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All Journal Media Ilmu Kesehatan Abdi Dosen : Jurnal Pengabdian Pada Masyarakat J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan PELS (Procedia of Engineering and Life Science) Promotor: Jurnal Mahasiswa Kesehatan Masyarakat
Khumaira, Nurul Fitri
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Ketidaktepatan Kode Diagnosis Kasus Bedah RSU ‘Aisyiyah berdasarkan ICD-10 Khumaira, Nurul Fitri; Wahyuni, Annisa; Siska, Siska
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.5080

Abstract

The high rate of coding inaccuracies can impact medical treatment cost claims, increase the workload of medical record staff, and lead to poor epidemiological disease data recording. This study aims to identify inaccuracies in inpatient surgical diagnosis coding based on ICD-10. The study uses a descriptive method. The population consists of all inpatient surgical medical records at RSU Aisyiyah Padang in 2023, with a sample size of 84 records selected using simple random sampling. Data analysis was performed descriptively using univariate analysis to determine the frequency distribution and the percentage of coding accuracy based on ICD-10. The study results show that 26.19% of diagnosis codes were inaccurate, while 73.81% were accurate. Coding inaccuracies were categorized into three groups: incorrect codes, fourth character errors, and third character errors. The Neoplasms category had the highest percentage of incorrect codes. The inaccuracies were mainly caused by a lack of attention to detail by coders and differences between the doctor's diagnostic terminology and the ICD-10. Solutions to reduce these errors include improving knowledge, effective communication with doctors, and adherence to coding guidelines.
Case Analysis of Compensation Audit by BPJS in Hospital X Year 2023 Yastori, Yastori; Khumaira, Nurul Fitri; Oashttamadea, Ressa
PROMOTOR Vol. 7 No. 5 (2024): OKTOBER
Publisher : Universitas Ibn Khaldun Bogor

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32832/pro.v7i5.933

Abstract

Audit Compensation Audits cause operational activities and hospital financial systems to become disrupted and unstable. Based on a preliminary survey at the Hospital, this research aims to analyze Compensation Audit cases carried out by health insurance providers in 2023. The type of research used is Mixed Method, namely a research approach that combines or links qualitative and quantitative forms. This research was conducted in January – June 2024. The research population was 5 compensation audit cases in 2023. In-depth analysis was carried out on 5 compensation audit cases based on analysis of medical resumes, related regulations and based on ICD-10 and ICD-9-CM coding rules. Compensation Audit Case Solution, namely coders must understand medical records, claim submission documents, ICD-10, ICD-9 CM coding rules, BPJS and hospital PPK claims regulations, doctors need to provide clear, specific management and be able to know the patient's condition. treatment class from the start of admission and the health insurance verifier must have the same perception as the previous verifier and be careful in reading and analyzing claim submission documents.
OPTIMIZING MEDICAL TERMINOLOGY INTERPRETATION AND ICD-10 CODING SKILLS FOR SURGICAL CASES AT RSKB ROPANASURI PADANG Khumaira, Nurul Fitri; Yastori, Yastori; Kader, Shaola Syafrullah; Novita, Dian
Abdi Dosen : Jurnal Pengabdian Pada Masyarakat Vol. 9 No. 3 (2025): SEPTEMBER
Publisher : LPPM Univ. Ibn Khaldun Bogor

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32832/abdidos.v9i3.2912

Abstract

This community service activity focused on improving the understanding of medical terminology and ICD-10 coding accuracy for surgical cases at RSKB Ropanasuri Padang. The main problem identified was the difficulty medical record officers faced in correctly interpreting medical terminology used by doctors, especially in surgical diagnoses. This often led to inaccurate coding, impacting the hospital's data and finances. The solution provided was a comprehensive training session, which included socialization, case studies, and discussions to enhance participants' understanding of medical terminology and improve their ICD-10 coding skills. The results showed significant improvement in participants' ability to interpret diagnoses and apply the correct ICD-10 codes, with pretest scores increasing by 71.43% after the training. This study emphasizes the importance of standardized medical terminology and continuous training for improving diagnostic coding accuracy in healthcare settings. Further training on diverse medical cases is recommended to enhance coding proficiency.
Compensation Audit Case at Casemix Hospital X Yastori, Yastori; Putri, Riza Suci Ernaman; Khumaira, Nurul Fitri; Oktavia, Dewi
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i0.1966

Abstract

Audit Compensation Audits result in operational activities and hospital financial systems becoming disrupted and unstable. Based on a preliminary survey at Hospital This research aims to analyze Compensation Audit cases carried out by health insurance providers in 2023. The type of research used is using the Mixed Method, a research approach that combines or associates qualitative and quantitative forms. This research was conducted in March - June 2024. The research population was 11 compensation audit cases in 2023. Total sampling technique. An in-depth analysis was carried out on 11 compensation audit cases based on analysis of medical resumes, related regulations and based on ICD-10 and ICD-9-CM coding rules. The results of research that carried out an in-depth analysis of compensation audit cases showed that most compensation audit cases were caused by the enforcement of treatment classes with a total of 3 cases, specific management 2 cases, combination code 1, availability of death reports 1, regulations for enforcing the main diagnosis 1, specific management for main diagnosis 1, unavailability of anatomical pathology attachments 1, errors in establishing the main diagnosis and non-compliance with medical procedures and supporting documents 1. Compensation Audit Case Solution, namely the coder must understand medical records, claim submission documents, ICD-10, ICD-9-coding rules CM, health insurance provider and hospital PPK claim regulations, doctors need to provide clear, specific management and be able to determine the patient's condition. treatment class from the start of entry and the health insurance verifier must have the same perception as the previous verifier and be careful in reading and analyzing the claim submission documents.
Concordance Between Physician’s Clinical Diagnostic Terminology and ICD‑10 on Surgical Patient Medical Records Khumaira, Nurul Fitri; Yastori; Kader, Shaola Syafrullah
MEDIA ILMU KESEHATAN Vol 14 No 3 (2025): Media Ilmu Kesehatan
Publisher : Universitas Jenderal Achmad Yani Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30989/mik.v14i3.1771

Abstract

Background: The accurate use of medical terminology in clinical diagnosis is crucial for proper disease classification, coding accuracy, and reliable health data reporting. However, inconsistencies remain due to non-standard terminology and abbreviations that do not comply with the International Classification of Diseases (ICD-10).Objective: This study aims to evaluate the conformity of physicians’ diagnostic terminology with ICD-10 and with the hospital’s official abbreviation guidelines.Methods: This descriptive quantitative cross-sectional study was conducted from March to July 2025 at RSKB Ropanasuri Padang. A 96 surgical patient medical records from 2024 were selected through simple random sampling. Diagnostic data were evaluated using a conformity checklist based on ICD-10 Volume 1 and 3 and the hospital’s standardized abbreviation guidelines.Results: : The results showed that not all diagnoses complied with ICD-10 terminology or abbreviation guidelines. Common discrepancies included non-standard abbreviations, inconsistent anatomical terminology, and non-specific terms such as “tumor” without further details.Conclusion: Concordance Physician’s diagnostic terminology with ICD-10 and Abbreviation guidelines remains inadequate. Strengthening standard operating procedures, enhancing clinician training in ICD-10 nomenclature, and establishing more structured coder–clinician communication are essential to ensure valid and reliable health data.
Co-Authors - Yastori, - Dian Novita Kader, Shaola Syafrullah Oashttamadea, Ressa Oktavia, Dewi Putri, Riza Suci Ernaman Siska Siska Wahyuni, Annisa Yastori