data collection and processing of morbidity and mortality. In an effort to organize and standardize medical language, health administrators have succeeded in developing disease nomenclature, disease classification systems, and clinical medical vocabulary1.

39 PROCEEDING INTERNATIONAL CONFERENCE ON MEDICAL RECORD (ICMR) 2020 E-ISSN: 2775-8680 DOI: https://doi.org/10.47387/icmr.v1i1.17

The important thing that must be considered by medical record personnel is the accuracy in providing a diagnosis code. Precise and accurate coding required a complete medical record. Medical records must contain documents to be coded as on the front sheet such as; in-out summaries, surgery sheets and action reports, pathology reports and patient exit resumes. One of the factors causing the inaccuracy in writing the diagnosis code was that the doctor did not write a complete diagnosis, resulting in an error by the medical record officer in conducting the diagnosis code. The impact that occurs if the writing of the diagnosis code is not correct is that patients sacrifice enormous costs, patients who should not take antibiotics but must be given antibiotics and the more fatal impacts are at risk of threatening the patient's life2. According to Permenkes RI Number 269/Menkes/Per/III/2008 the contents of the medical record documents include the actions that have been given to patients, which then will be coded by referring to the International Classification of Diseases Ninth Revision Clinical Modification (ICD-9-CM ). Giving code or coding is the provision of code determination using letters or numbers or a combination of letters in numbers that represent data components. Medical personnel as a coder must be responsible for the accuracy of the code of a diagnosis that has been determined by medical personnel3. The coding of the action diagnosis must comply with the ICD-9CM rules or the International Classification of Diseases 9 Clinical Modification. So that coder officers must have knowledge in determining disease diagnosis codes according to ICD 10 and action diagnosis codes according to ICD-9CM. The coding of labor procedures is given in Chapter 13: Obstetrics / Obstetric Procedures (72-75) in the ICD-9CM. The procedure of action that has been given by doctors and midwives must be recorded completely and clearly so that accurate coding is easy to do4. Based on research by Warsi Maryati et al, 2017, it shows that the procedure for giving action codes is not in accordance with fixed procedures. Evaluation based on elements shows the percentage of reliability is 60.3% and 39.7% is unreliable, the validity element is the percentage of 73.6% valid code and 26.4% invalid code, the Completness element shows 100% incomplete and no timeliness in setting the code5.

METHODS The research was conducted at hospital X, West Sumatera on July 2020. This research uses a descriptive method with a quantitative approach. The data used were all medical record files for the period of January 2019. The population in this study is all medical record files that contain medical procedures codes with total 33 medical record files. The sampling technique using total sampling, with total 33 medical record files that have medical procedure code.

RESULTS Results of Descriptive Statics of Study Variables Table 1: Analysis of the accuracy of the procedure code in cases of bacterial infection based on ICD-9 CM

ICD-9 CM code based No Procedure on data ICD-9 CM code Analysis from hospital X

40 PROCEEDING INTERNATIONAL CONFERENCE ON MEDICAL RECORD (ICMR) 2020 E-ISSN: 2775-8680 DOI: https://doi.org/10.47387/icmr.v1i1.17

1 88.44 87.44 Routine chest X-ray, so Not accurate, because Ro Thorax described procedure code 88.44 is the code for arteriography of other intrathoracic vessels 2 87.44 87.44 Routine chest X-ray, so Accurate Ro Thorax described 3 Ro Thorax 87.44 87.44 Routine chest X-ray, so Accurate described 4 Transfusion 99.04 99.04 Transfusion of packed cell Accurate PRC 5 Ro thorax 87.44 87.44 Routine chest X-ray, so Accurate described 6 CT-Scan 87.03 87.03 Computerized axial Accurate brain tomography of head 7 Ro Thorax 87.44 87.44 Routine chest X-ray, so Accurate described 8 EKG 89.52 89.52 Eletrocardiogram Accurate 9 EKG 89.52 89.52 Eletrocardiogram Accurate 10 Ro Thorax 87.44 87.44 Routine chest X-ray, so Accurate described 11 Sputum 99.04 90.42 Microscopic examination Not accurate, because culture of specimen from trachea, procedure code 99.04 is bronchus, pleura, lung, and other the code for Transfusion of thoracic specimen, and of packed cells sputum culture 12 Ro thorax 87.44 87.44 Routine chest X-ray, so Accurate described 13 USG 88.76 88.76 Diagnostic ultrasound of Accurate abdomain abdomen and retroperitoneum 14 Sputum 99.07 90.42 Microscopic examination Not accurate, because culture of specimen from trachea, procedure code 99.07 is bronchus, pleura, lung, and other the code for Transfusion of thoracic specimen, and of other serum sputum culture 15 Tranfusion 99.04 99.04 Transfusion of packed Accurate albumin cells 16 Transfusi 99.04 99.04 Transfusion of packed Accurate PRC 4 unit cells 17 USG thorax 88.73 88.73 Diagnostic ultrasound of Accurate other sites of thorax 18 Ro thorax 87.44 87.44 Routine chest x-ray, so Accurate described 19 BTA sputum 89.52 90.41 Microscopic examination Not accurate, because of specimen from trachea, procedure code 89.52 is bronchus, pleura, lung, and other the code for thoracic specimen, and of Electrocardiogram sputum bacterial smear 20 Urine culture 93.94 91.32 Microscopic examination Not accurate, because of specimen from bladder, procedure code 93.94 is urethra, prostate, seminal the code for Respiratory vesicle, perivesical tissue, and of medication administered urine and semen culture by nebulizer

21 Brain CT 03.31 87.03 computerized axial Not accurate, because Scan tomography of head procedure code 03.31 is the code for Spinal tap

41 PROCEEDING INTERNATIONAL CONFERENCE ON MEDICAL RECORD (ICMR) 2020 E-ISSN: 2775-8680 DOI: https://doi.org/10.47387/icmr.v1i1.17

23 EKG 89.52 89.52 Electrocardiogram Accurate 24 Ro thorax 87.44 87.44 Routine chest x-ray, so Accurate described 25 Ro thorax 87.44 87.44 Routine chest x-ray, so Accurate described 26 EKG 89.52 Electrocardiogram Accurate 89.52 27 Ro thorax 87.44 87.44 Routine chest x-ray, so Accurate described 28 Scan thorax 33.22 87.41 Computerized axial Not accurate, because tomography of thorax procedure code 33.22 is the code for fiber optic bronchoscopy 29 USG thorax 33.34 88.73 Diagnostic ultrasound of Not accurate, because other sites of thorax procedure code 33.34 is the code for thoracoplasty 30 Sputum 87.44 90.42 Microscopic examination Not accurate, because culture of specimen from trachea, procedure code 87.44 is bronchus, pleura, lung, and other the code for routine chest thoracic specimen, and of X-Ray, so described sputum culture 31 Urine culture 99.07 91.32 Microscopic examination Not accurate, because of specimen from bladder, procedure code 99.07 is urethra, prostate, seminal the code for transfusion of vesicle, perivesical tissue, and of other serum urine and semen culture 32 Ro thorax 87.44 87.44 Routine chest x-ray, so Accurate described 33 USG 99.07 88.7 Diagnostic ultrasound Not accurate, because procedure code 99.07 is the code for Transfusion of other serum

DISCUSSION For the smooth implementation of coding of medical procedures, all health workers, be it nurses, doctors, medical record officers, are responsible for the implementation of the coding of medical actions, especially for JKN (National Health Insurance) patients. In its implementation, it was found that there was still a lack of compliance in writing diagnoses and medical actions according to ICD 10 and ICD 10 CM, this was supported by the problems found were doctors' writings that were difficult to read and unclear, both writing on diagnosis and medical action, and the use of abbreviations that does not match ICD-10 and ICD-9-CM then the resume contents are still incomplete. According to Hatta (2008), the process of coding accuracy must monitor several elements, namely consistent when the officers code is different, the code remains the same (reliability), the code is correct according to diagnosis and action (validity), including all diagnoses and actions in the medical record (completeness). and on time (timeless). Human resources are one of the components that influence the successful implementation of a system, reliable human resources are needed in implementing coding to support the quality of the hospital to be better and more targeted. Responsibility and motivation are aspects that affect human resources. Some officers already have responsibilities at work. However, the coding officer is constrained by filling in an incomplete and unclear resume, filling out this resume is the responsibility of the treating doctor.

42 PROCEEDING INTERNATIONAL CONFERENCE ON MEDICAL RECORD (ICMR) 2020 E-ISSN: 2775-8680 DOI: https://doi.org/10.47387/icmr.v1i1.17

Awareness, compliance and concern for human resources documenting services in medical record files to support the implementation of patient service claims is still lacking, because there are still many diagnoses written by PPDS doctors that are incomplete, unclear and use unusual abbreviations according to the ICD 10 and ICD 9 CM rules. This incident will complicate and increase the workload of HR coding and grouping to do their job, which in general will affect the implementation of medical action coding. Errors in the diagnosis code are due to the lack of knowledge and training related to writing a diagnosis in accordance with the rules of ICD 10 and ICD 9 CM, for this reason doctors are also required to fully understand ICD 10 and ICD 9 CM through training and there must be programs to improve the quality of human resources. through skills including knowledge, insight, experience, and ability to carry out tasks6. Operation action code inaccuracy is due to incorrect code selection. This means that operation action code inaccuracy is caused by writing incorrect code for an operation action type. Not doing a review of the entire record / writing of the code on the type of operation. Not coding is performed for some types of operation7.

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.

REFERENCES

1. Republic of Indonesia. Decree of the Minister of Health of the Republic of Indonesia Number 377 / Menkes / SK / III / 2007 concerning Medical Recording Professional Standards and Health Information. Ministry of Health of the Republic of Indonesia 2007. 2. Hatta, G. Guidelines for Health Information Management in Health Service Areas. Revised Edition 2. Jakarta: University of Indonesia Press 2012. 3. Ministry of Health of the Republic of Indonesia. Guidelines for Hospital Medical Record Administration and Procedure. Jakarta: Directorate General of Medical Services 2006. 4. Practice Management Information Corporation (PMIC). ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification, 2004. 5. Maryati,W, Ika S,W. Quality of Action Codes on Inpatient Medical Record Documents at Rsud Simo Boyolali. National Seminar on Research Results (Snhp)-VII Institute for Research and Community Service, Pgri University Semarang 2017. 6. Sukawan,A, Palu, B, and Samsualam. Implementation of Accuracy Coding of Medical Diagnosis and Measures in the Inpatient Unit of the Makassar City General Hospital, South Sulawesi. Mitr Advisory Journal, Volume IX Number 1, May 2019 7. Hariani, R, Lena, D, and Riyoko. Analysis of the Accuracy of the Top 10 Codes for Operation Actions on Discharge Resume Forms Based on Icd-9-Cm at Brsd Raa Soewondo Pati in the first quarter of 2009 Conclusion. Journal of Health, Issn 1979- 9551, Vol. III, No.1, March 2009, Pages 11-28.