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All Journal NURSING UPDATE JURNAL ILMIAH ILMU KEPERAWATAN Journal Medical Informatics Technology EDU RMIK Jurnal Edukasi Rekam Medis Informasi Kesehatan Klinik: Jurnal Ilmiah Kedokteran dan Kesehatan
Rumondang, Christin
STIKes Widya Dharma Husada Tangerang
Computer Science & IT Dentistry Education Engineering Health Professions Immunology & microbiology Medicine & Pharmacology Nursing Public Health

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Accuracy of Clinical Coding in Cesarean Section Cases Using ICD-10 and ICD-9-CM Gama Bagus Kuntoadi; Indah Kristina; Hudiyati Agustini; Rumondang Christin
Journal Medical Informatics Technology Volume 4 No. 2, June 2026
Publisher : SAFE-Network

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37034/medinftech.v4i2.146

Abstract

Accurate clinical coding in cesarean section cases is essential for morbidity reporting, clinical data quality, and the validity of INA-CBG reimbursement claims under the national health insurance system. Obstetric cases are inherently complex, involving multiple diagnosis and procedure codes that must conform to ICD-10 and ICD-9-CM standards. Objective: This study aimed to analyze the accuracy of ICD-10 diagnosis coding and ICD-9-CM procedure coding across multiple obstetric coding components in cesarean section cases at a hospital in Jakarta, Indonesia. A descriptive quantitative study with a retrospective design was conducted on 95 medical records of obstetric and gynecological patients who underwent cesarean section in 2025, selected through total sampling. Coding accuracy was determined by comparing hospital-assigned codes against standard codes re-verified by researchers based on WHO ICD-10 Volume 2 and ICD-9-CM guidelines. Data were analyzed using frequency, percentage, mean, median, and standard deviation, following a Shapiro-Wilk normality test. The overall accuracy rate for ICD-10 diagnosis codes was 83.9% (266/317 codes) and for ICD-9-CM procedure codes was 91.5% (86/94 codes). Accuracy varied substantially across coding components: secondary diagnosis codes for cesarean delivery and delivery outcome codes each reached 90.5%, while codes for concomitant diagnoses reached only 34.7%. For procedures, cesarean section codes (74.x) achieved 85.3% accuracy, whereas non-cesarean section procedure codes showed accuracy of only 5.3%, predominantly due to undercoding of additional operative procedures documented in surgical reports. Coding accuracy for obstetric cesarean section cases was generally good to very good in aggregate; however, substantial gaps remain in the coding of concomitant diagnoses and additional procedures. This study contributes a component-level evaluation across diagnosis, delivery outcome, and procedure coding, offering a more granular assessment of coding accuracy than prior single-metric studies.
Analisis Kelengkapan Pengisian Laporan Operasi pada Tindakan Sectio Caesarean di Rumah Sakit Buah Hati Pamulang Rumondang Christin; Dede Resa Oktaviani; Gama Bagus Kuntoadi
Jurnal Ilmiah Kedokteran dan Kesehatan Vol. 4 No. 1 (2025): Januari : Jurnal Ilmiah Kedokteran dan Kesehatan
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/klinik.v4i1.6089

Abstract

The operation report form is a report or record of the surgical procedure on the patient. The operation report form is used to report and record the patient's condition before, during, and after receiving surgery. The type of research used is descriptive with a quantitative approach. Data collection using observation results and check list sheets. The population of this study was 200 operation report forms on sectio caesarea at RSIA Buah Hati Pamulang in March - May 2025. The sample of this study was 133 operation report forms on sectio caesarea with simple random sampling technique. From The results of the study found that the patient identity component was filled in completely, namely 100%, in the important report sub-component almost completely filled in with a percentage of 94% and there was a post-surgical diagnosis sub-component that was only mostly with the lowest percentage of 8%, in the researcher's authentication component there was a sub-component of the surgeon's TTD which was almost completely filled in with a percentage of 99%, and and there was a percentage of almost completely complete, namely 99% assistant anesthesiologist 98%, It is recommended for RSIA Buah Hati Pamulang to immediately use the electronic operation report form in accordance with PMK 24 of 2022 concerning Medical Records governing Electronic Medical Records in health service facilities (fasyankes) in Indonesia.
Co-Authors Abdul Aziz Angelina, Novia Astrid Novita, Astrid AYU SURYANI, AYU Az-Zahra, Dini Cahya Maulina, Fresty Darmawan, Dea Natania Dede Resa Oktaviani Gama Bagus Kuntoadi Herawati, Aryana Hudiyati Agustini Ima Rusdiana Indah Kristina Kristina, Indah LESTARI, SANTI Muchtar, Riska Indria Nurzanah, Ghina PUJI LESTARI Rahmi Junaida Rita Dwi Pratiwi Sucipto Sucipto Werfete, Anggraeny Rahma