Journal Medical Informatics Technology
Volume 4 No. 2, June 2026

Accuracy of Clinical Coding in Cesarean Section Cases Using ICD-10 and ICD-9-CM

Gama Bagus Kuntoadi (STIKes Widya Dharma Husada Tangerang)
Indah Kristina (APIKES Bhumi Husada Jakarta)
Hudiyati Agustini (APIKES Bhumi Husada Jakarta)
Rumondang Christin (STIKes Widya Dharma Husada Tangerang)



Article Info

Publish Date
30 Jun 2026

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.

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Journal Info

Abbrev

medinftech

Publisher

Subject

Computer Science & IT Dentistry Engineering Medicine & Pharmacology Public Health

Description

Journal Medical Informatics Technology publishes papers on innovative applications, development of new technologies and efficient solutions in Health Professions, Medicine, Neuroscience, Nursing, Dentistry, Immunology, Pharmacology, Toxicology, Psychology, Pharmaceutics, Medical Records, Disease ...