Jurnal Comprehensive Health Care
Vol. 9 No. 2 (2025): Comprehensive Health Care

The Accuracy of ICD-10 Codes for Clinical Diagnosis and Supporting Examinations of Hypertension Cases in Inpatient Care at Hospital

Agustina (Unknown)
Meilany, lilik (Unknown)
Muh Erwin Rosyadi (Unknown)
Rosana Dwiyanti Putri (Unknown)
Ruslan Agussalim (Unknown)
Jeny Rezkysadin Ilyas (Unknown)



Article Info

Publish Date
29 Aug 2025

Abstract

Background: Accurate diagnosis coding is essential to support processes such as the preparation of statistical reports, health insurance claims to BPJS, and data-based decision-making. A preliminary study at RSUD X Makassar in the first quarter of 2025 found 243 electronic medical records of inpatients diagnosed with hypertension with diabetes mellitus complications, of which 20 records contained incorrect codes. Objective: To determine the relationship between clinical diagnosis and supporting examinations with the accuracy of ICD-10 codes in hypertension cases among inpatients at RSUD X Makassar. Methods: This study employed a cross-sectional design with a quantitative approach. The population consisted of inpatient medical records from the first quarter, with a sample of 71 medical records of hypertension cases selected using random sampling. Results: Based on hypothesis testing, two variables were analyzed: clinical diagnosis and ICD-10 code accuracy. The significance value (p-value) was 0.184. Since the significance value of 0.184 > 0.05, the next variable tested was the completeness of supporting examinations and code accuracy, which yielded a significance value of 0.452 > 0.05. Further Pearson correlation testing revealed that the strength of the relationship between clinical diagnosis and code accuracy had a correlation coefficient of r = 0.158 with a significance value of p = 0.189 (p > 0.05). Meanwhile, the relationship between completeness of examinations and code accuracy showed a correlation coefficient of r = 0.089 with a significance value of p = 0.459 (p > 0.05), indicating a very weak correlation. Conclusion: Both variables demonstrated no significant relationship, suggesting that other factors may be more dominant. The experience and training of coders may have a greater influence than the completeness of medical records. Moreover, the implementation of health information technology could further enhance coding accuracy. Keyword: Code Accuracy, Clinical Diagnosis, Supporting Investigation

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Journal Info

Abbrev

chc

Publisher

Subject

Health Professions Nursing

Description

Nursing services have an important role in determining the overall success of health services. The nursing process is a scientific method that is systematically used scientific principles that are used systematically in achieving diagnoses of health problems, formulating goals to be achieved, ...