Relationship Between Specificity and Precision in Writing the Main Diagnosis and Accuracy of Main Diagnosis Codes with Financing Claims in Cases of DM in Dr Radjiman Wediodiningrat Hospital, Lawang

Abstract

Specificity and precision in writing the main diagnosis will give the accuracy of diagnosis code, and proper code will give an impact on the appropriate of the cost using INA-CBGs. Research objectives was to analyze the specificity and precision in writing the main diagnosis and the accuracy of main diagnosis code based on ICD-10, also the claims of financing in the case of Diabetes Mellitus (DM) in RSJ Dr. Radjiman Wediodiningrat Lawang, as well as analyzed their relationship. This type of research was a cross sectional correlasional. Independent variables were the specificity and precision in writing the main diagnosis and the accuracy of main diagnosis code, and the dependent variable was the claim of financing. The number of samples analyzed were 50 inpatient medical record document (MRD) of DM cases which hospitalization from January to September 2017, selected by simple random sampling. The results showed the unspecific and unprecise in writing the main diagnosis of DM disease had a risk 1.6 times greater impacting the inaccuracy the main diagnosis code of DM disease (95% CI: 1.05 - 2.30) and 1.8 times greater resulting in the claims for financing treatment not accordance (95% CI: 1.03 - 3.12). An internal verification team is needed for submission of financing claims, consisting of elements from the medical committee, medical recorders and other related elements, as well as conducting periodic monitoring and evaluation of how to write the main diagnoses and their coding.